Column | Sustained Investment In Primary Health Care Will Strengthen Our Republic: Randeep Guleria

There are patients whose stories stay with you long after the consultation has ended. One such story has repeated itself countless times over the course of my career. A family arrives at a tertiary-care hospital in Delhi after travelling hundreds, sometimes thousands, of kilometres. They have spent days on trains or buses, exhausted their savings, left behind work, children and elderly parents, all in the hope that the treatment available in Delhi will offer a second chance. As physicians, we do everything possible for them. Yet, I have often found myself asking a difficult question: did they really need to travel all this way to receive the care they needed?

For many of these patients, the answer is no. They did not need the most advanced tertiary intervention. They needed timely diagnosis, a well-equipped district hospital, a trained specialist, a functioning intensive-care unit, reliable diagnostics and the confidence that quality care was available close to home. Their long journey was often not a medical necessity, but a reflection of the uneven distribution of health care in our country. The future of Indian health care will not be defined solely by the number of world-class hospitals in metropolitan cities, but by the quality of care available in every district, town and village.

India’s health-care story over the past decade has been remarkable. We have expanded health insurance, strengthened disease surveillance, built new All India Institutes of Medical Sciences (AIIMSes) and other medical colleges, accelerated digital health initiatives, improved vaccination coverage and demonstrated during the Covid pandemic that the country can mobilise its health-care system at an unprecedented scale. These achievements deserve recognition. But they should also encourage us to ask a more relevant question: what should the next phase of India’s health-care transformation look like?

The next chapter of India’s health-care journey lies in bringing quality health care closer to where people live. It is about strengthening health care systems across districts, towns and villages, ensuring that every citizen has timely access to high-quality care, irrespective of geography. Advances in digital health, telemedicine, diagnostics and workforce innovations provide us an unprecedented opportunity to overcome many barriers and leapfrog to the next level.

For decades, our health care system has evolved around a few centres of excellence. Institutions such as AIIMS have become symbols of clinical excellence, research and medical education. While this model has served the country well, it has also created a perception that good health care exists only in a handful of cities. Consequently, many patients travel directly to tertiary hospitals, even for conditions that could have been managed closer to home. This not only places avoidable pressure on these institutions, but also blurs their primary role. Tertiary hospitals are meant to provide highly specialised care through an effective referral system, not serve as the first point of care for the majority of patients.

However, the solution does not lie simply in constructing more hospital buildings. Health care infrastructure is far more than bricks and mortar. A modern hospital without trained doctors, nurses, technicians, biomedical engineers, laboratory support, essential medicines and standard treatment protocols is only a building. The true strength of a health care institution lies in its people and in the systems that enable them to deliver consistent, evidence-based care and this remains India’s biggest challenge.

Over the years, India has made significant progress in increasing undergraduate and postgraduate medical seats. This is encouraging, but numbers alone will not solve the problem. We must ensure that specialists are available across the country and that they have both professional opportunities and adequate support to practise outside metropolitan centres. Career progression, academic opportunities, research support, continuing medical education and quality of life influence where health care professionals choose to work.

Strengthening district hospitals and teaching institutes should therefore become a national priority. Every district hospital should be capable of managing common medical emergencies, maternal and child health, trauma, infectious diseases and the growing burden of non-communicable diseases. These hospitals should also serve as centres for training, mentoring and continuous professional development.

Digital Outreach

Medical education itself must evolve to support this vision. Future doctors should be trained not only in highly specialised tertiary care settings but also in district hospitals and community health systems, where they encounter the realities of health care delivery in India. Exposure to resource-appropriate decision-making, preventive health care and multidisciplinary teamwork will prepare young physicians to serve diverse populations more effectively.

While skilled health care professionals remain the cornerstone of every health-care system, technology can extend their reach in ways that were unimaginable just a few years ago. The rapid expansion of telemedicine during the Covid pandemic demonstrated that geography need not always be a barrier to expert consultation. Digital platforms have the potential to become one of the greatest equalisers in health care, provided they are used wisely. A physician sitting in a metropolitan city can today review investigations, guide treatment and support colleagues hundreds of kilometres away. Digital platforms can facilitate specialist consultations, follow-up care, chronic disease management and continuing medical education.

