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Lancet Reg Health Southeast Asia
Lancet Reg Health Southeast Asia
The Lancet Regional Health - Southeast Asia
2772-3682
Elsevier

S2772-3682(24)00117-3
10.1016/j.lansea.2024.100467
100467
Comment
Primary health care in South Asia: a time for reform
Rao Krishna D. kdrao@jhu.edu
a∗
Prinja Shankar b
Masud Sayed c
Afsana Kaosar c
Perera Susie d
Ramani Sudha e
Weerasinghe Manuj C. f
a Department of International Health, Johns Hopkins University, USA
b Department of Community Medicine & School of Public Health, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
c BRAC James P Grant School of Public Health, BRAC University, Bangladesh
d World Health Organization, Sri Lanka
e Independent Consultant, India
f Coventry University, UK
∗ Corresponding author. Department of International Health, Johns Hopkins University, USA. kdrao@jhu.edu
20 8 2024
9 2024
20 8 2024
28 1004671 8 2024
1 8 2024
© 2024 The Author(s)
2024
https://creativecommons.org/licenses/by-nc/4.0/ This is an open access article under the CC BY-NC license (http://creativecommons.org/licenses/by-nc/4.0/).
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pmcSouth Asian countries share common bonds of history, culture, religion, demography and health. The region is home to around two billion people or about a fourth of all humanity; changes in population health here will have an impact on a global scale. South Asia has experienced remarkable achievements in health. Since 1990, life expectancy at birth has increased by 10 years and now stands at 72 years; the infant mortality rate declined by 66% and now stands at 30.7 per 1000 live births; the region is close to replacement fertility levels.1 Every country of the region has experienced this demographic transition to varying degrees. These achievements, however, hide the large inequalities between and within countries. The storied health achievement of geographies like Sri Lanka, and the Indian state of Kerala place them closer to high income countries, while health in some other countries in the region is at sub-Saharan levels.1 The demographic transition in South Asia has given rise to a large young working age population that can transform economies of the region–investment in health and human capital is necessary to capitalize on this demographic dividend.

Health systems in South Asia will face many common challenges in the coming decades. The region faces a high dual burden from both communicable and non-communicable diseases. Population aging has begun in several countries. The region is rapidly urbanizing and cities struggle to provide residents, particularly the poor and migrants, with access to basic health services, and to the social determinants of health like safe water, sanitation, clear air, adequate housing, green spaces, and education, among others. Inequalities in health in every country of the region remains an obstinate challenge. The COVID-19 pandemic highlighted how vulnerable health systems in South Asia are to pandemics. Strengtheing the health sector has been a challenge in the region because of historically low levels of public spending on health.

Primary health care (PHC) with its emphasis on integrated health services, community empowerment, and the social determinants of health, offers a cost-efficient way for South Asian countries to address their many health challenges, and health inequities.2, 3, 4 The Series “Primary Health Care in South Asia” aims to take stock of PHC performance in the region and draws attention to the need for orienting health systems towards PHC. This Series offered an opportunity for researchers from the region to learn how countries in the region have addressed common health challenges and build synergies. The Series covers a range of topics that are key for reforming PHC. The first paper provides a comparative assessment of PHC performance in the region; the second paper synthesizes evidence to inform how PHC services can be re-oriented to address non-communicable diseases; the third paper focuses on PHC in the context of urban health; the fourth paper discusses community health worker programs in the region and the future directions for these initiatives; and, the final paper in the Series summarizes key findings from the Series papers and provides recommendations for PHC reform in the region.

There is a pressing need to reform PHC in South Asia to achieve the policy aspiration for universal health coverage. Historically PHC in the region has emphasised maternal and child health, and select infectious diseases. New context relevant PHC models are required to consolidate the gains made and address the health challenges arising from non-communicable diseases, injuries, newly emerging diseases, population ageing, and urbanization. In developing new models it is important to consider the material, human, and fiscal constraints that health systems face; an important reason for the variable success of PHC implementation is the divergence between policy aspirations and the resources available.

The success of South Asian countries in strengthening PHC holds important learnings for countries beyond this region. South Asia has been a pioneer in PHC. Well before the Alma Ata declaration of 1978, countries in the region were implementing aspects of the PHC approach. The region has produced several innovations—Sri Lanka introduced community health workers as early as 1920s5; India’s Bhore Committee report (1946) inspired a publicly financed health system build on the foundations of the PHC approach, and Bangladesh demonstrated the feasibility and effectiveness of civil society participation at scale in the delivery of primary health care services. It is time once again for countries in this region to become pioneers in PHC.

Contributors

KDR drafted the note; SP, SM, KA, SP, SR, MCW reviewed and edited.

Declaration of interests

None declared.
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References

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