CHAPTER - II

REVIEW OF LITERATURE

2.1: Introduction

2.2: Current Picture of the Primary Health Care System in Rural India

2.3: Rural-Urban Inequalities

2.4: Funding

2.5: Disease Profile of Rural India

2.6: Availability of Medicines in PHCs

2.7: People’s Health and Decentralised Health Care Planning in India

2.8: Primary Health Care System in Kerala

2.9: Beneficiaries’ Opinion on the PHC

2.10: Conclusion

41

CHAPTER 2

REVIEW OF LITERATURE

2.1: INTRODUCTION

In this chapter, the researcher is making an attempt to critically

evaluate the existing primary health care systems by going through the

literature available on this subject. Some of the research studies in the

subject areas carried in India, the official reports by the state

government and the central government and the articles published in the

peer reviewed journals have formed sources of this literature review.

2.2: CURRENT PICTURE OF THE PRIMARY HEALTH

CARE SYSTEM IN RURAL INDIA

The report by World Bank (1996) indicated that owing to scarcity

of resources, the existing public health system has been unable to

provide care to all. At present as many as 135 million Indians do not

have access to health services. Despite the Bhore Committee‟s

recommendations in 1946 of the provision of one health centre for every

20 000 people, the country currently has one PHC per 31 000

population. Even the existing public health facilities run with abysmally

42

low resources. Just for example; presently, an average Indian PHC has

as its budget only Rs 1 per capita for drugs. Since 1996, there has been

lot of improvement in organization and delivery of primary health

services in India. However, the picture is still below the standards set up

by the health authorities and agencies in the country and abroad.

2.2.1: Neesha (2005), evaluating the role of primary health centres in

India, highlighted that primary health centres are the solution to global

problems of lack of equity, lack of efficiency, lack of effectiveness and

lack of responsiveness of their health systems. Based on the results of

many international studies conducted on the primary system, Neesha

argued that primary health care is essential health care based on

practical, scientifically sound and socially acceptable methods and

technology made universally accessible to individuals in the community

through their full participation and at a low cost. According to her the

strength of a country‟s primary care system is associated with improved

population health outcomes for all-cause mortality, all-cause premature

mortality, and cause-specific premature mortality from major respiratory

and cardiovascular diseases. This relationship is significant after

controlling for determinants of population health at the macro-level

(such as GDP per capita, total physicians per one thousand population,

percentage of elderly) and micro-level (such as average number of

43

ambulatory care visits, per capita income, alcohol and tobacco

consumption).

Neesha also reiterated the benefits of the improved access to

primary healthcare stating that the gate-keeping function of the primary

health care system could lead to less hospitalisation, less utilisation of

specialist and emergency centres and less chance of patients being

subjected to inappropriate health interventions. In low-income settings,

the cost effectiveness of PHC compared to other health programmes has

been reinforced by World Bank findings. Selected primary healthcare

activities such as infant and child health, nutrition programmes and

immunisation appeared as „good buys‟ compared to hospital care and

such interventions could save a large population of deaths. Thus, it is

evident that the success of health systems exists in tapping the existing

potential and making appropriate structural changes. In this context, the

role of primary care should not be defined in isolation but in relation to

the constituents of the health system.

Neesha also presented the idealistic picture of the Indian primary

health care centres as the cornerstone of rural healthcare which

characterises as the first port of call for the sick and an effective referral

system, being the main focus of social and economic development of the

community, the first level of contact, and a link between individuals and

44

the national health system. Indian primary health care system brings

healthcare delivery as close as possible to where people live and work, is

promotional, preventive, curative and rehabilitative care centre and

offers a wide range of services such as health education, promotion of

nutrition, basic sanitation, the provision of mother and child family

welfare services, immunisation, disease control and appropriate

treatment for illness and injury. She also pointed a number of positive

approaches used in the developing countries in order to improve primary

care services such as capacity building and encouraging community

involvement.