Technology, however, cannot by itself correct structural deficiencies in health care. Digital platforms are only as effective as the health system they support. A remote consultation has little value if essential medicines are unavailable, investigations cannot be performed or trained personnel are absent. The objective should therefore not be to replace health care delivery through technology, but to strengthen it. One model that deserves greater emphasis is the hub-and-spoke approach. Large tertiary institutions should function as knowledge hubs, continuously supporting peripheral hospitals through teleconsultations, shared treatment protocols, multidisciplinary discussions and structured referral pathways. Such a system allows expertise to travel even when patients do not have to.

Such an interconnected health care system is also well suited to the changing health needs of the country. While infectious diseases remain an important public health challenge, non-communicable diseases such as diabetes, hypertension, cardiovascular disease, chronic respiratory illnesses and cancer now account for a growing share of the disease burden.

These conditions require continuity of care, regular monitoring and early intervention—services that are best delivered close to where people live rather than relying primarily on tertiary hospitals. This makes prevention even more important. Investments in vaccination across the life course, early screening, tobacco control, nutrition, physical activity and health education not only improve health outcomes, but also reduce the long-term burden on the healthcare system.

India has repeatedly demonstrated that sustained public-health programmes can achieve remarkable results. The success of childhood immunisation, disease control initiatives and large-scale vaccination campaigns reflects the country’s ability to deliver preventive healthcare at scale. Building on these achievements, the next step is to strengthen adult vaccination, expand screening programmes for non-communicable diseases and integrate preventive health services more effectively into routine care, particularly for vulnerable groups such as the elderly and those living with chronic illnesses.

The greatest strength of public health is that its successes are often measured by what does not happen. Outbreaks are prevented, diseases are detected before they become advanced and chronic illnesses are managed before complications arise. These achievements may not always attract public attention, but they improve the quality of life, reduce health care costs and lessen the long-term burden on hospitals.

The Covid pandemic reinforced another important lesson: strong public-health systems cannot be created in the midst of a crisis. India’s response demonstrated the value of coordinated action across governments, health care institutions, scientists and frontline workers. It also underscored that health cannot be viewed in isolation. Air pollution, climate change, antimicrobial resistance, emerging infections and changing lifestyles increasingly shape health outcomes.

Strong Governance

The concept of ‘One Health’, which recognises the interconnectedness of human, animal and environmental health, has therefore moved from being an academic framework to an operational necessity. Strengthening surveillance systems, promoting rational antibiotic use and building preparedness for future health threats will require sustained collaboration across multiple sectors.

Such coordination is possible only when these initiatives are supported by strong governance. Health care systems depend not only on skilled professionals and modern infrastructure, but also on clear standards, accountability and effective coordination. Standard treatment protocols, continuous quality improvement, accreditation and robust health information systems help ensure that the quality of care remains consistent across the country. A patient should receive the same evidence-based standard of care, irrespective of whether they seek treatment in a metropolitan hospital or a district healthcare facility. Building that confidence in the health care system is as important as expanding its reach.

As we celebrate India’s journey as an independent nation, we should remember that the strength of a republic is reflected not only in its economic progress or scientific achievements, but also in how it cares for its people. Health care is perhaps the most visible expression of that commitment. It is therefore imperative that we develop a model where every citizen can receive quality care within a reasonable distance from home, with seamless referral to higher centre when required. This requires sustained investment in primary care, empowered district hospitals, integrated referral networks, robust health financing and community participation. The day a family no longer feels compelled to travel hundreds of kilometres because they trust the health care available in their own district, we will know that we have truly transformed health care in India. That would not merely be a public health achievement, it would be a fulfilment of one of the Republic’s most enduring promises: that every citizen, regardless of geography, has an equal claim to dignity, opportunity and hope.

(Views expressed are personal)

Randeep Guleria Former Director, AIIMS, Delhi

(This story appeared in Outlook magazine’s August 31 issue, 'Whose Idea of India?', in which India’s noted public intellectuals, policymakers, cultural practitioners, political leaders, scholars and economists write in detail about the idea of India they believe can best secure the nation’s future as we celebrate 80 years of independence.)