Challenges in India’s Primary Health Care System and How to Address Them

India’s primary health care system is the bedrock of public health for more than a billion people, yet it continues to grapple with deep-rooted gaps that prevent quality care from reaching every village and slum. From overburdened sub-centres to widespread nutritional deficiencies, the system reflects both impressive progress and persistent shortcomings. Understanding these deficiencies is the first step toward building a healthier, more equitable future.

Why primary health care matters
Health education gaps
Why awareness is low
The cost of poor health literacy
Nutritional deficiencies
The triple burden among children and mothers
Why nutrition programmes fall short
Inadequate sanitation and water supply
The disease toll
Sanitation beyond toilets
Maternal and child health shortcomings
Rural-urban and regional disparities
Where the system slips
Cross-cutting weaknesses in the system
How to address these challenges

Why primary health care matters

Primary health care is the first point of contact between people and the health system. It includes preventive care, basic curative services, maternal and child health, immunisation, nutrition counselling, and health education. According to the Indian Public Health Standards framework, sub-centres, Primary Health Centres (PHCs), and Community Health Centres (CHCs) form the three-tier backbone of rural health delivery. When this network works well, hospitals are not overwhelmed and diseases are caught early. When it fails, the burden falls disproportionately on the poor.

Despite decades of reforms through the National Health Mission and now Ayushman Bharat, several structural deficiencies continue to weaken the system. Four of the most pressing are gaps in health education, widespread nutritional deficiencies, inadequate sanitation and water supply, and shortcomings in maternal and child health services.

Health education gaps

Public awareness about hygiene, immunisation, family planning, non-communicable diseases, and mental health remains uneven, especially in rural areas. A study published in the National Library of Medicine notes that the utilisation of health services is highly dependent on residence and educational level, with around 70% of illiterate women availing no antenatal care compared with a much smaller share of literate women. This single statistic shows how literacy and health behaviour are tightly linked.

Why awareness is low

Several factors drive this gap. Many rural households are first-generation literates with limited exposure to scientifically accurate health information. Folk beliefs and traditional remedies often take precedence over modern medicine, and cultural and traditional beliefs can delay people from seeking timely medical care. Frontline workers like ASHAs and Anganwadi workers carry an enormous workload, which limits the time they can spend educating individual families.

The cost of poor health literacy

When people do not recognise warning signs of diseases like tuberculosis, diabetes, or hypertension, they seek care late, when complications are harder and costlier to treat. Poor awareness also fuels vaccine hesitancy, misuse of antibiotics, and delayed screening for cancers. Health education is not a one-time event but a continuous process that needs to be embedded in schools, panchayats, self-help groups, and digital platforms.

Nutritional deficiencies

Nutrition is the foundation of health, yet malnutrition continues to haunt large sections of the population. The National Family Health Survey-5 (2019-21) shows that 35.5% of children under five are stunted, 19.3% are wasted, and 32.1% are underweight. These are improvements over NFHS-4, but the absolute numbers remain staggering.

The triple burden among children and mothers

The picture worsens when we look at micronutrient deficiencies. The United Nations’ 2025 State of Food Security and Nutrition in the World report flagged that India had the highest rate of child wasting globally at 18.7%, with more than 21 million children affected. Anaemia is equally alarming, with more than half of Indian women aged 15-49 suffering from it and prevalence among children crossing 67%, as captured in NFHS-5 analyses on mother-child malnutrition pairs.

Why nutrition programmes fall short

India runs some of the world’s largest nutrition schemes, including the Integrated Child Development Services (ICDS), POSHAN Abhiyaan, the Mid-Day Meal scheme, and Anemia Mukt Bharat. Yet challenges persist. Anganwadi centres often lack adequate infrastructure, take-home rations may not reach the most vulnerable, and counselling on dietary diversity is limited. Poverty, low maternal education, and food inflation make balanced diets unaffordable for many families.

Community-based nutrition programmes need to be strengthened with locally available foods, kitchen gardens, fortification of staples, and continuous behaviour change communication. Linking nutrition counselling with antenatal care, immunisation visits, and school health programmes can multiply impact.

Inadequate sanitation and water supply

Safe water and proper sanitation are non-negotiable for primary prevention, yet these basics remain unevenly distributed. WaterAid estimates that around 37.7 million Indians are affected by waterborne diseases each year, with 73 million working days lost and an economic burden of roughly USD 600 million annually. UNICEF notes that groundwater from over 30 million access points supplies about 85% of rural drinking water, but this source is increasingly contaminated and over-extracted.

The disease toll

Diarrhoea remains a leading killer of children under five. Cholera, typhoid, hepatitis A and E, and parasitic infections continue to occur in waves, particularly during monsoons. Chemical contaminants like fluoride, arsenic, and excess iron affect millions of habitations, leading to dental and skeletal fluorosis, skin lesions, and long-term toxicity. The Jal Jeevan Mission has expanded tap water coverage significantly, but quality monitoring, last-mile maintenance, and source sustainability remain weak.