Having given an idealistic picture of primary health care system

in India, Neesha also critically analysed the present health status of the

Indian population and primary health care scenario in India and

observed that fertility, mortality and morbidity are high in India. The

reasons for such a scenario are poverty and low levels of education and

poor stewardship over the health system. She stated that India‟s primary

healthcare system is based on the Primary Health Centre (PHC) which is

unable to detect diseases early due to lack of multi-disciplinary medical

expertise, laboratory facilities and insufficient quantities of general

medicines, patients usually not visiting PHCs in the early stages of their

45

diseases and healthcare providers are forced to focus only on seriously

ill patients due to the volume of cases.

According to her, in India, there are not only pre-existing

inequality in healthcare provisions, but these pre-existing inequalities

are enhanced by difficulties in accessing it, which is due to

geographical, socio-economic or gender distance. Added to those are the

lack of political commitment, inadequate allocation of financial

resources to PHCs and stagnation of inter-sectoral strategies and

community participation. There are also bureaucratic approach to

healthcare provision, lack of accountability and responsiveness to the

general public and incongruence between available funding and

commitments. In this context, Neesha quoted the World Health

Organisation (WHO) by specifically pointing out that the current PHC

structure is extremely rigid, making it unable to respond effectively to

local realities and needs, political interference in the location of health

facilities often results in an irrational distribution of PHCs and sub-

centres. Government health departments are not focused on measuring

health system performance or health outcomes, lack of health

management experience among the District Health Officers, lack of

accountability, no formal feedback mechanism and incentive to treat

citizens as clients, lack of resources, which is acute in some states.

46

2.2.2: In 1995, Dreze and Sen observed that “India has poor health

achievement despite spending comparatively large part of its GNP on

health when public and private spending taken together, due to

malfunctioning of the public health care system especially in the rural

areas. In some states, this system is a little more than a collection of

deserted primary health centres, filthy dispensaries, unmotivated and

chaotic hospitals‟‟.

2.2.3: Abhijit Das (2009) described the pitiable face of present primary

health care scenario in the rural India by detailing some of the health

indicators of the people in the central and northern states of India.

Abhijit observed that shark disparities exist in the health care

infrastructure and services available to the rural and urban Indians. His

findings on the rural health care infrastructure and services are of great

interest in the context of the present study. Das stated that less than 50%

of primary health centres (PHCs) had a labor room or a laboratory, and

less than 20% had a telephone. Less than a third of these centres stocked

very cheap but essential drug like iron and folic acid.

Despite major advances in medical science, people continue to

die in large numbers from preventable illnesses like tuberculosis,

gastroenteritis and malaria in the central and northern states of India.

500000 of people succumb to tuberculosis alone. Emergency services

47

for delivery complications are unavailable outside cities, resulting in

maternal death rates in the northern states. He states that even this trend

is greater than maternal deaths rates in sub-Saharan African countries.

India accounts for a fourth of all maternal deaths worldwide, and the

numbers are increasing. Uttar Pradesh has a huge population base and

very poor health system. Therefore, UP contributes to a large proportion

to the overall preventable mortality and morbidity in the country.

According to Das, even the existing health care delivery system in Uttar

Pradesh is preoccupied with pulse polio campaign and chasing family

planning targets, rather than dealing with treating patients or controlling

diseases.18 states that have weak public health indicators, including the

seven north eastern states, and 11 states in north and eastern India.

The provision of curative services at the peripheral level is an

area of weakness in present government healthcare service delivery.

There is an acute shortage of medical officers.

2.2.4: Further, a recent study conducted by the Rural Medical College,

Loni(2002) on functioning of the PHCs has revealed the following facts

on qualification of the general practitioners in PHCs, risk to patients‟

lives due to irrational cost effective calculation by the doctor,

beneficiaries‟ lack of awareness about the PHC staff, programmes and

the facilities.

