Abstract: Background: The current situation of Comprehensive Primary Healthcare (CPHC) in India with reference to its characteristics is lesser known. Objectives: 1. To explore various characteristics of research based on CPHC in India. 2. To identify gaps in research on CPHC. Materials and Methods: A broad search strategy was developed to obtain articles on CPHC from PubMed and Google scholar. Out of 218 articles, 17 were explored for objectives, key findings. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) extension for Scoping Reviews (PRISMA-ScR) was used. Results: Most were on reproductive and child health, non-communicable diseases, and utilization & gaps in services. Only one study was randomized controlled trial, followed by mixed method (n=2). Fourteen studies focussed on current situation of CPHC and none on service delivery of CPHC. Conclusion: Limited studies have been conducted on CPHC in India. Significant number of research are needed for strengthening primary health care.
Key Words: Comprehensive Primary Health Care (CPHC); Health and Wellness centres

Introduction:

The National Health Mission (NHM), the country's flagship health systems strengthening program, particularly for primary and secondary health care have a vision of attainment of universal access to equitable, affordable and quality health care which is accountable and responsive to the needs of people.(1) Earlier NHM focused on strengthening Reproductive and child health (RCH) services. While such attention on selective primary health care interventions enabled improvement in major indicators associated with RCH and certain communicable diseases, the range of services delivered at the primary care level did not consider increasing burden of chronic diseases.(2)

To take care of all aspects of health care, the concept of CPHC was launched by GOI (Government of India). For primary health care to be comprehensive, it is a necessity to provide preventive, promotive, curative, rehabilitative, and palliative aspects of care.(3)

The Government of India launched the Ayushman Bharat Yojana- Health and Wellness Centres (AB-HWCs) in 2018 to provide Universal Health Coverage (UHC) and CPHC for addressing the epidemiological transition, to improve the utilization of severely under-utilized public health facilities and to reduce out-of-pocket expenditure, henceforth ensuring continuum of care near the residence of beneficiaries or within a reach of 30 minutes. In regard to this, existing Sub-Health Centers (SHCs) & Primary Health Centers (PHCs) are being transformed as AB-HWCs for providing 12 essential service packages catering all the primary health care needs.(4) CPHC is still in its developmental stage in India, hence limited is known regarding research conducted in this domain. Multiple and broad research are required to provide feedback for existing policies and to implement various innovations which can further enhance the effective delivery of health care through CPHCs. To understand the gaps and lacunae in areas of existing literature related to CPHCs in India, this scoping review was thought to be necessary.

Materials and Methods

In order to understand the current status of research being conducted in India, a scoping review of articles on CPHC was done. This was done by systematically using the keywords such as Comprehensive Primary Health Care (CPHC) and India and Boolean operators OR and AND (("comprehensive primary health care") AND "India") and the timeline selected was last 5 years, i.e., 2017-2021. Articles published on CPHC in PubMed Indexed Journals and Google scholar were included in the study. PubMed database and Google scholar were assumed to be more comprehensive for the search of high-quality articles from a well-defined set of journals. PubMed uses Medical Subject Headings (MeSH) vocabulary which offers controlled searching mechanisms. It offers more features that allow the user to narrow down the retrieval of articles from clearly identified source, when there is information overload in an online environment.(5)

Inclusion and exclusion criteria: Original articles based on data on CPHC conducted in India and published on indexed journals were included. Articles published on CPHC which are either viewpoints/general discussion or based on secondary data were excluded. Also, studies conducted outside India were excluded.

Data Collection and Analysis
The various research mentioned in this review were explored using a scoping review guide by Arksey and O' Malley five stage methodological framework.(6)

At the inception phase, the finalization of the research question was done based on articles published on CPHC in Indexed journals.

In the second step, a comprehensive search strategy was developed for 2 electronic citation databases, Pubmed and Google scholar using the keywords and Boolean operators to obtain maximum articles from 2017 and onwards with the assumption that these databases index the journals of good quality.

