At over three million square kilometres, stretching 3,000 kilometres from one tip to another, in both directions, with a population crossing 1.2 billion individuals living in over 600,000 habitations, India is one of the largest countries in the world. Some our districts have populations that are comparable to entire countries. For example, Burdwan District of West Bengal at eight million has a population comparable to that of Bolivia in Latin America.

On average, as a country, we annually spend Rs.2500 or $ 55 per capita on healthcare with the government spending only about Rs.500 or $11 per capita. This is a minuscule number when compared with a developed-nation average of $5,000 per capita and is smaller even than the amounts being spent by our neighbours China and Thailand who both spend over $150 per capita on health care with, in the case of Thailand, over 75 per cent of that being borne by the government.

Unfortunately our problems do not end here. We have a very low supply of physicians that are qualified in allopathic medicine and the few that are qualified are unwilling to serve in remote and challenging locations. Our disease burden continues to have a high proportion of infectious diseases such as tuberculosis (TB) but we have, over the past few years, become conscious of a large burden of chronic diseases as well.

India had 32 million people living with diabetes in 2000 and as estimated by the WHO this number is projected to rise to 80 million by 2030. Within cancers, cervical and oral cancers are the most prevalent forms among women and men, respectively, in India and both these cancers are highly amenable to primary prevention.

A study based on approximately 4,000 patient visits to six primary healthcare clinics being operated by SughaVazhvu Healthcare in rural Tamil Nadu also reveals some interesting trends which corroborate the global findings. In these six clinics, while more than 30 per cent of men seeking primary care were between 50–69 years old, about 40 per cent of all women seeking primary care were between the ages of 30–49 years.

The top four complaints with which all patients presented to the clinics were cold, body pain, multiple joint pain, and weakness. However, when analysed by age, the proportion of complaints indicative of chronic conditions (such as osteoarthritis and pain) increased – going from 33 per cent in patients aged 30–49 years to 51 per cent in patients aged 50–69 years.

The four most common diagnoses were pharyngitis, allergic bronchitis, osteoarthritis, and non-specific body pain. While acute, episodic conditions constituted 48 per cent of all diagnoses, chronic conditions such as osteoarthritis, body pain, hypertension (high blood pressure), hyperlipidemia (high cholesterol), and diabetes represented 29 per cent of all diagnoses. In fact, hypertension, hyperlipidemia, and diabetes, three modifiable risk factors for CVDs, together contributed to about 30 per cent of all chronic diagnoses made in patients over the age of 30 years.
 
Given these debilitating limitations is there any hope at all of us offering even a reasonable quality of healthcare to our citizens or are we, as it were, dead in the water? 

As recommended by the World Health Organization (WHO), we require one physician to serve a population of 1,000 people, which for a country like India would need 1.2 million physicians. As of today, we have about half of this estimated number of allopathic providers in India, and with fewer than 30,000 being added every year.

However in India, physicians who have formal degrees from Ayurvedic, Siddha, and Unani, disciplines are legally permitted to offer allopathic services to their patients. There are over 750,000 registered Ayush (Ayurveda, Yoga, Unani, Siddha, and Homoeopathy) practitioners in the country, about 70 per cent of who fall under the legally permitted categories. These numbers when combined with the total number of physicians who are trained in the allopathic tradition start to come close to the total requirements of medical practitioners that we need as a country.

There is no doubt that there are gaps in their training, which need to be bridged before they are main-streamed to practice modern medicine. A comparative analysis of the AYUSH curricula with that of the MBBS reveals that while there is an 80 per cent overlap, pharmacological training, relating to the pharmacodynamics and pharmacokinetics of modern drugs, in addition, to training in areas such as mental health, geriatrics, ophthalmology, dentistry, maternal care, cervical screening and treatment, dental procedures, and emergency patient management, are gaps that would need to be filled through a focussed 6 to 12 months long bridge training programme.

As a country the missing link that we need to address is the lack of an effective and accountable primary healthcare system. A well-functioning primary healthcare system integrated with higher levels of care will not only ensure local access to people who seek care for primary services but also better utilization of secondary and tertiary care facilities by referring only those patients that need immediate attention. Challenges that face primary health-care specifically for rural Indian populations are daunting, right from appropriate human resources to financing viable service delivery systems. Our work in rural healthcare, demonstrates a pathway that integrates some of the solutions together as a well-functioning healthcare system for rural Indian population.
The six clinics mentioned earlier operate using the IKP Centre for Technologies in Public Health (ICTPH) model of primary care in which, a well-trained and legally qualified physician (who does not have an MBBS degree), assisted by a locally-hired health extension worker (HEW), provide the broadest possible range of healthcare services.

In addition to treatment for acute conditions, services such as dental fillings and scaling, cervical cancer screening, vision screening and dispensation of glasses and management of chronic diseases are also a part of their suite. Prior to establishing each of these village-based health centres, the entire catchment population is geo-mapped, and each household is issued a bar-coded enrolment ID containing all family details.

Community-based risk profiling of all adults is then performed to identify high risk individuals who have modifiable risk factors for non-communicable diseases. Identified high risk individuals, for example for CVD (based on height, weight, blood pressure, tobacco consumption, and waist and hip circumference as risk markers) are then exhorted to seek treatment at the health centre immediately, and are followed up until they do so regularly. The Health Information Management System ensures that there is a strong control environment within which each health centre operates.
 
Having outlined a framework for universal healthcare delivery and the proposed pathway it becomes even more essential to consolidate models that have managed to demonstrate care delivery not only at higher levels of care but most essentially primary care, not only for urban populations but rural populations as well. Such functioning service delivery models can then be integrated with higher levels of care such as secondary and tertiary to provide a continuum of healthcare service to our Indian populace.