48

According to the study, 80% of general practitioners in PHCs

practice western medicine (allopathic medicine) without proper training.

73% of the doctors consider cost to be the most important factor when

prescribing a drug, without considering pharmacological properties.

75% of the beneficiaries were not aware of the Government-run Primary

Health Centre (PHC) or village sub centres and also did not know the

names of the medical officer at the PHC; half (53%)of the respondents

did not know the health workers in their own area. About 67% of the

respondents had knowledge of various national health programs but only

33% participated. Over 68% received information regarding the health

programs through the media, and only 28% received information

through public health staff. About 74% of PHCs provided family

planning services, mainly oral contraceptives and condoms. General

practitioners provided services to pregnant women (65%), but only 35%

of the cases were registered. Almost all general practitioners routinely

handle cases of diarrhoea, but only 29% knew the exact composition of

oral dehydration solution (ORS); amazingly, none knew the right

method to prepare the ORS packet.

2.2.5: Lalitha‟s (2003) looked in to the availability of medicine at

primary health centres and access for the patients in the state of Tamil

Nadu and found that in 2003 there were 1411 PHCs and 8682 health sub

49

centres in Tamil Nadu. According to her study, an important factor that

decided the accessibility of health services was the location of the PHC.

Lalitha also studied the infrastructure and the functioning of

PHCs in her study area along with the main objective of studying the

availability of drugs in the PHCs. In all PHCs, no positions of the doctor

and the auxiliary mid wife were vacant. The study also found that the

doctors had good rapport with the patients and the patients liked the

way, the doctors motivated them. All of the PHCs had their own

building with a few infrastructural equipments were unavailable.

Regarding the funding, the study reported that the budget

allocated for the drugs and the surgical equipments were under special

schemes and under other schemes. Department of public health allocated

the highest amount of funds. Only 5 percent of the total funds were

meant to buy the medicines. Some of the PHCs reported that if they did

not get special funds allotments under the special schemes, shortages

would occur.

In terms of drug procurement, majority of the PHCs had to travel

between 50 and 90 KMs to collect their drug from the district

warehouse. Some did not have vehicle of their own and had to depend

on the main PHCs vehicle to bring their stock. However, in reality, only

two or three PHCs stocks could be collected in one trip due to space

50

constraint in vehicle. A few PHCs did not depend on the main PHCS

vehicle rather they either hired a private vehicle or depended on the

public transport services.Doctors in general observed that the drugs

available in the PHCs covered all their needs.

Further Laitha‟s observation indicated that rich and poor,

illiterate and the literate made use of the PHCs services. Women and

children attended the PHCs for their health needs. The most of them

were regular users and were able to describe the improvement in the

quality of the PHCs services from the previous times. The patients were

able to get their medicines from the PHC itself. The availability of the

doctors was almost 100 percent whenever a patient visited the PHC.

2.2.6: Ashok et al(2002), writing on the rural health scenario in rural

India, commended on the relationship existing between the socio

economic inequalities and poor health indicators of the population. They

observed that even after 54 years of independence and after a number of

urban and growth-orientated developmental programs having been

implemented, nearly 716 million rural people (72% of the total

population), half of which are below the poverty line (BPL) continue to

fight a hopeless and constantly losing battle for survival and health.

2.2.7: The authors have observed that the policies implemented so far

which concentrate only on growth of economy not on equity and

51

equality have widened the gap between „urban and rural‟ and „haves and

have-nots‟. Nearly 70% of all deaths and 92% of deaths from

communicable diseases occurred among the poorest 20% of the

population. They stated that though some improvement has happened

over the last 54 years, however, interstate, regional, socioeconomic

class, and gender disparities still remain high. The authors had compared

these achievements, though significant, to the poorest nations of sub-

Saharan Africa. They blamed the socioeconomic, cultural and political

onslaughts, arising partly from the erratic exploitation of human and

material resources have endangered the naturally healthy environment

(e.g. access to healthy and nutritious food, clean air and water, nutritious

vegetation, healthy life styles, and advantageous value systems and

community harmony). The basic nature of rural health problems is

attributed also to lack of health literature and health consciousness, poor

maternal and child health services and occupational hazards.

