PHC with a work culture will transform health

Pavitra Mohan and Sanjana B. Mohan

THE past 20 years have special significance for India’s public healthcare. One of the most important reforms in public healthcare, the National Rural Health Mission (NRHM), was seeded at that time. We, too, started working closely with public health systems 20 years ago. In the past 10 years we have been working closely with marginalized communities in south Rajasthan. 

It is difficult to capture all the changes that have taken place in two decades, but, having witnessed our health systems up close, we have shortlisted six key trends that we found striking and defining for healthcare in our country during a period of rapid change. 

For the first time, India has achieved a fertility rate of 2.1, which is the replacement fertility rate. Simply speaking, based on current fertility patterns, a couple on an average would produce two children in their lifetime — in numerical terms, they would replace themselves. At such a fertility rate, the population will continue to grow for some decades because of the large numbers of existing couples (demographic inertia), but as they grow out of childbearing age, population will stabilize.

Since Independence, high levels of fertility and high population growth were always quoted, in academic circles and by the media, as impediments to India’s development. This led to an obsession with population control, culminating in the infamous Emergency-era sterilizations. Following the International Conference on Population Development (ICPD) at Cairo, India committed to pursuing a development approach rather than a control approach to population stabilization. As part of this approach, targets and coercion for adoption of contraception were to be abolished and replaced with broader efforts at improving health and development and promoting choices.

Targets and coercion, however, remain firmly prevalent in India’s population programme, to this date. Tubectomy or sterilization performed on women, remains the most-focused approach. More than one-third of all women of childbearing age continue to undergo tubectomy, as opposed to less than one percent of men having undergone vasectomy. Women know little about the different choices that exist, and the option of “operation” or female tubectomy is taken right to their homes through the ASHAs and ANMs. There is an urgent imperative to widen choices for family planning in the truest sense, and not let the burden of contraception continue to be on women.

 

SHIFTS IN DISEASE PATTERNS 

India also saw the eradication of poliomyelitis and elimination of neonatal tetanus, the two scourges that killed and maimed millions of children. As paediatric residents in the early 1990s, our wards were full of children with poliomyelitis and neonatal tetanus. This is a stupendous achievement indeed and underscores the value of India’s extensive public health system for vaccination and surveillance. Besides eradicating poliomyelitis, routine vaccination coverage has also increased significantly and equitably.

India’s epidemiological transition is characterized by the double burden of diseases. On the one hand, there are high levels of communicable diseases, such as tuberculosis and, on the other, diabetes and heart diseases are assuming epidemic proportions.

Chronic Respiratory Diseases are an example of a continuum between communicable and non-communicable diseases. Alongside, there are threats of epidemics of emerging diseases such as Covid, sometimes referred to as a triple burden. Even in some of the most marginalized populations such as those we serve in rural south Rajasthan, there is a high burden of communicable and a growing burden of non-communicable diseases.

Such a situation, where multiple conditions are simultaneously prevalent, can be taxing for any health system, but especially one with limited resources. We need higher investment in healthcare along with a much higher prioritization of primary healthcare, especially primary health centres (PHCs). 

 

MALNUTRITION PATTERNS

There has also been a shift in malnutrition patterns. While there has been a decline in undernutrition levels, high levels persist, more so among marginalized communities.  Simultaneously, the prevalence of overweight and obesity has increased, leading to a double burden of malnutrition. We have found high levels of undernutrition as well as growing levels of overweight even among labour-migrant men across the cities of Gujarat, who come from underdeveloped states such as Odisha and Rajasthan.

Such a situation has been caused, to a large extent, by non-availability and high costs of nutritious food, and easier availability and lower costs of an unhealthy, high-carbohydrate diet. Climate change, a push away from animal foods, disrupted food systems, and high food inflation will continue to affect the nutritional status of populations. Nutrition security, instead of just food security, can reverse this trend.

 

MORE HEALTH PROVIDERS

There has also been a significant increase in the production and deployment of doctors in India.  Currently, India creates about 80,000 to 100,000 doctors per year. This has led to increasing numbers of doctors being deployed in rural PHCs as well. Based on rural health statistics, in 2005, there were 20,000 doctors posted in 23,000 PHCs, a doctor to PHC ratio of less than one.

