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How context affects implementation of the Primary Health Care approach: an analysis of what happened to primary health centres in India
  1. Sudha Ramani1,
  2. Muthusamy Sivakami2,
  3. Lucy Gilson3,4
  1. 1Tata Institute of Social Sciences, Mumbai, India
  2. 2School of Health Systems Studies, Tata Institute of Social Sciences, Mumbai, India
  3. 3University of Cape Town, Cape Town, South Africa
  4. 4London School of Hygiene and Tropical Medicine, London, UK
  1. Correspondence to Sudha Ramani; sudha_ramani{at}


Introduction In this paper, we elucidate challenges posed by contexts to the implementation of the Primary Health Care (PHC) approach, using the example of primary health centres (rural peripheral health units) in India. We first present a historical review of ‘written’ policies in India—to understand macro contextual influences on primary health centres. Then we highlight micro level issues at primary health centres using a contemporary case study.

Methods To elucidate macro level factors, we reviewed seminal policy documents in India and some supporting literature. To examine the micro context, we worked with empirical qualitative data from a rural district in Maharashtra—collected through 12 community focus group discussions, 12 patient interviews and 34 interviews with health system staff. We interpret these findings using a combination of top–down and bottom–up lenses of the policy process.

Results Primary health centres were originally envisaged as ‘social models’ of service delivery; front-line institutions that delivered integrated care close to people’s homes. However, macro issues of chronic underfunding and verticalisation have resulted in health centres with poor infrastructure, that mainly deliver vertical programmes. At micro levels, service provision at primary health centres is affected by doctors’ disinterest in primary care roles and an institutional context that promotes risk-averseness and disregard of outpatient care. Primary health centres do not meet community expectations in terms of services, drugs and attention provided; and hence, private practitioners are preferred. Thus, primary health centres today, despite having the structure of a primary-level care unit, no longer embody PHC ideals.

Conclusions This paper highlights some contextual complexities of implementing PHC—considering macro (pertaining to ideologies and fiscal priorities) and micro (pertaining to everyday behaviours and practices of actors) level issues. As we recommit to Alma-Ata, we must be cautious of the ceremonial adoption of interventions, that look like PHC—but cannot deliver on its ideals.

  • primary health care
  • peripheral health clinics
  • health policy and systems research
  • contextual factors

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  • Handling editor Seye Abimbola

  • Contributors SR developed the initial design for the study, with mentorship from LG and SM. Data collection was done by SR, and both LG and SM commented on initial data summaries and the analysis. The first draft of the paper was written by SR, and reviewed by SM and LG. The final draft has been reviewed by all three authors. SR is the guarantor of the paper.

  • Funding This study is funded through the Health Policy Analysis Fellowship programme, supported by the Alliance for Health Policy and Systems Research, Switzerland, and managed through the University of Cape Town, South Africa. The Alliance for Health Policy and Systems Research funded the Health Policy Analysis Fellowship programme to build the capacity of doctoral level students to undertake research in this field. The first author of this paper was awarded this fellowship.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Ethics approval Ethical approval for the study was taken from the Institutional Review Board at the Tata Institute of Social Sciences, Mumbai, India, in April 2018.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement No additional data are available.

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