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Strengthening the rural primary health care in India: “The community-based nurse-led clinic model”:– A stride toward sustainable development goal 3

1 Department of Psychiatric Nursing, College of Nursing, Pt. B.D. Sharma University of health Sciences, Rohtak, Haryana, India
2 College of Nursing, Bhopal Memorial Hospital and Research Centre, ICMR, Bhopal, Madhya Pradesh, India
3 College of Nursing, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India

Date of Submission29-Mar-2021
Date of Decision17-May-2021
Date of Acceptance31-Jul-2021

Correspondence Address:
Abin Varghese,
College of Nursing, Bhopal Memorial Hospital and Research Centre, ICMR, Bhopal, Madhya Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/mjdrdypu.mjdrdypu_229_21

How to cite this URL:
Joseph J, Varghese A, George G, Vijay V R. Strengthening the rural primary health care in India: “The community-based nurse-led clinic model”:– A stride toward sustainable development goal 3. Med J DY Patil Vidyapeeth [Epub ahead of print] [cited 2022 Dec 7]. Available from: https://www.mjdrdypv.org/preprintarticle.asp?id=339383

Dear Sir,

A major proportion of India's population lives in rural areas. Even after more than 70 years of the Bhore Committee report, health in India remains a luxury and there is a wide range of disparities in the three-tier model of health-care delivery system in the rural areas [Figure 1]. The availability and accessibility of primary health care in rural areas remain a huge challenge, leading to higher out-of-pocket expenditure and there seems no universal solutions.[1] This is further substantiated by indigent health-care outcome indicators from rural areas; maternal mortality ratio (397), infant mortality rate (29), and under 5 mortality rate (50).[2],[3],[4] The broad goal of primary health is to improve the health of rural people by providing optimal public health services efficiently and effectively. There is a need to build a strong comprehensive primary health-care system to reduce the disparities.[5]
Figure 1: Rural health care system in India

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Despite the commitment shown by the government for building up and fortifying primary health care through its numerous lead projects and strategies, a significant hole exists in inciting it from papers to activities. Various reasons can be attributed to the malfunctioning health-care system in rural areas. Lack of quality infrastructure and the critical shortage of health manpower and resources were enduring problems throughout the different decades even after revamping primary health care through the National Rural Health Mission in 2005. People are forced to avail of private health-care facilities due to the unavailability of health-care personnel and diagnostic facilities in the rural community areas, resulting in a higher out-of-pocket expenditure (62.6% in 2015) with a catastrophic economic impact (19.2%).[6] Strengthening the existing primary health-care system in rural areas is more important than the creation of new facilities. Upgradation of the health-care personnel by task sharing to nonphysicians at the grassroot level is a well-proven strategy for making health care more accessible and affordable without compromising quality.[7] Surprisingly, 9.6% of PHCs in India are functioning without an allopathic doctor. Nurses, the largest health-care personnel, can certainly ensure the doorstep delivery of health services. The concept of nurse-led-clinics (NLCs) is a new paradigm shift in the nursing discipline that is unique and diverse from the conventional physician-centered model, emerging from a broad perspective around the world. The available evidence suggests that a community-based nurse-led clinic is a safe and cost-effective strategy to improve the performance of the health-care system.[8] The present article aims to describe a comprehensive and pragmatic public health nursing model for improving and furnishing the rural health-care system in India.

  The Community-based Nurse-led Clinic Model Top

As rural India is facing an acute shortage of physicians, the community-based nurse-led clinic model represents a decentralized and family-centered approach to strengthen the rural primary care setting which is a need of the hour in this dynamic 21st century. The community-based nurse-led clinic is an extension of nursing services to monitor the health status and to deliver the therapeutic interventions within the community setup. The proposed model is conceptualized as pyramid shaped, with a broad “base” in the community at the subcenter level through the community-based nurse-led clinic and telephonic follow-up [Figure 2]. The referral services will operate through primary health centers and tertiary centers. The purpose of the “base” is four-fold: (a) to maximize disease surveillance, (b) to identify and initiate primary treatment, (c) to facilitate access to the services, and (d) to refer patients to either of the two higher levels.
Figure 2: The community-based nurse-led clinic model for strengthening rural primary health care in India

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Scope of the model

As per this model, a trained graduate nurse can lead the community-based clinic and the community level workers such as Accredited Social Health Activists (ASHAs), Multipurpose Health Workers (MPHWs), and others would need to sensitize the public to seek the services during their house visits. The graduate nurse should undergo brief orientation programs and training and they should be taught the basics of early identification and management of common and specific illness as per the general and vulnerable population within the community.

