2017 is coming to an end. This year could have been a crucial one in transforming India’s health policy because of major healthcare crisis country witnessed. But thanks to our insensitive and insular political class, the state elections were fought on frivolous issues that have nothing to do with the welfare of the country. Healthcare has completely disappeared from the discourse.
Since August hundreds of infants have died in the BRD Medical College in Gorakhpur partially because of encephalitis and partially because of our abysmal state of public health. Recently, a family was handed Rs 18 lakh bill by a private hospital in Gurgaon, for admitting their child for 15 days, who had dengue. The hospital walked away with profit margins as high as 1000% on consumables. In my previous blog post I have tried to map all such cases across the country where the public health services have failed us majestically.
These cases are the best example of a phenomenon which could be well described as ‘absent state’. The healthcare has been historically neglected by the successive governments over the years. The government spending on health has been abysmally low at around 1% of the total GDP, the infrastructure is inadequate, the care providers are absent, or their positions are vacant in the rural health centers, the supplies of medicines, consumables and equipment are irregular, and the quality of care is poor. This has made people, in large numbers, flock to private sector which is costly, unregulated and in most cases exploitative.
The recent Rural Health Statistics (RHS) 2017 report, has once again pointed out the crisis in primary health care in India in the form of poor infrastructure, staff vacancies, shortage of doctors and specialists and inadequate facilities in government health centers.
Rural Health Statistics 2017 explained in 10 charts
There has been a consistent increase in the number of sub centers (SCs), primary health centers (PHCs) and community health centers (CHCs) over the years but the current numbers are not sufficient to meet the population needs.
Since the 6th plan for the years 1981-85 till the present 12th plan for 2012-2017, the health infrastructure has increased, but so is the population. Since 2005 to 2016 the number of SCs has increased by 6%, number of PHCs has increased by 9% and the number of CHCs has increased by 65%.
What has happened is that the increase in population has outstripped the increase in the number of sub centers and primary health centers. Being the first contact point between the primary health care system and the community in case of SC and the first point of contact between a medical officer and the community in case of PHC, the insufficient number of SCs and PHCs are just not enough to cater to the needs of the rural population. As a result, people are going either to the private sector or to the government third-tier health facilities thus increasing patient burden there.
The report also claims that the average rural population covered by these health facilities has increased over the years. Here is the population coverage status of the public health facilities in 2017:
|Health facility||Norm||Status (2017)|
|Primary Health Center||20000-30000||32505|
|Community Health Center||80000-120000||148248|
While the number of the SCs and the PHCs have increased by 6% and 9% respectively, the number of CHCs have increased by a whopping 65%. Now this increase in the number of CHCs is counterproductive in two ways: firstly the CHCs form the third tier of public health facility after the SCs and the PHCs. They serve as a referral point for 4 PHCs. Inadequate infrastructure and manpower at the SCs and the PHCs force people to reach out to the specialists at the CHCs, thus increasing the burden of work on the CHCs. Secondly, the CHCs in rural India have a shortfall of nearly 81% of specialists, thus aggravating the problem. Thus the rural community is stuck between inadequate and understaffed SCs and PHCs and the CHCs where doctors are missing.
Don’t get me wrong. I am not, for a moment, suggesting that the CHCs are not necessary. Infact the same RHS 2017 report says that the shortfall of CHCs as per 2011 census population in India is 30%. Similarly, the shortfall of SCs and PHCs, as per the population, is 19% and 22% respectively. But inadequate, poorly staffed and poorly equipped SCs and PHCs are aggravating the problem further because now people are going to CHCs which are chronically understaffed.
Unfortunately, the focus of our policy makers is more towards upgrading the buildings of the health facilities and not ensuring whether these buildings are completely manned by doctors, ANMs and specialists.
For instance, the number of SCs running in a government building has increased by 71% since 2005. In case of PHCs and CHCs the increase is 46% and 92% respectively. The result of this massive level of infrastructure upgradation is that we have rural health centers without the staff and facilities where nobody wants to go. So even if the government is building these health centers in the villages, due to inadequate staff and equipment the purpose of building those health centers gets defeated because the footfall is low.
It is a classic case of ‘poor designing’ of health policies.
While the first line of health facilities is not able to cope up with the rising demands and population because there are not enough of them that are functional, the disproportionate increase of the third tier health facilities are understaffed because there are no specialists to look after the patients.
There is no denying the fact that India’s healthcare is suffering from the ‘great Indian human crises’. There are not enough doctors, nurses and supporting staff in our public health facilities. According to a recent Rajya Sabha data, India has around 8 lakh allopathic doctors which makes the doctor-population ratio of 0.63:1000. This is less than the WHO’s prescribed doctor-population ratio of 1:1000.
Another study claims that India will need around 20 lakh doctors by 2030 to come up to the WHO’s prescribed ratio of 1:1000.
Not only there is a shortage of doctors but also the nursing and other support staff is inadequate. The RHS 2017 claims that in SCs and PHCs the staff is inadequate as there are lots of vacancies which are not filled.
The shortage of staff is chronic in case of CHCs. The CHCs in rural India are suffering from ‘missing doctors syndrome’. Nearly 82% of the posts of specialists in the CHCs are vacant. The CHCs are required to have 4 specialists- surgeon, physician, gynecologist and pediatrician. According to RHS 2017, the CHCs in rural India are facing a shortage of these specialists. There is a shortfall of 87% surgeons, 74% gynecologists & obstetricians, 85% physicians and 81% pediatricians in the CHCs.
In terms of facilities also the SCs, PHCs and CHCs are ill equipped to cater to the community healthcare needs.
For instance only 55.4% SCs have quarters for the ANMs. Amongst these SCs with quarters, in 56.4% of them ANMs are living in those quarters. This data might appear as a simple piece of statistic but its significance is huge. An ANM living in the quarter of a SC increases the likelihood of the patient receiving healthcare from the ANM even during odd hours. Obviously it also increases the likelihood of the SC to be operational during the normal working hours. This also increases the probability of a pregnant woman receiving basic care even at midnight.
69% of the PHCs have labour rooms. But the report does not say how many of these labour rooms are functional as per IPHS norms and whether they have basic equipment such as ambu bag, oxygen cylinder and baby warmer.
In case of CHCs there are again aberrations. Majority of the CHCs have necessary facilities but the tragedy is that there are no care providers to dispense healthcare as we have seen above. In only 8% of the CHCs all 4 specialists are working. 84% of the CHCs have new born care corner but there is a shortfall of 81% pediatricians; 92% of the CHCs have labour room but there is a shortfall of 74% obstetricians and gynecologists; 83% of the CHCs have operation theaters but there is a shortfall of 87% surgeons.
In my previous posts, I have repeatedly written about the lack of ambulances and referral transport in public health facilities. According to RHS 2017, only 55% of the PHCs have referral transport. All the referral transport is stationed at the CHC. Nearly 93% of the CHCs have referral transport.