PHCs were given the role of gatekeepers in the system

Alexander Thomas

When India gained independence in 1947, its vision for public health was bold and inclusive. At the heart of it were Primary Health Centres (PHCs), envisaged as institutions which would be the first point of contact between communities and the health system, promoting wellness, preventing disease, and providing accessible, affordable care.

Nearly eight decades later, PHCs remain a vital yet under-realized component of India’s health infrastructure. With multiple burdens of non-communicable diseases (NCDs), infectious diseases, an ageing population and rising expectations, PHCs must be revitalized to serve as digitally-enabled, community-driven and prevention-focused hubs of care.

The Bhore Committee Report of 1946 laid the foundation for India’s public health system. The report proposed a three-tiered structure with PHCs forming the crucial base. These PHCs were designed to serve a population of around 30,000 and were intended to provide a comprehensive range of services including outpatient care, maternal and child health services, basic diagnostics, immunization, disease prevention, sanitation promotion and health education.

PHCs were envisioned as holistic health units catering to the diverse medical and social needs of communities. Each was to be staffed by a full-time doctor, nurse, pharmacist and multipurpose health workers. The system emphasized decentrallization, equity and community engagement. Crucially, PHCs were expected to act as gatekeepers of the health system — delivering primary care and linked seamlessly to secondary and tertiary facilities through strong referral networks.

The original vision went beyond curative services. It recognized the role of the social determinants of health such as nutrition, clean water, hygiene, and environmental sanitation. Health workers were to serve as educators and health promoters, integrating themselves into the lives of the communities they served. Programmes like school health, maternal nutrition counselling, early childhood immunization and infectious disease surveillance were all essential to this integrated approach.

PHCs were foreseen as more than treatment centres. They were to be the nerve centre of a local health ecosystem, the cornerstones of preventive and promotive healthcare, empowered by village-level committees and local governance bodies. The goal was geographic and social equity in access to health services, ensuring that no Indian, regardless of caste, income, or remoteness, would be denied basic healthcare.

 

PHC SPREAD

India currently has around 170,000 Sub-Centres, 30,000 PHCs and 6,500 Community Health Centres (CHCs). At tertiary level there are medical colleges, regional institutes, national institutes, state-level AIIMS (All India Institute of Medical Sciences). They are referral units for four or five PHCs and 30-bed facilities with specialists. At secondary level is the Community Health Centre and a block-level PHC, which are referral units for four or five PHCs.

Villages have Health and Wellness Sub-Centres (HWSC) which serve a population of 5,000 or 3,000 in tribal areas. These are staffed by health workers and a Community Health officer. The ASHA (Accredited Social Health Activist), ANM (Auxiliary Nurse Midwife) and AWW (Anganwadi Worker) serve as links between the community and the PHC.

India’s 30,000 PHCs have played a pivotal role in numerous public health victories from the eradication of smallpox and reduction in polio cases to the Covid-19 vaccination drive. PHCs are often the frontlines during outbreaks and emergencies, serving millions across remote and rural areas.

However, the performance and functionality of PHCs vary widely across the country, with a significant urban-rural divide and inter-state discrepancies. While some PHCs have evolved into well-functioning health hubs, many continue to struggle due to systemic and structural deficiencies.

PHC Dhanora in Gadchiroli district, Maharashtra, stands out as a successful government-run PHC. It caters to tribal communities with high levels of trust and health-seeking behaviour. The centre maintains regular staff attendance, runs robust community outreach via ASHAs and offers a wide range of maternal, child, and chronic disease care. This success is attributed to active district health leadership, consistent supply chains, and NGO collaboration with SEARCH (Society for Education, Action and Research  in Community Health) even though the PHC itself remains government-operated.

In contrast, many PHCs in Bihar and Jharkhand remain plagued by systemic issues. Common deficiencies include irregular staff presence, dilapidated infrastructure, non-functional laboratories, frequent stock-outs of essential medicines, and weak coordination with secondary and tertiary centres. There is also often no implementation of Indian Council of Medical Research-mandated diagnostic protocols. These PHCs suffer from administrative neglect, low utilization of National Health Mission (NHM) funds, and limited technical oversight from the State.

 

MANY DOWNSIDES

PHCs, however, face a multitude of key challenges. These are inadequate infrastructure, including unreliable electricity, water supply, and deteriorating buildings. There are persistent vacancies in sanctioned posts for doctors, nurses, pharmacists, and lab technicians. Diagnostic capabilities too are limited and very few centres offer even basic blood or urine tests.

Added to that are non-functional or weak referral linkages to higher-level facilities, resulting in treatment delays and increased out-of-pocket expenses for patients. Poor record-keeping, absence of digital health tools, and lack of continuity in care are also issues.

Community involvement is minimal in some PHCs with Village Health and Sanitation Committees (VHSCs) often inactive or poorly trained. And perceived inefficiencies lead to distrust among local populations, especially in underserved regions.