2.3: RURAL-URBAN INEQUALITIES

2.3.1: The literature also point towards the reality that there exists rural–

urban inequalities in terms of organization and delivery of primary

health care services.

52

2.3.2: Duggal (1997) observed that it is unfortunate that while the

incidence of all diseases are twice higher in rural than in urban areas, the

rural people are denied access to proper health care, as the systems and

structures were built up mainly to serve the better off. While the urban

middle class in India have ready access to health services that compare

with the best in the world, even minimum health facilities are not

available to at least 135 million of rural and tribal people, and wherever

services are provided, they are inferior. While the health care of the

urban population is provided by a variety of hospitals and dispensaries

run by corporate, private, voluntary and public sector organisations,

rural healthcare services, mainly immunisation and family planning, are

organised by ill-equipped rural hospitals, primary health centres and sub

centres.

The budgetary allocation for health programmes and services

have been always insufficient, and even the rural and urban investment

pattern has been uneven with the result of health of rural people

suffering. The total expenditure on health in India is estimated as 5.2%

of the GDP; public health investment is only 0.9%, which is by far too

inadequate to meet the requirements of poor and needy people

(Duggal,1997). The supplies in the Centres have attributed to gross

underutilisation of the infrastructure. Successive 5-year plans allocated

53

less and less (in terms of per cent of total budget) to health. A major

share of the public health budget is spent on family welfare. While 75%

of India‟s population lives in rural areas, less than 10% of the total

health budget is allocated to this sector. Even here the chief interest of

the primary health care is diverted to family planning and ancillary

vertical national programs such as child survival and safe motherhood

(CSSM) which are seen more as statistical targets than as health

services. It is estimated that 85% of the PHC budget goes on personnel

salaries.

2.3.3: According to Government of India‟s report (2001), there is a

marked concentration of health personnel to maintain the heavy

structures, in the urban areas. Of the 1.1 million registered medical

practitioners of various medical systems, over 60% are located in urban

areas. In the case of modern system (allopathic) practitioners, as many

as 75% are in cities.

As a result, a large number of unqualified people (quacks) have

set up medical practice in rural areas, and the rural population as a result

exerts pressure on urban facilities. Curative care, which is the main

demand of rural people, has been ignored in terms of investment and

allocation. In addition, the percentage share of health infrastructure for

rural areas has declined from 1951 to 1993(GOI, 2000).

54

In the case of medical research, a similar trend is observed. While

20% of research grants are allocated to studies on cancer, which is

responsible for 1% of deaths, less than 1% is provided for research in

respiratory diseases, which accounts for 20% of deaths.

In 2001, Government of India released result of Evaluation Study

conducted by the Programme Evaluation Organisation on Functioning of

Primary Health Centres (PHCs) assisted under Social Safety Net

Programme. This study comprehensively highlights the good and bad

aspects of the primary health care system in India.

2.3.4: In 1992-93, under The Social Safety Net Programme (SSNP),

World Bank initiated family welfare programmes in 90 poor performing

districts for a period of five years. Those 90 districts were characterised

by high maternal mortality rate and low levels of institutional deliveries.

The programme had envisaged to reduce the maternal mortality rate by

creating essential health infrastructural facilities including the post of

lady doctor in the identified PHCs for facilitating institutional deliveries

of pregnant mothers.

The programmes insisted that certain essential infrastructural

facilities were required to be created in each PHC which included (a)

well equipped operation theatre, (b) labour room, (c) an observation

ward, (d) two quarters, one each for auxiliary nurse mid-wife and lady

55

health worker, (e) a generator, (f) provision of supply of safe drinking

water (g) an ambulance. In addition, however, the post of a lady doctor

is required to be created by the concerned state governments. The

amount sanctioned per PHC was Rs.10.00 lakh.

