Discussion
AB-HWC could, arguably, be termed as the second wave of PHC reforms in India after NRHM in 2005. There is a higher likelihood of success of this initiative than all the earlier initiative, due to many factors. The most important being that AB-HWCs start on an advantage of already strengthened and existing PHC system through NHM between 2005 and 2018. The other factors being the ongoing attention on advancing UHC; states showing increasing and more than ever interest in improving PHC services through their own mechanism and increasing civil society participation and engagement in health [45].
The AB-HWCs could be considered a national initiative to harmonize PHC service delivery on a common platform for all states. This is a major approach in federal system, where health is a state subject as per constitution of India. In the recent years, a number of Indian states have started initiatives to strengthen PHC services, which should provide learnings for AB-HWC and potential harmonization between state initiatives and HWCs (Box 3) [50–52, 54–58]. Clearly, for success, the Indian states have to take leadership in designing their own additional initiatives. Even when implementing AB-HWCs, innovative context specific approaches and adaptations for local setting would be needed.
Box 3 PHC strengthening initiatives by Indian states since 2015 [50–52, 54–58]
▪ Mohalla Clinics, Delhi [50–52, 54]: India’s first large scale state government led community clinics initiative in urban settings was launched in July 2015 in Delhi. These clinics, one each for every 10,000 population, are two to three room facilities with provision of primary care services including consultation by doctor with provision of nurse or pharmacist and an attendant. In addition to out-patient consultation services, there is provision of nearly 212 diagnostics tests and 108 medicines available free of cost at these clinics. Soon after launch, these clinics had become immensely popular amongst target beneficiaries and political leadership. As on March 2020, there were 480 clinics functioning with plan to set up 1,000 such clinics.
▪ Basthi Dawakhana in Telangana[51]: Basthi Dawakhana are arguably India’s first urban local body led community clinics. These have been openly claimed to be replication of Mohalla Clinics of Delhi and started by the Greater Hyderabad Municipal Corporation (GHMC). First few Basthi Dawakhana were launched on 6 April 2018. By end of November 2019, there were 115 such clinics with plan to open additional 132 in Telangana state. These clinics have been set up in close collaboration with state Govt of Telangana, Greater Hyderabad Municipal Corporation (the Urban local bodies); Mission for Poverty Elimination in Municipal Areas (MEPMA) and the union government led National Urban Health Mission. There is an improvisation on Mohalla Clinics of Delhi by provision of more services such as public health, preventive and promotive, more integrated referral system and provision of specialist services.
▪ Family Health Centres, Kerala, India [55]: Government of Kerala in mid-2017 started to upgrade and transform all primary health centres in states as part of Mission Aardram program and renamed these facilities as Family Health Centres (FHC). These facilities focus on upgrading the infrastructure, and provision of more doctors and staff, in closer collaboration with rural elected governments (Panchayati raj Institution) members. There is attention of preventive and promotive health services and by mid of 2018, of nearly 700 PHC in state, nearly 170 were upgraded to Family Health Centres (FHCs). The initial response to initiative has been very positive and utilization to most facilities has nearly doubled with wider community-based services and participation elected representatives and community members. Such facilities are also being considered as future of rural PHC in India.
▪ Community Clinics in other Indian states [50–52, 56–58]: Inspired by Mohalla Clinics of Delhi, at least a dozen Indian states or Municipal Corporations have either set up or announced similar facilities in their settings. First such clinics were started in Pune by the Municipal Corporation in August 2016. Since then Appla Clinics in Mumbai, Maharashtra (June 2019) and Atal Clinics in Jharkhand (August 2019) have been started, though, the numbers of most such new clinics is in range of 10–50 with promise for more similar facilities. States such as Punjab, Karnataka and Chhattisgarh governments have also planned to start similar clinics. Most recent addition to this list are the ‘Sanjivani Clinics’ of Madhya Pradesh, & Janata Clinics of Rajasthan, both launched in December 2019. In early February 2020, Govt of Andhra Pradesh had announced ‘Village Clinics’ for every 2,000 population in rural parts of state, which appear another promising approach to deliver PHC services in rural areas. However, success of each of these will be dependent upon how well these are implemented. 
