Historical Evaluation

India has a long tradition of studying health care.  Early modern efforts began with the setting up of the sanitary commissions in the three provinces of Madras, Bombay, and Calcutta to implement public health measures, establishing the link between environmental sanitation and disease to understand the high death rates from malaria, cholera, typhoid, and venereal diseases (Rao, 2016). Later, the British government appointed the Bhore Committee (Health Survey and Development Committee), under the guidance of Sir Joseph Bhore, to inquire into the existing health system and make recommendations for the future. The committee, set up in 1943, submitted its report in 1946. The committee recommended short- and long-term goals to establish primary health centres and increase health spending. And the promise of providing preventive, promotive, and curative services at primary, secondary and tertiary levels (Bhore, 1943).

Criteria for Sub-Centre, Primary Health System and Community Health System

ContemporaryIndia has a mix of public and private healthcare systems. The majority of private healthcare is located in urban areas. This has led to the exclusion of the rural population from accessing healthcare, limiting them to depending on the public or traditional healthcare system. In rural areas, the public healthcare system is a three-tier system developed on population-based criteria. Ranging from Sub-Centre, Primary Health Centre, to Community Health Centre. However, these criteria are in accordance with the Indian Public Health Standard (IPHS) 2022.

The population criteria for Sub-Centres (SC) for plain and hilly or tribal areas are 5,000 and 3,000, respectively. These centres are the first point of contact between the community and the Primary Healthcare System. Each SC needs to be staffed by one Auxiliary Nurse Midwife (ANM)/female health worker and one male health worker. SCs are tasked with interpersonal communication-related responsibilities. In order to promote behavioural change and offer services related to maternal and child health, family welfare, nutrition, immunisation, diarrhoea control, and the control of communicable diseases. However, the intention was to provide services within 30 minutes of walking from the residence. 

Along similar lines, the Primary Health Centre (PHC) is the first point of contact between the village community and the medical officer. They are set up in plain areas with a population of 30,000 and in hilly or tribal areas with a population of 20,000. PHCs were intended to provide rural residents with integrated curative and preventive healthcare, with a focus on preventive and promotive care. According to the Indian Public Health Statistics (IPHS), it should be staffed with 14 members, with additional members on contract. 

The criteria for the Community Health Centre (CHC) are 80,000 and 1,20,000 for hilly/tribal and plain areas, respectively. A CHC must have four medical specialists, including a surgeon, a doctor, a gynaecologist/obstetrician, and a paediatrician, as well as twenty-one paramedical and other staff members, in accordance with minimum standards. It has 30 beds, a lab, an X-ray machine, and an operating room. In addition to offering obstetric care and specialist consultations, it functions as a referral facility for PHCs in the block.

The role of the National Rural Health Mission (NRHM)

In 1983, the first National Health Policy (NHP) came, based on an integrative approach. The underlying ideas behind the curative-oriented Western healthcare model, the NHP of 1983, emphasised the need for a Preventive, Promotive, and rehabilitative primary healthcare approach based on community participation. The National Rural Health Mission (NRHM) began on 20 April 2005. The focus was to place it under the Panchayati Raj institutions to improve service delivery in rural areas and cover sectors that directly impact health, such as safe drinking water, sanitation, and nutrition. The major aim of the National Health Mission was to provide accessible, affordable, accountable, effective and reliable primary healthcare services to the rural population, especially the marginalised population, including women and children.

Everyday Experience of the Rural Villagers

India’s health system is complex and dynamic. It has undergone a significant transformation after Independence, determining the delivery of services, their utilisation, and accessibility among the population. The village that I studied – Bhameth in the Bhawanipur block – consists of 120 households and a homogeneous scheduled caste population. They live in small huts and kaccha houses on the outskirts of the village. They live amidst dirt, surrounded by a foul smell near the cultivation land. They are mostly uneducated, and school dropout rates are high. They are associated with weaving and daily-wage labour during the agricultural season, and migrate to Haryana, Punjab and other states as migrant labourers.

Experience of primary healthcare & availability of other health services

There are sub-centres, Primary health centres, and a community health centre. The sub-centre has recently been upgraded to a Health and Wellness centre. The sub-centre, which is supposed to be providing services “within 30 minutes” of walking, is not accessible to most of the people. The reason behind their inaccessibility is the distance, unaffordability and unavailability of public transport services at large. Very few of them used the services in the past. Many women pointed out that they did not get cured with the medicine. There are also cases of medicine being unavailable at these centres. Some diseases that need long-term treatment are also prevalent in the community. Some of the diseases they mentioned include Tuberculosis (TB), Malaria, Dengue, Dental Cavity, Oral Cancer, Hernia and Babasir. They are accustomed to living with pain from one disease or another.

For any symptoms or disease, their first preference is traditional, that is, plants and herbs. They believe the disease can be cured through worship of their traditional god, “Dina Bhadri” or “Jhar Phuk”. The second step after the traditional practice is approaching quack services or practitioners. There is no medical store within a 2-3 km radius of their village. Most households in the village use the practitioner’s services. All sections, including women, children, young people, and older people, feel that the practitioners (people having some experience of working with any medical store or as a compounder at any private clinic in the past) provide better medicine that helps them cure more than the medicines available at the health centres. In my conversation with the Practitioner, he pointed out that I give medicines to the entire village at a lower cost and sometimes on debt (Udhar). He also pointed out that people at the health centres do not engage with them gently, and they cannot afford to pay the high charges in the private hospitals.

Conclusion

The paradox is that the district is popularly known as “Wrench and Syringe” among the neighbouring districts. This is due to the large numbers of private practitioners and multi-speciality hospitals. The functioning of the primary healthcare system at the rural level remains poor and inaccessible to the villagers at large. The villagers’ narrative shows the lack of engagement with India’s healthcare system. This raises a question about the population criteria that are used to categorise the rural healthcare system. This village, along with other villages, is not randomly settled around the health centres. The population norms need to be revisited and cannot be justified for the rural population, as they are not clustered around these centres. Along with these criteria, inaccessibility, unaffordability, and the unavailability of public services make it exclusionary for the rural population. This needs to be addressed through mutual understanding and trust. So that every section receives equal access to healthcare despite socioeconomic differentials in the population.

References:

Bhore, J. (1943). Health survey and development committee. Manager of Publications.

Chokshi, B. P. (2016). Health systems in India. Journal of Perinatology.

Rao, K. S. (2016). Do we care? Oxford University Press.

Ministry of Health and Family Welfare. (2022). Indian public health standards: Revised guidelines. Directorate General of Health Services, Government of India.

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Pritam Kumar Singh is pursuing a PhD in Public Health at Dr B. R. Ambedkar University Delhi.