The study assessed the impact of SSNP simultaneously through a

combined design i.e while carrying out the field survey on CHCs,

information on relevant aspects of sample PHCs were collected. The

same methodology was adopted in the case of the study on functioning

of CHC. Both primary and secondary data were generated through

sample survey. A multi-stage sample design was adopted for the study.

The sample units at different stages were: States, Districts, PHCs and

patients. The first sample units were the six states initially selected to

represent the good and poor health status of the population by using

infant mortality rate as a stratifying parameter. However, the study

eventually was confined to the selected districts in the three states of

Haryana, Orissa and Uttar Pradesh where the programme was

implemented. The study design has adopted with and without approach

to yield therapeutic results and, therefore, two districts - one assisted and

the other not assisted under SSNP were selected from each state in the

second stage of sampling. In the third stage, four PHCs from each

district were selected. Eight patients from each PHC were selected in the

56

fourth stage of sampling. In nutshell, 167 patients, 24 PHCs spread over

six sample districts of three states were selected for the study. In each

selected village, the views of the knowledgeable persons were taken for

preparation of qualitative notes on functioning of PHCs.

The evaluation study had come out with the following results

regarding the Health Infrastructure in PHCs in terms of their availability

and adequacy. During 1995-96 none of the 12 assisted sample PHCs

was found to be equipped with all the eight essential facilities; viz; well

equipped operation theatre, labour room, observation ward, two

quarters, generator, drinking water, ambulance and lady doctor that were

required to be created in each PHC. Of the eight essential

complementary facilities including the post of lady doctor, a maximum

of six facilities were created in 3 PHCs followed by five facilities in 4

PHCs, four facilities in 1 PHC and two facilities in 4 PHCs. The

facilities in PHCs have been created thinly and in an isolated manner as

against the envisaged plan of creation of a complete package of

complementary facilities in PHCs for facilitating institutional deliveries.

Among the requisite facilities, the post of lady doctor for attending on

delivery cases was envisaged to be most essential, but none of the

sample PHCs had been posted with a lady doctor. Though, a few

facilities like labour rooms, operation theatres and observation wards

57

were available in many of the sample PHCs, such facilities could not be

utilised for attending delivery cases without the availability of lady

doctors. The study found mis-match between the manpower and

essential facilities. Ambulances were available in seven out of 12 sample

PHCs. Availability of Man-power especially the adequacy of doctors

against their sanctioned posts was encouraging, as 75 per cent of doctors

were in position in assisted PHCs, while 96 per cent of them were found

in position in non-assisted PHCs. However, it was observed that the

absenteeism among the doctors from their work places was very high-a

binding constraint in utilisation of health care services in sample PHCs.

On population coverage, the study reported that on an average, a

programme assisted PHC was 68386 people and it was 57705 people by

a non-assisted PHC against the prescribed norm of 20,000 to 30,000

people per PHC. As far as coverage of sub-centres by a PHC was

concerned, it was noticed that at the aggregate level, about 11 sub-

centres were served by a programme assisted PHC and the coverage of

sub-centres by a non-assisted PHC was about 12 sub-centres against the

prescribed norm of 6 sub-centres per PHC. This indicated the fact that

adequate number of PHCs have not been established against their

requirement, leading to not only a negative impact on the quality and

58

delivery of health care services, but also accentuating the problem of

overcrowding in CHCs and district hospitals.

The findings on the utilisation of medical services revealed that

none of the sample PHCs had attended the delivery cases during 1995-

96, pointing out to the reality that such PHCs were not equipped with all

essential complementary facilities including the posts of lady doctors for

attending on delivery cases. The overall fining suggested that Social

Safety Net Programme had not been able to achieve the objective of

facilitating and popularisation of institutional deliveries.