The community-based nurse-led clinic is a decentralized team approach strategy, in which the ASHA workers and MPHW identify the priority health needs by periodic maintenance of family folders. The NLC nurse provides need-based care and services at the family or subcenter setting depending on the nature of the illness and priority. Irrespective of the type of care, adherence to the treatment through direct or telephonic follow-up is considered the prime responsivity of the NLC nurse. The following are the proposed job responsibilities of a community-based nurse-led clinic nurse assumed to perform at the subcenter level.

  1. General clinic:-this is aimed at the management of the most common health-care problems as per the involved community

    1. Primary care management in common health-related issues such as fever, common cold, and vaccination against animal bites
    2. Early identification and prompt management of seasonal diseases such as malaria, chikungunya, and dengue fever
    3. Management of chronic illness such as diabetes and hypertension through screening and referral to treatment services, follow-up care of confirmed cases through regular monitoring

  2. Maternal and child health-care clinic: -immunization for children and pregnant women, antenatal care including iron and folic acid supplementation, nutritional counseling, and management of general ailments such as diarrhea
  3. Mental health and de-addiction clinic: -initial management of psychiatric emergencies through various restraint approaches, early identification, and counseling regarding the management of substance use disorders, follow-up care of those with repeated relapses
  4. Geriatric and palliative care clinic:- need-based care for those requiring hospice services such as management of pain and physical symptoms, care during bowel and bladder dysfunction through tube feeding, urinary catheterization, and colostomy care.

  Strength and Limitations Top

The numbers of students residing in the rural areas who are graduating in nursing are quite higher than medical graduates and they will prefer to work in a rural area if job opportunities are created in their nearby villages. Moreover, integration of middle-level health-care provider courses in the curriculum of BSc Nursing final year and post basic BSc Nursing 2nd year are already recommended and enacted by the Indian Nursing Council and the index model can act as a catalyst for the extension of nursing services in the community setting. However, the optimal outcome of this model purely depends on the quality of training as per the desired accountability.

  Conclusion Top

There is an epidemiological transition in the primary health-care system in rural India with many public health priorities. The existing lacuna in the rural health system suggests the need to move from quantity to quality. Even though the flagship programs announced by the Government of India such as the “Ayushman Bharat and Prime Minister Jan Arogya Yojana” can strengthen the rural primary health care, universal health coverage depends on a fully functional model – “the community-based nurse-led clinic model.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Bhaumik S. Health and beyond. Strategies for a better India: Concept paper on primary health care in India. J Family Med Prim Care 2014;3:94-7.  Back to cited text no. 1
[PUBMED]  [Full text]  
International Institute for Population Sciences (IIPS) and ICF. National Family Health Survey (NFHS-4), 2015-2016. India, Mumbai: IIPS; 2017.  Back to cited text no. 2
Census. Primary Census Abstracts, Registrar General of India, Ministry of Home Affairs, Government of India; 2011. Available from: http://www.censusindia.govin/2011census/PCA/pca_highlights/pe_data. [Last accessed on 2021 Mar 25].  Back to cited text no. 3
Montgomery AL, Ram U, Kumar R, Jha P, Million Death Study Collaborators. Maternal mortality in India: Causes and healthcare service use based on a nationally representative survey. PLoS One 2014;9:e83331.  Back to cited text no. 4
Ramani S, Sivakami M, Gilson L. How context affects implementation of the primary health care approach: An analysis of what happened to primary health centres in India. BMJ Glob Health 2018;3:e001381.  Back to cited text no. 5
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;8:2837-44.  Back to cited text no. 6
[PUBMED]  [Full text]  
Sharma DC. India still struggles with rural doctor shortages. Lancet 2015;386:2381-2.  Back to cited text no. 7
Betihavas V, Crawford T, Currie J, Randall S, River J. Impact of community based nurse-led clinics on patient outcomes, patient satisfaction, patient access and cost effectiveness: A systematic review. Int J Nurs Stud 2017;73:24-33.  Back to cited text no. 8


  [Figure 1], [Figure 2]


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