Without addressing these foundational gaps, the promise of PHCs as equitable, accessible, and community-oriented care centres will remain largely unfulfilled. The opportunity now lies in revamping these systems with a focus on technology, accountability, and community ownership.

 

SOME POSITIVES

Despite these challenges, several promising initiatives are underway.

The Ayushman Bharat scheme, launched in 2018, seeks to upgrade Sub-Centres (SCs), PHCs and Urban Primary Health Centres (UPHCs) into Health and Wellness Centres (HWCs) providing comprehensive primary care, including prevention and management of NCDs, mental health services, palliative care and rehabilitation, dental and geriatric care, basic diagnostics and free medicines.

This shift marks a paradigm change from a curative, episodic model to a preventive, continuous, and holistic care approach bringing universal health coverage closer to the community, especially in rural and underserved areas.

The Indian Council of Medical Research (ICMR), through its 2025 National Essential Diagnostics List (NEDL), set a new benchmark for diagnostics at the PHC level, mandating access to haematology, urinalysis, blood glucose and HbA1c (diabetes), lipid profile, ECG and pregnancy tests, rapid tests for malaria, dengue, HIV, syphilis, hepatitis and cervical cancer screening.

In addition, transport services are required for sample collection and complex testing. Successful implementation requires reliable power supply, trained personnel, cold chain, quality assurance, and IT-enabled tracking systems.

Another transformative step towards diagnostic equity is the inclusion of ultrasound services at PHCs. The Ministry of Health and Family Welfare, with endorsement from the Supreme Court of India, has approved basic obstetric ultrasound to be performed by MBBS doctors after certified training.

This is critical given the severe shortage of radiologists, compounded by restrictive clauses in the PC & PNDT (Pre-Conception and Pre-Natal Diagnostic Techniques (Prohibition of Sex Selection) Act and the fact that existing ultrasound machines at PHCs are underutilized.

MBBS doctors, if trained, can provide affordable, point-of-care scans that identify high-risk pregnancies early, reduce preventable complications, and improve referral accuracy.

This facility exists but is not widely implemented, and scaling this across states is a rapid and impactful reform opportunity.

 

NEW PROGRAMMES

PHCs should shift from sick care to health promotion by offering nutrition, physical activity, and sleep counselling. Yoga, meditation, and stress reduction programmes should be part of the services it offers along with wellness clubs, group therapy, and garden walks. Another important service is tobacco cessation and addiction management.

This approach is vital to reducing the non-communicable disease burden and building long-term population health.

As part of life-course immunization, adult vaccination must become an integral component of PHC services. With rising life expectancy and the growing burden of chronic conditions, adults — particularly the elderly — are increasingly vulnerable to vaccine-preventable illnesses such as influenza, pneumococcal disease, Hepatitis B and shingles.

PHCs can play a crucial role in integrating adult vaccination into routine outpatient and geriatric care and raising awareness among communities and frontline workers. PHCs should also maintain vaccination records through digital systems (like ABHA or Ayushman Bharat Health Account) and help to reduce hospitalizations, complications, and healthcare costs in vulnerable populations.

By promoting adult vaccination, PHCs shift the focus from reactive to preventive healthcare, reinforcing their role as wellness-oriented institutions.

Mental health disorders are increasingly recognized as a major component of India’s disease burden — ranging from anxiety and depression to severe psychiatric conditions. However, the country faces an acute shortage of mental health professionals, with fewer than 0.75 psychiatrists per 100,000 people.

To bridge this gap, pioneering initiatives like the Public Health Foundation of India (PHFI)’s Certificate Course in Primary Care Psychiatry and similar programmes have trained hundreds of MBBS doctors in foundational mental healthcare. These short-term, evidence-based programmes enable primary care physicians to recognize and manage common mental illnesses, offer psychosocial support and provide early referrals when needed.

Such task-shifting models are scalable and essential for ensuring that mental healthcare reaches underserved populations via PHCs and HWCs.

India’s demographic profile is rapidly shifting — with the elderly projected to make up 14.2 percent of the population by 2036. This demographic transition necessitates the strengthening of PHC-based services across geriatric domains.

However, the availability of trained specialists in geriatrics — especially in rural and semi-urban settings — remains severely limited. To address this gap, institutions like Christian Medical College (CMC), Vellore and others have pioneered short-term geriatric training programmes for MBBS doctors.

These capacity-building efforts empower generalist physicians to deliver age-sensitive, life course oriented care, equipping PHCs to respond effectively to evolving population health needs.

To serve the elderly with dignity, PHCs must also offer routine geriatric assessments, ensure early detection of cognitive decline and mobility impairments as well as integrate rehabilitation services and age-friendly infrastructure. PHCs can also provide linkages to community-based hospice care, social support, and home care.

Together, these measures promote continuity of care, improve quality of life, and support the vision of inclusive, people-centred primary healthcare.

