Tracking the progress of primary care reforms in Kerala India: Findings from a baseline assessment

Abstract The south Indian state of Kerala has a legacy of gains in population health at a low cost. Kerala's recent health reform initiative has emphasized increasing the scope and quality of primary care services. Beginning in 2017, 171 of 848 Primary Health Centres (PHCs) were upgraded to Family Health Centres (FHCs) by increasing staff, training, infrastructure and working hours. In support of this process, we carried out a baseline assessment to assess differences between upgraded FHCs and PHCs We undertook a cross-sectional study in four districts randomly selected from clusters made using data from the latest National Family Health Survey (2015-16). One FHC and PHC per district were randomly chosen. Monitoring indicators were selected through a modified Delphi process; a structured questionnaire was shared with health staff to report data for the financial year 2018-19. The eight facilities jointly served a population of 2,79,992 (60% in FHC). The proportion of average monthly outpatients to the population served was 8.3% in FHCs as against 7.9% in PHCs. The patients screened for high blood pressure and blood sugar in FHCs was nearly double that in PHCs. FHCs were better equipped with patient amenities, laboratory and staff. Coverage indicators like full antenatal care, full immunisation were higher than the national average but not appreciably different in PHCs versus FHCs, nor were health outcomes like low birth weight among infants and acute diarrhoeal diseases among under-fives. Findings were presented to the facility, district and state officials and feedback sought. Primary care reforms in Kerala has improved infrastructure but are still in their early days, reflected in the lack of difference in coverage and outcome indicators. A robust monitoring process benefits from periodic surveys providing valuable insights to the program implementation Key messages Health care reforms in resource poor settings need to be monitored rigorously and constructing a base line data is vital in measuring the change. Primary care reforms in Kerala has improved infrastructure but are still in their early days, reflected in the lack of difference in coverage and outcome indicators.