Intended for healthcare professionals

Analysis Health in South Asia

Tackling the primary care access challenge in South Asia

BMJ 2018; 363 doi: (Published 29 November 2018) Cite this as: BMJ 2018;363:k4878
  1. Amit Sengupta, associate global coordinator1,
  2. Shehla Zaidi, associate professor and head2,
  3. T Sundararaman, professor3,
  4. Sharad Onta, professor4,
  5. Manuj C Weerasinghe, senior lecturer5
  1. 1People’s Health Movement, New Delhi, India
  2. 2School of Health Policy and Management Unit, Aga Khan University, Karachi, Pakistan
  3. 3School of Health Systems Studies, Tata Institute of Social Sciences, Mumbai, India
  4. 4Department of Community Medicine and Public Health, Institute of Medicine, Tribhuvan University, Kathmandu, Nepal
  5. 5Department of Community Medicine, University of Colombo, Sri Lanka
  1.  Correspondence to: A Sengupta asengupta{at}

Increased public financing for primary care and medical education as well as regulation of private services are vital to tackle the primary care crisis in South Asia, argue Amit Sengupta and colleagues

Key messages

  • Poor investment and shortages in the health workforce underpin the fragility of primary healthcare in South Asia

  • Private providers are heavily relied on for primary care, albeit with little regulation of costs and quality of care

  • Tackling the primary care crisis requires substantial increases in public provision and financing of primary care, medical education, and health worker training, and regulation of privately provided primary care services

Well designed and accessible primary care reduces the need for hospital based care and contributes to better overall health. Despite a large network of primary care facilities, large sections of the population in South Asia lack access to reliable and effective primary care. This is reflected in poor health indicators across the region.1 The 2015 Human Development Report found that five of six South Asian nations (India, Nepal, Bangladesh, Pakistan, and Afghanistan) have higher mortality rates among under 5s and adults, greater prevalence of child malnutrition, higher mortality rates from tuberculosis, and lower life expectancy at 60 years compared with the global average.2 Deficiencies in public funded primary health services have contributed to rapid expansion of private providers in the region. The growth of the private sector has largely been determined by market forces with minimal oversight and regulation, and there are concerns about both the quality and the cost of care. In this paper we reflect on the challenges of primary care in the region, the opportunities it poses, and the implications for public policy.

Challenges of primary care in South Asia

Lack of investment

Health policy in the region has been profoundly influenced by the 1978 Alma Ata declaration, which recognised primary care as the “central function and …

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