 

SPACE FOR TRADITION 

India’s diverse medical traditions must be leveraged through safe, validated practices. PHCs can incorporate home remedies and herbal formulations and promote Ayurveda, homoeopathy, naturopathy, and yoga. It’s important to respect cultural norms while ensuring scientific oversight.

One model example is AYUSH Grama — Soukya Foundation in Karnataka.

In partnership with the state government, the Soukya Foundation runs a comprehensive integrative care model in Hoskote taluk. This cost-effective, culturally acceptable model complements allopathic care and strengthens community participation.

 

CLIMATE AND HEALTH 

PHCs also have a critical role to play in addressing the growing intersection of climate change and public health. Rising temperatures, extreme weather events, air pollution, and vector-borne diseases disproportionately impact rural and vulnerable communities — those most reliant on PHCs.

As the first responders to climate-exacerbated health conditions such as heatstroke, respiratory illness, malnutrition, and waterborne diseases, PHCs must be equipped with climate-resilient infrastructure and sustainable energy sources like solar power. PHCs should also be equipped with safe water and sanitation systems and be schooled in climate-sensitive disease surveillance.

Initiatives under the HELP (Health and Environment Leadership Platform) — a unit of PHFI — and National Action Plans on Climate Change and Human Health are beginning to promote “green PHCs” that minimize carbon footprints while improving health outcomes.

Embedding climate resilience and mitigation in the PHC system is not only environmentally responsible — it is a public health imperative.

 

PEOPLE, TRAINING, SERVICES 

Academic and training institutions such as medical colleges, nursing schools, and public health institutes, and the Healthcare Sector Skill Council should take the lead in driving training and capacity-building initiatives, with strong government backing.

As a global supplier of healthcare professionals, India must ensure that its own needs are met by training a sufficient number of well-qualified caregivers for domestic deployment.

To retain healthcare workers in rural areas, it is essential to provide structured incentives, clear career pathways and robust tele-mentoring systems. These build professional confidence and reduce attrition.

India’s healthcare workforce must be equipped for evolving demands. Focus areas include point-of-care diagnostics, digital health tools and telemedicine, NCD and cancer screening, lifestyle medicine and counselling as well as geriatric and palliative care.

 

TECH TOOLS 

Digital innovation can transform PHC delivery through Electronic Health Records (EHRs) and ABHA Health IDs. For high quality diagnostics and triage, AI tools can be effective. Also, to prevent stock-outs, drug inventory systems need tech tools. Drones can effect medicine/sample delivery in hard-to-reach areas. Dashboards help in real-time outbreak surveillance and service monitoring.

Digital inclusion should be a non-negotiable pillar of PHC modernization.

 

BRIDGING THE LAST MILE

Telemedicine platforms, such as eSanjeevani, enable PHC doctors to consult with specialists in real time. This reduces unnecessary travel and referrals and enhances diagnosis and treatment of chronic conditions. It also builds PHC workforce confidence and lowers out-of-pocket expenditure for patients.

As broadband access improves, telemedicine must become a core component of equitable, specialist-supported care.

PHCs can be revitalized through collaboration. Public-Private Partnerships (PPPs) have proved to be effective. Here are some examples: CMC Vellore’s Community Health and Development (CHAD) hospital supports 82 villages through mentoring and mobile clinics; the Karuna Trust in Karnataka runs over 70 PHCs under government contracts; Basic Health Services in Rajasthan operates AMRIT Clinics in tribal belts; Piramal Swasthya enables telemedicine and health helplines and SEWA Rural in Gujarat, as well as Janani in Bihar and UP, support adolescent and maternal care.

These partnerships improve efficiency, trust, innovation, and accountability.

Empowering communities is essential for PHC success. Centres must engage with  the Village Health Sanitation and Nutrition Committees (VHSNCs), panchayats, youth clubs, Self-Help Groups, and local influencers and schools, Anganwadis, and frontline workers.

Local accountability fosters long-term behaviour change and system resilience.

 

STAMP OF QUALITY

Accreditation of PHCs is a powerful tool to ensure that services meet defined standards of quality, safety, and patient satisfaction. The National Quality Assurance Standards (NQAS) framework — developed by the Ministry of Health and Family Welfare — provides a rigorous, evidence-based system to assess PHC performance across key domains such as service provision, infection control, patient rights and community participation.

Accreditation drives continuous quality improvement, encourages data-driven decision-making, and fosters a culture of accountability among healthcare workers.

States like Kerala and Tamil Nadu have successfully scaled up NQAS-certified PHCs, demonstrating improvements in service uptake, trust, and health outcomes. Linking accreditation to incentives under programmes like Kayakalp and Ayushman Bharat further reinforces the commitment to quality. Mainstreaming PHC accreditation across the country is essential to institutionalizing excellence and regaining community confidence in the public health system.

The story of India’s PHCs is one of vision, struggle, and transformation. We stand at a historic moment in reinventing the PHC. ν

 

Alexander Thomas is a veteran of the healthcare system and founder of the Association of Healthcare Providers India.