In the third step, as per the eligibility, articles which were evidence-based, were selected and viewpoints/ general discussion on this topic were excluded.

Further, in fourth step, characteristics such as year of publication, objectives, type and setting, sample size, study participants, and key findings in the study were reviewed.

Finally, in the fifth step, all articles were summarized, and frequency analysis was done. Analysis was done by three investigators & any discrepancy between them was resolved by mutual discussion. This scoping review was reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) extension for Scoping Reviews (PRISMA-ScR) as shown in the Figure 1.(7,8)

Ethical Clearance
Ethical clearance was taken from the Institutional Ethics Committee for further proceedings. (IEC No.: EC/BU/2022/Ex.05/24/2022). 

Figure 1: Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) for scoping reviews flow diagram of the search and study selection process

Results

This review was done on the articles published from 2017 onwards till 2022 (5 years period). The reason of defining this timeline was that not much was thought on CPHC before 2017 as per our search findings. Total 218 articles were found on PubMed database and 81 articles were found on Google scholar relevant for this scoping review. Both the databases were compared, and 52 duplicates were removed. Total 247 articles were screened and 211 were removed from the selection criteria based on eligibility.

Out of 17 articles reviewed, 3 were conducted in 2017(9-11) followed by 5 each in 2019 (12-16) and 2020 (17-21) and 4 in 2021 (22-25). As the CPHC programme was implemented in the year 2018, there was a rise in publication during this time period.

Maximum number of studies (n=6) were conducted in west zone of the country (9,10,12,14,17,21) followed by north (15,18,22,25) and south (11,13,16,20) zone each (n=4).

It was found that out of 17 studies, only 2 studies were mixed method (13,18) studies whereas most of the studies (n=5) were quantitative (11,15,19,23,25) and others were qualitative (12,16,20) followed by analysis of secondary data (9,17,21,22,24,26) and randomized controlled trial. (14)

It was also seen that the major focus of study participants were health care workers (n=8) (14-17,20,21,23,25) followed by community members, patients (n=5) (11-13,18,19) and others.

As per the analysis, it was found that 14(9,12,13,15-17,19-26) out of total 17 studies focussed on evaluating the current situation of the CPHC and only 3(10,13,17) studies were conducted on innovations. None of the studies were conducted to study the service delivery of CPHC.

Discussion

Current situation of CPHC in India has been evaluated in few previous studies as well but only a handful focused on new interventional aspects for better service delivery. Only a few of these studies were focused on implementation of innovative digital technologies viz. early implementation of TeCHO+ (Technology for Community Health Operations) program of Gujarat (17); integrated health information system for primary health care.(15) Other studies mainly focused on human resources, infrastructure provision of few specific services. (12,23)

Despite a plethora of articles published on CPHC worldwide, (27-33) India lags behind the research published on CPHC where it is recently conceptualized and rolled-out. The broad areas covered were Maternal and Child health (MCH), Non-communicable diseases and gaps in the utilization of the services by the community members. We were unable to find any studies related to CPHC service delivery.

Conclusion

The CPHC concept is in its developmental stage in India and other lower middle-income countries (LMICs) in comparison to its western counterparts although the need is extremely high in LMICs. It is a high time that policy makers, stakeholders and researchers focus on ideas to explore context specific innovative interventions for improvement of service delivery for CPHC. Hence, more research is required on all the 12 essential service delivery packages encapsulated under the umbrella programme of CPHC with more focus on context specific innovations in service delivery. The current review will thus offer a focused direction for future research. This study provides an idea about the characteristics and gaps in the studies that are being conducted for CPHC hence providing the researcher an insight about the context specific areas to be explored in future related to CPHC in India.

Limitations

The search strategy used was broad, however there is a possibility that the appropriate studies may have been missed. We might have also missed articles indexed on other databases. 