The average utilisation of cases in PHCs with SSNP was 30

cases/day/doctor, while it was 25 in non-assisted PHCs. However, the

inter-PHC comparison of utilisation rate revealed a variation across the

sample states. In the contest of evaluating the utilisation rate of health

care services in PHCs in relation to true performance and functionality

of PHCs, qualitative information gathered by PEO field teams through

their in depth probing and discussions revealed that in the absence of

doctors, the cases coming to PHCs were attended by para-medical and

auxiliary para-medical staff. It was also observed by the field teams that

since the PHCs were not equipped with diagnostic facilities, the patients

preferred to visit tertiary/district hospitals for treatment of their ailments.

59

Illness profile of the beneficiaries who utilised services of PHCs

and their views on services revealed that a maximum of 32.93 per cent

of beneficiaries have sought the treatment for minor ailments, like, cold,

cough and fever. This was followed by the cases suffering from water

borne diseases (14.63%), vaccine preventable diseases (8.54%),

respiratory diseases (8.53%) and gynaecological complications (4.88%)

respectively. Similar results were found for non-assisted PHCs. As

many as 51.22 % of beneficiaries belonging to programme assisted

PHCs were found to be dissatisfied with the functioning of PHCs.

Further, of the dissatisfied beneficiaries, a majority had

complained about medical and para-medical staff of PHCs. The main

reasons for their dissatisfaction included non-availability of medical and

para-medical staff (42.85%), not being examined by doctors (52.38%)

and proper attention not given (35.71%). The second important reason

for dissatisfaction of beneficiaries was the non availability of medicines

in PHCs. About 66.67 per cent of the beneficiaries expressed this view.

Similar results were obtained for non-assisted PHCs also. Despite

inadequacies in the delivery of health care services by PHCs, a vast

majority of about 89 per cent of beneficiaries belonging to programme

assisted PHCs and about 96 per cent beneficiaries from non-assisted

PHCs had still expressed their preferences for PHCs for seeking health

60

care services over other alternative sources of treatment. It was revealed

that 54.88 per cent of beneficiaries belonging to assisted PHCs and

94.12 percent belonging to non-assisted PHCs had incurred private

expenditure on various items while seeking treatment in PHCs. A

majority of 73.33 per cent beneficiaries belonging to assisted PHCs and

52.50 per cent belonging to non-assisted PHCs had incurred private

expenditure below Rs.100 per illness episode. Besides, major chunk of

expenditure made by the sample beneficiaries of all categories was on

purchasing medicines. The income profile of beneficiaries belonging to

programme assisted PHCs revealed that the beneficiaries whose average

monthly income was below Rs.500 have formed a small percentage of

3.66, while a majority (63.41%) of the beneficiaries are from the

monthly income group of above Rs.1000.. Similar results are obtained

for non-assisted PHCs also. The low-income group households seemed

to stay away from the public health care delivery system primarily

because of non-availability of medicine, indirect cost on transport and

high opportunity cost in terms of foregone income (due to loss of wage

income say). They, therefore, seemed to depend on cheaper alternatives,

such as traditional Indian medicines or unqualified medical practitioners.

It was interesting to note that large majority beneficiaries of the public

health delivery system have expressed willingness to pay for the

61

services if the quality of delivery improved. The beneficiaries were

willing to pay 25% of the market cost of treatment if the quality of

delivery improved. About 62% of the beneficiaries replied in the

affirmative.

2.3.5: Primary Health Care system in urban area

The Eighth Plan pointed out that it is not only the rural poor who

are deprived: in large cities, where about 40-50 per cent of urban

dwellers live in slums, their health status "is as bad, if not worse than in

rural areas". Further, "the infrastructure for primary health care in urban

areas hardly exists" (VHAI. 1998).

The following three studies depict the deplorable situation of

urban primary health care system and factors that influence their health

seeking behaviour and the personalised spending for their health

problems.

