A look at the Public Health Care System in India

A look at the Public Health Care System in India

Health care delivery in India has been envisaged at three levels namely primary, secondary and tertiary.

Primary Healthcare

Primary healthcare denotes the first level of contact between individuals and families with the health system. According to Alma Atta Declaration of 1978, Primary Health care was to serve the community it served; it included care for mother and child which included family planning, immunisation, prevention of locally endemic diseases, treatment of common diseases or injuries, provision of essential facilities, health education, provision of food and nutrition and adequate supply of safe drinking water. In India, Primary Healthcare is provided through a network of Sub centres and Primary Health Centres in rural areas, whereas in urban areas, it is provided through Health posts and Family Welfare Centres. The Sub centre consists of one Auxiliary Nurse Midwife and Multipurpose Health worker and serves a population of 5000 in plains and 3000 persons in hilly and tribal areas. The Primary Health Centre (PHC), staffed by Medical Officer and other paramedical staff serves every 30000 population in the plains and 20,000 persons in hilly, tribal and backward areas. Each PHC is to supervise 6 Sub centres.

Secondary Health Care

Secondary Healthcare refers to a second tier of health system, in which patients from primary health care are referred to specialists in higher hospitals for treatment. In India, the health centres for secondary health care include District hospitals and Community Health Centre at block level. . The CHCs were designed to provide referral health care for cases from the Primary Health Centres level and for cases in need of specialist care approaching the centre directly. Four PHCs are included under each CHC thus catering to approximately 80,000 population in tribal/hilly/desert areas and 1,20,000 population for plain areas. CHC is a 30-bedded hospital providing specialist care in Medicine, Obstetrics and Gynaecology, Surgery, Paediatrics, Dental and AYUSH.  A district hospital has the following functions:

It provides effective, affordable health care services (curative including specialist services, preventive and promotive) for a defined population, with their full participation and in co-operation with agencies in the district that have similar concern. It covers both urban population (district head quarter town) and the rural population in the district.

1. Function as a secondary level referral centre for the public health institutions below the district level such as Sub-divisional Hospitals, Community Health Centres, Primary Health Centres and Sub-centres.

2. To provide wide ranging technical and administrative support and education and training for primary health care

Tertiary Health Care

Tertiary Health care refers to a third level of health system, in which specialized consultative care is provided usually on referral from primary and secondary medical care. Specialised Intensive Care Units, advanced diagnostic support services and specialized medical personnel on the key features of tertiary health care. In India, under public health system, tertiary care service is provided by medical colleges and advanced medical research institutes.

Long term goal: Under Ayushman Bharat – National Health Protection Scheme, the government is setting up or converting some 150,000 sub-centres in the country into so-called ‘health and wellness’ centres that will provide comprehensive primary healthcare to the target beneficiaries who otherwise cannot afford medical treatment due to the costly medicines and investigations. At these centres they will have access to free diagnostic services and essential drugs. The services will cover maternal and child health, mental health, vaccinations against selected communicable diseases, and screening for hypertension, diabetes and some cancers, among others.

When we visit various public health care Centres, we notice that Public health care system gives unequal opportunities to doctors. Some doctors (particularly in medical colleges) are overburdened and examine too many patients and also get opportunities to update their knowledge and skills while others (particularly doctors at PHC and CHC) have very little exposures or highly underutilized. Doctors lose their confidence and skills gradually if they do not get enough exposure on a regular basis. 

The delivery system at the Primary Health Centres (PHC), Community Health Centres and district hospitals can be improved by reducing the gaps in the availability of medicines, Laboratory facilities, crucial staff like anaesthesiologists, radiologists, gynaecologists, etc. along with mobility of health personnel to give them better exposure for updating their knowledge and skills.

	HEALTH MANPOWER IN RURAL AREAS (As on 31/3/2017)
Description	Required	Required	Sanctioned	In Position	Vacant            (S-P)	Shortfall (R-P)
At Sub-centres (SC) (Total number 156231)	ANM	156231	186479	198356	26172	6104
	HW(Male)	156231	89296	56263	33448	99572
SCs & PHCs	ANM	181881	211388	220707	28741	10112
At PHCs (Total number 25650)	HA(Female)	25650	21748	14267	7552	11712
	HA (Male)	25650	22753	12288	10731	15592
	Doctors	25650	33968	27124	8286	3027
At CHCs ( Total Number 5624)	Surgeons	5624	2830	758	2138	4866
	Obstetricians & Gynaecologists	5624	3103	1463	1816	4170
	Physicians	5624	2945	864	2150	4760
	Paediatricians	5624	3032	1071	2046	4554
	Total specialists	22496	11910	4156	8105	18347
	GDMOs	14859	14350
	Radiographers	5624	4155	2129	2061	3629
At PHCs and CHCs	Pharmacists	31274	29315	25193	4582	7092
	Laboratory Technicians	31274	23902	18952	5753	12511
	Nursing staff	65018	77956	70738	11288	13194

Health is the State subject. However, GOI provides assistance to all the Sub-centres in the country since April 2002 in the form of salary of ANMs and LHVs (Female Health assistant), rent (if located in a rented building) and contingency, in addition to drugs and equipment kits. The salary of Male Health Worker is borne by the State Governments.

Policy makers in health sector have not adequately appreciated that there is paucity of funds with the State Governments. While approving the scheme for the construction of new building for new health centres following points needs consideration. Information, education and communication (IEC) combines strategies, approaches and methods that enable individuals, families, groups, organisations and communities to play active roles in achieving, protecting and sustaining their own health. Primary and preventive health care reduces pressure on secondary and tertiary health care. Programmes and talks by the doctors of reputed medical colleges on a fixed date and time on TV and radio, may be more effectively used for preventive health care, allowing citizens to get their doubts clarified. A doctor who sees very small number of patients and doesn't interact with other doctors or attend medical conferences, he/she gradually loses his/her skills. Doctors need availability of latest medicines, equipment and availability of minimum Laboratory facilities within 5 km and all diagnostic tests facilities within 15-20 km. Vaccination can be done by skilled para medical staff on a fixed date and time in every village and all Sub Centres, PHC and CHC.

The weak link in health services in most of States is not the number of health centres (Sub Centres, PHC,CHC, District Hospitals) but availability of medicines and inadequate diagnostic tests facilities , making most of health centres (SC,PHC and CHC)  almost non-functional in most of the States. Patients are forced to get exploited by the private doctors. In the medium and long run the capacity utilisation of existing health centres up to district hospitals can be improved by strengthening diagnostic tests facilities and making available medicines at PHCs, CHCs and district hospitals. Mantra should be: focus on mobility, medicine and trained medical manpower. Providing rural health services, particularly secondary health care on fixed date, time and location through fully equipped mobile vans can be very effective.

Ayushman Bharat-National Health Protection Scheme, which will cover over 10 crore (one hundred million) poor and vulnerable families (approximately 50 crore (five hundred million) beneficiaries providing coverage up to 5 lakh rupees per family per year for secondary and tertiary care hospitalization. Benefits of the scheme are portable across the country and a beneficiary covered under the scheme will be allowed to take cashless benefits from any public or private empaneled hospitals across the country. This is a very cost effective intervention as the policy of this scheme include all existent ailments and still affordable for the Central and State Governments because of the scale of the scheme. What is required:  Government may keep close watch on the private hospitals through regular feedback from the beneficiaries of the scheme. While good hospitals should be appreciated in the public domain, others may be given reasonable opportunities to improve themselves.