As part of accountability and governance, the union government initiative such as ranking of states on health, and the proposed ranking of district hospitals should be further expanded to rank the states/districts on their performance on PHC [59, 60]. As a next step, responsibility for such ranking can be assigned to an independent & non-governmental organization. The annual report on state of primary health care in India can be started, on the line of Annual Status of Education Reports (ASER) in India [61]. These could be built upon NITI Aayog’s state health index and proposed district hospital ranking [59, 60].
As India plans to strengthen cPHC, the learnings and initiatives from NRHM/NHM can facilitate the strengthening of AB-HWCs (and the harmonized and integrated NHM and ABP convergence) can help India to make rapid progress towards UHC as analyzed in Table 2. The ongoing attention on health by various approaches should be optimally used to place health higher on development agenda. These opportunities includes the reforms in medical education through the NMC Act, 2019 [34]; dialogue and discourse on the Right to Health [62] which has become stronger following three Indian states considering enactment of a legislation; the recommendation from health subcommittee of 15th Finance commission [62, 63] and the renewed global focus on UHC and PHC, as reflected in Astana 2018 and United Nations High Level Meeting (UNHLM) on UHC in Sept 2019 [17, 18].
This brings in an important question of when can AB-HWC be considered a success in India? To answer this question, the performance of PHC system in India needs to be measured based upon health system outcomes. There would be a need of explicit attention, engagement and linkage to deliver interventions to tackle Social Determinants of Health (SDH) through PHC system. World over, including in India, while inputs to health systems are measured regualrly, the goals on improved health (outcomes  and equity), responsiveness, efficiency, and financial protection are not monitored sufficiently. It is expected that this challenge would partially be resolved through initiative of the global UHC monitoring reports. The progress and success of AB-HWCs should also need to be measured against some of the objectives of health systems and functions (Fig. 4). AB-HWCs will be credited with the real and lasting fixing of the primary health care system in India, if people start using services at the upgraded facilities, for broad range of health needs. A few more approaches and ideas for effective roll-out of AB-HWCs are provided in Appendix 2 [34, 35, 62, 64–68].
Fig. 4 AB-HWCs and potential to impact various components of health systems
In early 2020, novel Corona virus (SARS-CoV2) disease or COVID-19 pandemic hit the world [69]. Across the countries, hundreds of thousand people got affected and many thousands died due to the disease [70]. Experience from countries, affected at the start of pandemic indicated that the asymptomatic patients visiting hospitals for non-COVID-19 health reasons partly contributed in spread of infections to many other people- attending the same facility- for some other health condition. Learning from these experiences, in India, from the start of cases being reported, except for the large hospitals, most of the private facilities were either partially functioning or out patient departments were completely closed, at least for short period of time. There were reports of gross shortage of even essential health services for non-COVID-19 patients, which were mostly provided through government primary health care facilities and smaller clinics. COVID-19 pandemic has underscored the relevance of stronger primary health care and is a proof that the world needs better health systems than it has. The weak health systems and primary health care facilities are in those countries, where the burden of diseases are already high and the epidemics and pandemic can further devastate those settings, as had been experienced during the Ebola epidemic in three African countries around 2014 [71, 72].
In late March 2020, COVID-19 pandemic resulted in the government of India to release the guidelines to legalize prescription through telephonic consultation [73]. The home delivery of medicines were allowed during COVID-19 pandemic [74]. These initiatives may be continued through AB-HWCs and have potential to change the PHC service delivery in the years ahead. COVID-19 has indicated that ensuring healthier population in the time ahead would need approaches such as mass education on hand washing, cough etiquettes, personal hygiene and physical distancing. The mental health issues are a major health challenge in India. However, there are not enough mental health services in the country [75]. COVID-19 is expected to exacerbate the psychosocial and mental health issues and the provision of such services should be prioritized through AB-HWCs. COVID-19 challenge should be used as an opportunity to deliver broader public health messages and services and PHC system is expected to be the most appropriate as well as the cost-effective approach. Alongside, while designing health services, the specific focus needs to be retained on how to make primary health care, in specific, and the health systems, in general, ready and resilient for epidemics, pandemics and natural calamities, which keep affecting, one or other part of the country (and the world), on regular intervals.