References

1. Ministry of Health and Family Welfare, India. Ayushman Bharat - Health and Wellness Centre. MoHFW. Available from: https://ab-hwc.nhp.gov.in/#about
2. Ministry of Health and Family Welfare, India. National Health Mission. Available from: https://www.nhm.gov.in/
3. WHO. Universal health coverage (UHC). Available from: https://www.who.int/news-room/fact-sheets/detail/universal-health-coverage-(uhc)
4. National Health Systems Resource Centre. Ayushman Bharat - Comprehensive Primary Health Care through Health and Wellness Centers Operational Guidelines. Available at https://www.nhm.gov.in/New_Updates_2018/NHM_Components/Health_System_Stregthening/Comprehensive_primary_health_care/letter/Operational_Guidelines_For_CPHC.pdf
5. Shultz M. Comparing test searches in PubMed and Google Scholar. Journal of the Medical Library Association. 2007;95(4):442-5.
6. Arksey H, O'Malley L. Scoping studies: towards a methodological framework.  https://doi.org/101080/1364557032000119616. 2007 Feb;8(1):19-32.
7. Rahimi SA, Légaré F, Sharma G, Archambault P, Zomahoun HTV, Chandavong S, et al. Application of Artificial Intelligence in Community-Based Primary Health Care: Systematic Scoping Review and Critical Appraisal. J Med Internet Res. 2021 Sep 1;23(9).
8. PRISMA. Available from: http://www.prisma-statement.org/Extensions/ScopingReviews
9. Perry HB, Rassekh BM, Gupta S, Freeman PA. Comprehensive review of the evidence regarding the effectiveness of community-based primary health care in improving maternal, neonatal and child health: 7. shared characteristics of projects with evidence of long-term mortality impact. J Glob Health. 2017;7(1).
10. Black RE, Taylor CE, Arole S, Bang A, Bhutta ZA, Chowdhury AMR, et al. Comprehensive review of the evidence regarding the effectiveness of community-based primary health care in improving maternal, neonatal and child health: 8. summary and recommendations of the Expert Panel. J Glob Health. 2017;7(1).
11. Jayaram G, Goud R, Srinivasan K. Overcoming cultural barriers to deliver comprehensive rural community mental health care in Southern India. Asian J Psychiatr. 2011 Dec 1;4(4):261-5.
12. Ramani S, Sivakami M. Community perspectives on primary health centers in rural Maharashtra: What can we learn for policy? J Family Med Prim Care. 2019;8(9):2837.
13. Jayanna K, Swaroop N, Kar A, Ramanaik S, Pati MK, Pujar A, et al. Designing a comprehensive Non-Communicable Diseases (NCD) programme for hypertension and diabetes at primary health care level: evidence and experience from urban Karnataka, South India. BMC Public Health. 2019 Apr 16;19(1).
14. Patel AB, Kuhite PN, Alam A, Pusdekar Y, Puranik A, Khan SS, et al. M-SAKHI-Mobile health solutions to help community providers promote maternal and infant nutrition and health using a community-based cluster randomized controlled trial in rural India: A study protocol. Matern Child Nutr. 2019 Oct 1;15(4).
15. Faujdar D, Sahay S, Singh T, Jindal H, Kumar R. Public health information systems for primary health care in India: A situational analysis study. J Family Med Prim Care. 2019;8(11):3640.
16. Abdel-All M, Abimbola S, Praveen D, Joshi R. What do Accredited Social Health Activists need to provide comprehensive care that incorporates non-communicable diseases? Findings from a qualitative study in Andhra Pradesh, India. Hum Resour Health. 2019 Oct 22;17(1).
17. Saha S, Kotwani P, Pandya A, Patel C, Shah K, Saxena D, et al. Addressing comprehensive primary healthcare in Gujarat through mHealth intervention: Early implementation experience with TeCHO+ programme. J Family Med Prim Care. 2020;9(1):340.
18. Faujdar DS, Sahay S, Singh T, Kaur M, Kumar R. Field testing of a digital health information system for primary health care: A quasi-experimental study from India. Int J Med Inform. 2020 Sep 1;141.