Sanitation beyond toilets

The Swachh Bharat Mission added millions of toilets across the country, but behaviour change has lagged in some districts. A study on water and sanitation practices in open-defecation-free villages of North India found that 57.2% of respondents reported a family member having suffered from a waterborne disease in the preceding year, even after ODF status was declared. This highlights how toilet construction alone is insufficient. Faecal sludge management, safe disposal of greywater, menstrual hygiene, and food hygiene all need integrated attention.

Maternal and child health shortcomings

Maternal and child health is the area where primary care can save the most lives, and India has made remarkable progress here, but gaps remain. According to the Sample Registration System data shared by the Ministry of Health and Family Welfare, the Maternal Mortality Ratio declined from 130 in 2014-16 to 97 in 2018-20 per lakh live births, and the Infant Mortality Rate fell from 39 in 2014 to 28 per 1000 live births in 2020. While this is significant progress, the country still has miles to go before reaching the Sustainable Development Goal target of an MMR under 70 by 2030.

Rural-urban and regional disparities

According to publicly available SRS analyses, the rural IMR stood at 28 in 2023 compared with 18 in urban areas, and states like Madhya Pradesh, Uttar Pradesh, and Assam continue to lag behind Kerala and Tamil Nadu. In the poorest rural households, around 15% of pregnant women still do not receive any antenatal care, and over a quarter continue to have home births. These disparities reflect uneven access to skilled birth attendants, emergency obstetric care, and well-equipped delivery points.

Where the system slips

Neonatal mortality, which now accounts for nearly three-quarters of infant deaths, is closely linked to gaps in antenatal screening, anaemia management, skilled care at birth, and newborn care units. A study on antenatal and delivery care in rural India found that consuming the recommended number of iron-and-folic-acid tablets during pregnancy had a protective effect against both maternal and infant mortality, while deliveries by untrained personnel raised the risk of maternal death. Adolescent pregnancies, short birth intervals, and undernutrition among mothers compound these risks.

Cross-cutting weaknesses in the system

Beyond these four areas, several cross-cutting deficiencies weaken primary care delivery. There is a chronic shortage of trained personnel. The Lancet Regional Health-Southeast Asia notes a shortfall of around 79.9% of specialists at community health centres compared with the required numbers. Many sub-centres lack regular supplies, diagnostic equipment, and even electricity. Health workers posted to remote areas often face poor housing, limited schooling for their children, and professional isolation, which fuels absenteeism and high turnover.

Out-of-pocket expenditure on health remains high, pushing millions of families into poverty every year. Referral systems are weak, so patients often bypass PHCs and head straight to overcrowded district hospitals or unregulated private clinics. Data systems for tracking diseases, deaths, and service quality are improving but remain fragmented at the periphery.

How to address these challenges

Solutions need to work on people, infrastructure, and governance together. First, strengthen the health workforce by recruiting and retaining doctors, nurses, ANMs, and ASHAs through better pay, housing, career growth, and respectful work environments. Family medicine training and a dedicated public health cadre, as argued in academic discussions on primary healthcare evolution in India, can restore community confidence in PHCs.

Second, upgrade infrastructure at sub-centres and PHCs into Health and Wellness Centres under Ayushman Bharat, with continuous power, telemedicine links, point-of-care diagnostics, and reliable drug supplies. Third, invest in convergence between health, nutrition, water, sanitation, education, and women’s empowerment, because no single sector can fix malnutrition or maternal mortality alone.

Fourth, empower communities through Village Health, Sanitation and Nutrition Committees, Mahila Arogya Samitis, and self-help groups so that local people own their health outcomes. Fifth, use technology wisely through tools like the Ayushman Bharat Digital Mission, e-Sanjeevani telemedicine, and mobile-based decision support for frontline workers. Finally, increase public spending on health closer to the National Health Policy target of 2.5% of GDP, so that primary care is genuinely strengthened rather than starved.

What do you think? If you had to choose one deficiency in India’s primary health care system to fix first, which would it be and why? And how do you think your own community can contribute to bridging the gap between policy on paper and care on the ground?

References

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Challenges in India’s Primary Health Care System and How to Address Them

Table of Contents

Why primary health care matters 🔗

Health education gaps 🔗

Why awareness is low 🔗

The cost of poor health literacy 🔗

Nutritional deficiencies 🔗

The triple burden among children and mothers 🔗

Why nutrition programmes fall short 🔗

Inadequate sanitation and water supply 🔗

The disease toll 🔗

Sanitation beyond toilets 🔗

Maternal and child health shortcomings 🔗

Rural-urban and regional disparities 🔗

Where the system slips 🔗

Cross-cutting weaknesses in the system 🔗

How to address these challenges 🔗