In January, the World Health Organization (WHO) published a report calling for compassion in primary healthcare systems. “Compassion — characterised by awareness, empathy and action — is identified as a transformative force for PHC, driving quality care and health system transformation,” the report read. “Compassionate primary healthcare means being responsive, adapting to the community’s needs, and also includes a focus on quality, through training, audits, hand-holding and on-job support,” says Sanjana Brahmawar Mohan, physician and co-founder of Udaipur-based non-profit Basic Health Services (BHS).
India has an extensive primary healthcare system. There are sub-centres in remote areas serving 3,000-5,000 people, primary health centres (PHCs) serving 20,000-30,000 people, and community health centres (CHCs) for 80,000-1,20,000 people. In all, there are 1.6 lakh sub-centres; 26,636 PHCs; and 6,155 CHCs,according to the National Health Mission.
Let’s take a close at three instances of compassion in health systems — one each in a rural, an urban, and a tribal area. In these examples, are lessons for the rest of the country. They provide a sense of grounding, showing the importance of prioritising certain aspects at all times, but especially in a crisis, and call for the display of courage to carry forward.
Clinical courage in Rajasthan
Vidith Panchal, a physician, sees hundreds of patients at Ravaj, a remote village in the tribal belt of Udaipur district. The PHC, called an Amrit clinic, is run by BHS. There are six such clinics serving close to 90,000 people in southern Rajasthan. Primary healthcare should connect with communities and understand their problems and their priorities, he says: “But [most] primary healthcare [services] in India lack that conversation with communities. That’s the basic flaw.”
Dr. Mohan wrote in a 2022 article in BMJ GH Blogs, “In India, a physician working at a PHC is entrusted with managing over 40 national health programs, the operations of the PHC and 5-6 sub centres, attending and conducting various trainings and meetings, and documentation and reporting, in addition to seeing patients at the PHC.” Compassionate care is often difficult to provide in this setting.
Dr. Panchal gave the example of Tukaram (name changed), a 22-year-old who had had tuberculosis for nearly a decade. When Tukaram came to Dr. Panchal, he could barely walk and he weighed only 23 kg. Dr. Panchal had seen hundreds of such patients across Rajasthan’s PHCs, often in the mining districts. In 2023, India had a record 28 lakh TB cases, with 3 lakh deaths. Tukaram had also worked in mines for nearly a decade. His treatment across three States had resulted in no improvement. He had relapsed twice.
Physicians at PHCs usually refer such patients to a CHC or a district hospital. But this is usually 50-70 km away, Dr. Mohan said. The reasons for referral may be poor infrastructure, lack of lifesaving drugs, patient safety, medico-legal consequences, risk of community transmission or even evidence-based medicine. But compassionate care in this case might warrant managing the patient at the PHC. Dr. Panchal knew that referring Tukaram to a CHC or higher centre would only drain his health and pocket; so he made sure Tukaram’s family wasn’t exposed to TB and gave the young man access to pain relief medicines through his final months.
Dr. Mohan called Dr. Panchal’s decision to put the patient’s needs at the centre, “clinical courage”. In the BMJ GH Blogs article, she wrote that administrative and clinical workload, support from reporting officers, support for clinical guidance, and capacity for support staff can build such courage and foster compassionate care. In Rajasthan, this can mean having community health workers accompany patients to referrals, especially when there are no family members; raising awareness of national programmes for TB and silicosis; ensuring diagnostics and drugs are accessible; making home visits and negotiating with families and patients; and so on.
The Amrit clinics have thus seen a rise in footfall: from around 40,000 patients in 2021 to 51,930 in 2024. The vast majority are members of Scheduled Tribes.
Dr. Mohan says that while compassion is central to the way BHS works, “‘dignity’ is perhaps the most important value that drives us and that is reinforced every day.” She said BHS ensures staff at all levels are treated with dignity and respect, their talent is nurtured, and they are valued. This has had positive effects on patient interactions at all levels. “In the government, one sees compassion is missing: it is visible in the struggles and pressures of the auxiliary nurse midwives, the ASHAs [Accredited Social Health Activists]. If there was more compassion for them, things would be so different,” she adds.
Helping survivors of violence in Gujarat
Praveena Ben (43) is an ASHA worker in Borsan in Patan district, Gujarat. While she has served a community of over 800 people for nearly a decade, identifying and supporting survivors of violence wasn’t part of her duties. Three years after she became an ASHA, Society for Women’s Action and Training Initiatives (SWATI), an NGO working on violence prevention offered her this training. She was taught to identify signs of abuse, have discreet conversations with women during fieldwork and home visits, and encourage them to seek help through the primary health system.