By 2022, some 30,000 doctors were posted for 25,000 PHCs. For the first time in the past 20 years, there is at least one doctor for each PHC. During this period, the availability of nurses and Auxiliary Nurse Midwives (ANMs) in rural healthcare systems has increased even more remarkably. In addition, there is now a million-strong new cadre of ASHAs, that have extended healthcare to the village level.   

Therefore, a shortage of doctors and nurses cannot any more be an excuse for poor healthcare for rural populations. However, inequities in availability of human resources for health persist: PHCs and CHCs in tribal and other underserved areas continue to have fewer doctors and nurses, adversely affecting the care they receive. In the absence of a transparent health policy, many doctors and nurses manage to get transferred out of such “difficult” areas, denying the healthcare that marginalized communities need.

One of the most significant issues that continue to plague India’s primary healthcare systems is a hierarchical and non-motivating work culture. A study of PHCs in Rajasthan by Abhijit Banerjee and Esther Duflo in Rajasthan in 2005, highlighted high levels of absenteeism among primary healthcare staff. Kritika Goel and Reetika Khera visited the same facilities 10 years later and found that while some parameters including infrastructure and availability of drugs had improved, levels of absenteeism remained the same and the utilization of the PHCs remained sub-optimal.

 

DECLINE IN EXPENDITURE

Overall expenditure on healthcare as a proportion of GDP has declined in the past 20 years. Despite recommendations of the National Health Policy 2002 and 2017, and commitments by subsequent governments to increase government allocations to at least two percent of GDP, allocations continue to hover around one percent (from 0.96 percent in 2005 to 1.35 percent in 2019-20). In the same period, worryingly, there has been a decline in overall health expenditure by both the government and people themselves from 4.25 percent to 3.3 percent of GDP.

The National Health Policy of 2017 for the first time spoke of expanding the government’s role from provision of healthcare to strategic purchasing of healthcare. The policy paved the way for the Ayushman Bharat  Pradhan Mantri Jan Arogya Yojana (AB-PMJAY), the government-funded scheme that provides a health insurance cover for secondary and tertiary care.

Different states have adapted the scheme according to their own needs. A study that sought to understand the expenditure incurred by cancer patients across six states suggested that those who were covered by the scheme did indeed incur less expenses and were less likely to be indebted.

According to Shram Sarathi, a not-for-profit organization that provides microfinance and finance literacy to rural, marginalized populations of south Rajasthan, repayment of expenditure on healthcare is the single most important reason (76 percent) for families seeking emergency loans.  With the existence of a publicly funded health insurance scheme (Chiranjeevi Yojana) that commits to provide cashless treatment of upto `25 lakh per annum per family, such a situation appears paradoxical.

We have identified a few reasons why families continue to pay large sums, delay treatment or fall into debt for seeking care. Firstly, the hospitals that are empanelled are often very far from where marginalized people live, making it extremely difficult for them to access. Secondly, information regarding the entitlements under these schemes are difficult to understand. In the absence of clear information on which diseases will be covered, which hospitals will provide that care and what will be the other costs that they will have to bear, people are wary of travelling hundreds of km only to be denied the cashless services that they need. Therefore, they would rather not seek care, or take loans and seek expensive private care when the disease is advanced.

 

RIGHT TO HEALTH UNREALIZED

Over the past two decades, sustained advocacy by networks such as Jan Swasthya Abhiyan led to a wider understanding of the value of a legislated right-to-health act, and a promise to do so in the draft National Health Policy. However, by the time the final draft came out, it was dropped, stating that Indian health systems are not prepared yet to honour this right.

Continued advocacy by health activists led to a legislated Right to Health (RTH) Act in Rajasthan. The Act commits to provide free the full range of health services at public health facilities to all persons in the state of Rajasthan, as a matter of right. In the face of an unexpected and unfair opposition by doctors, the Act was diluted to accommodate their interests. While the Act has been legislated, the rules are yet to be drafted.

So, India did come closer to having a right to health, but also saw unprecedented opposition, stalling or dilution of such a right. States such as Tamil Nadu have also been working to legislate an RTH Act. Hopefully, it will be well thought through and pave the way for equitable and dignified healthcare for all. 

 

Dr Pavitra Mohan and  Dr Sanjana Brahmawar Mohan are founders of Basic Healthcare Services.