19. Pati S, Swain S, Knottnerus JA, Metsemakers JFM, Van Den Akker M. Magnitude and determinants of multimorbidity and health care utilization among patients attending public versus private primary care: a cross-sectional study from Odisha, India. Int J Equity Health. 2020 Apr 29;19(1).
20. Nambiar D, Hari Sankar D, Negi J, Nair A, Sadanandan R. Monitoring Universal Health Coverage reforms in primary health care facilities: Creating a framework, selecting and field-testing indicators in Kerala, India. PLoS One. 2020 Aug 1;15(8).
21. Amin A, Dutta M, Brahmawar Mohan S, Mohan P. Pathways to Enable Primary Healthcare Nurses in Providing Comprehensive Primary Healthcare to Rural, Tribal Communities in Rajasthan, India. Front Public Health. 2020 Nov 27;8.
22. Singh D, Prinja S, Bahuguna P, Chauhan AS, Guinness L, Sharma S, et al. Cost of scaling-up comprehensive primary health care in India: Implications for universal health coverage. Health Policy Plan. 2021 May 1;36(4):407-17.
23. Goswami P, Chakraborty A, Das DK, Ray S. Gap Analysis in Workforce and Infrastructure in the Subcenters for Upgradation to Health and Wellness Center in a Community Development Block of Purba Bardhaman District, West Bengal. Indian J Community Med. 2021 Apr 1;46(2):300-3.
24. Swain S, Preetha G, Kumar S, Aggarwal D, Kumar R, Kumar S. Human Resources for Health in India: Need to go Beyond Numbers. Indian J Community Med. 2020;45(3):266.
25. Brar S, Purohit N, Prinja S, Singh G, Bahuguna P, Kaur M. What and how much do the community health officers and auxiliary nurse midwives do in health and wellness centres in a block in Punjab? A time-motion study. Indian J Public Health. 2021 Jul 1;65(3):275-9.
26. Perry HB, Rassekh BM, Gupta S, Wilhelm J, Freeman PA. Comprehensive review of the evidence regarding the effectiveness of community-based primary health care in improving maternal, neonatal and child health: 1. rationale, methods and database description. J Glob Health. 2017;7(1).
27. Freeman T, Baum F, Lawless A, Labonté R, Sanders D, Boffa J, Edwards T, Javanparast S. Case Study of an Aboriginal Community-Controlled Health Service in Australia: Universal, Rights-Based, Publicly Funded Comprehensive Primary Health Care in Action. Health Hum Rights. 2016 Dec;18(2):93-108. Available from: https://pubmed.ncbi.nlm.nih.gov/28559679/
28. Baum F, Freeman T, Lawless A, Labonte R, Sanders D. What is the difference between comprehensive and selective primary health care? Evidence from a five-year longitudinal realist case study in South Australia. BMJ Open. 2017 Apr 1;7(4):e015271.
29. Costello M, Taylor J, O'Hara L. Impact evaluation of a health promotion-focused organisational development strategy on a health service's capacity to deliver comprehensive primary health care. Aust J Prim Health. 2015;21(4):444-9.
30. Bentley M, Freeman T, Baum F, Javanparast S. Interprofessional teamwork in comprehensive primary healthcare services: Findings from a mixed methods study. Journal of Interprofessional Care. 2018;32(3):274-283. DOI: 10.1080/13561820.2017.1401986.
31. Lin MP, MacDonald LQ, Jin J, Reddy A. Association between care delivery interventions to enhance access and patients' perceived access in the Comprehensive Primary Care Initiative. Healthc (Amst). 2020 Jun;8(2):100412. doi: 10.1016/j.hjdsi.2020.100412.
32. Reddy A, Sessums L, Gupta R, Jin J, Day T, Finke B, et al. Risk Stratification Methods and Provision of Care Management Services in Comprehensive Primary Care Initiative Practices. Ann Fam Med. 2017;15(5):451-4.
33. Johnston S, Hogel M, Burchell AN, Rebick G, Antoniou T, McLaren M, et al. Developing a performance framework for measuring comprehensive, community-based primary healthcare for people with HIV. Prim Health Care Res Dev. 2016 Jan 7;17(4):361-84.