This training was useful during the COVID-19 pandemic, she says. Praveena could identify women facing domestic violence at home, and convince them to seek help at the nearest sub-centre, where SWATI would send a counsellor. SWATI designed this ‘upward referral’ chain to address the highly decentralised, multi-tiered rural health system in India. It operates from the grassroots, starting with an ASHA worker in a community, and moves up through sub-centers, PHCs, CHCs, and finally to district-level hospitals. In this chain, healthcare providers play a critical role in identifying cases of domestic violence based on the symptoms women present.
By using existing infrastructure, the system aims to address violence against women as a public health issue, ensuring a compassionate response at every level of care. Since 2012,SWATI has worked with more than 400 ASHA workers and counsellors. A counsellor visits a sub-centre every few weeks or on-demand. ASHAs are empowered to refer, while keeping in mind a patient’s needs, their relationships within communities, and the relevant national health policies. Sub-centres, also called ‘Health and Wellness Centres’ under the Ayushman Bharat Scheme, are relatively closer to the survivors’ homes and thus more accessible.
“At the sub-centre we only do the counselling,” SWATI founder-director Poonam Kathuria says. For mediation and further intervention, women are referred to district hospitals, bypassing the PHCs. Ms. Kathuria said this ensures survivors aren’t revealed in the community, since PHCs are accessed and staffed by community members. ASHAs are able to offer emotional support, address sensitive issues in a culturally appropriate manner, and create a safe space that is also private. This is crucial to reduce the fear and stigma associated with reporting violence.
A multifaceted strategy must encompass systemic changes, resource allocation, and capacity building to effectively scale up the responsiveness and compassion demonstrated by ASHAs in addressing women’s health and needs. Primary healthcare systems should be identified as a pivotal first stop for women, and gender-sensitive and trauma-informed care should be included in primary health protocols.
Tamil Nadu’s responsive primary health systems
University of Maryland research professor Monica Das Gupta has studied how public health systems in India and Sri Lanka are structured, and respond to disasters and epidemics. A 2019 paper she coauthored noted that the Centre has tasked many basic services, including aspects of sanitation and public health, to be devolved from line agencies to elected local bodies without strong mechanisms to ensure these bodies are held accountable for their services. The lack of accountability, fragmentation of services, and poor high-level view into ever-evolving public health issues caused these services to unravel.
In an interview, Dr. Das Gupta uses the example of disaster management in India, which typically involves the army and administrative services rather than the health system. In Odisha and West Bengal, both prone to cyclones, these agencies are deployed to respond to disasters and to evacuate people. The army is well-versed in public health and sanitation measures. But the effectiveness of the response can vary depending on which authorities are involved. She recalled visiting some districts in eastern India after a cyclone where the local PHC focused on supplying chlorine but lacked broader engagement in disaster response. When asked about the overall death toll, they deferred to the police. Dr. Das Gupta adds that while the PHC staff was dedicated, they were not given training in public health measures to prevent disease outbreaks after a disaster, as are their counterparts in Tamil Nadu.
On the other hand, she lauded Tamil Nadu’s disaster preparedness, emphasising that its public health staff undergoes annual epidemic training. This ensures that every level of the health system — from entomologists in Chennai to district health officers — knows exactly what to do during a disaster. During the 2004 tsunami, Tamil Nadu’s health workers coordinated with other departments, ensuring proper disposal of dead bodies; timely removal of dead animals, fish, and fly control; followed by ensuring sanitary conditions in temporary housing for displaced populations, and food safety checks on donated food supplies. Their preparedness is a result of continuous training and interdepartmental coordination, unlike their counterparts in many other States.
Chennai takes a considered approach to devolution that distributes responsibilities between line agencies, technical personnel, and elected representatives and is governed by the Chennai Municipal Corporation Act. It also has a State Public Health Directorate that supports the Corporation.
Dr. Das Gupta explains that Tamil Nadu’s system includes annual district-level meetings, where the roles of various departments (health, revenue, education, etc.) are clearly defined, leading to effective cooperation during crises. Whereas other States struggle with fragmented management, lack of supervision, and ineffective delegation, Tamil Nadu succeeds through structured governance, accountability mechanisms, and proactive disaster response. While Dr. Das Gupta and her co-authors didn’t mention compassion in their paper, the features of successful health governance they described echo the WHO’s.
People-centred healthcare
Two key takeaways of the WHO report were that compassionate human relationships, built on trust and mutual respect, are the bedrock of high-quality care delivery in primary healthcare systems and that when the levers of this system operate with compassion, they can effectively respond to the unique needs of different populations.
As the examples above show, despite long-standing issues of underfunding and understaffing that have affected service delivery for decades, the existing infrastructure can meet varied needs by empowering its people to be responsive.
(Mahima Jain is an independent journalist covering the socio-economics of gender, environment and health. [email protected])
Published – April 04, 2025 06:00 am IST