2.3.5.1: Sonya et all(1996) looked in to whether primary health care is

accessible, available and affordable to the urban dwellers by

interviewing OPD users in Mumbai‟s KEM Hospital, a tertiary care

centre in the middle of the city. Their results of their study revealed that

54% of the patients who attended the OPD came from the urban

unorganized sector. Over two-thirds had earlier gone to a private doctor

but shifted because the treatment didn‟t work, or it became too costly.

62

They did not go to the urban health centre because there was just one

municipal dispensary for a population of 50,000 compared to a private

practitioner for less than 2,000 people in the municipal ward where the

hospital was located. The dispensary could hardly match the coverage of

the private sector or consider itself the main provider of first –level care.

2.3.5.2: Study by Aditi and others (1996) throw some insights in to the

affordability and the accessibility aspects of health seeking behavior.

They surveyed inhabitants of a densely populated ward in Greater

Mumbai with a predominantly lower middle class population to study

the reason for why people travel to distant public health centre to seek

treatment for their illness. They found that financial reasons forced 30%

of those surveyed to travel to another ward for public sector in patient

care. Fifteen per cent went outside for outpatient public care. Apparently

for this group, the cost and inconvenience of travel was less than the

cost of a private hospital. Though the majority of households used the

private sector for outpatient care and slightly fewer for in patient care, a

substantial percentage of households said they would rather go to the

public sector if it were available in the locality.

2.3.5.3: In another study by Garg in 1995 in Dharavi revealed that the

patients of Dharavi rarely used the urban health centre due to lack of

facilities, not being accessible and affordable. Rather they went to

63

private doctors for minor problems or the public tertiary hospital for

major illnesses. When these researchers interviewed patients in that

tertiary hospital to know the reasons retrospectively as to why the

patients came to the tertiary hospital, they found 3.2% of the patients

were not provided with beds, 19.5% were not provided with linen, and

16.3% were not given hospital clothing and 21.1% of them did not have

linen and 27.6% of hospital clothes had never been changed. 68.1% of

the patients had to buy medicines from outside pharmacies. One out of

three had to get tests done outside. Only the poor come to public

hospitals, many of them after being exploited and neglected at private

hospitals.

2.4: FUNDING

2.4.1: Lack of funding has been a fundamental problem to the primary

health care system in India. Funding for the health care in India has

always been insufficient throughout the period since independence even

after the economic reforms introduced from the nineties. In the

following part of the literature review will focus on the funding and the

impact of lack of funding has on the primary health care system in India.

Insufficient funding and consequential use of private health care sector

64

by people made the Eighth Plan to support the philosophy of a

minimalist State position in health (Malavika Karlekar).

2.4.2: A longitudinal analysis by K.N. Reddy and V. Selvaraju(1994) of

GDP, health expenditure between 1974-1991 indicates that though

spending under the heads of family welfare, nutrition, water supply and

sanitation - all clubbed under the health budget -increased, that of

medical and public health declined. Also during the period from 1974-5

to 1990-1, the total expenditure on medical and public health declined

from 62.14% of the relevant budgetary head to 48.62% (Reddy and

Selvaraju 1994).In addition, while salaries accounted for a large

percentage of the outlay, non-salary components such as medicines,

equipment and fuel were inadequately funded (Duggal, 1995).

2.4.3: The Economic Survey presented to the Parliament in 1996 states

that after the introduction of economic reforms, the Central Plan outlay

for programmes of the Department of Health has been stepped up from

Rs. 302 crores in 1992-3 to Rs.670 crores in the 1995-6 period. A large

percentage of these funds are ear-marked for the control of

communicable diseases such as malaria, tuberculosis, leprosy, blindness

and now AIDS (Rs. 421 crores) as well as salaries and maintenance

(GOI 1996).

65

A nation-wide survey conducted by the National Council for

Applied Economic Research to establish the market structures for a

variety of consumer goods revealed a number of things in relation to the

health care funding and people‟s utilization of public and private health

care services. The survey, which was conducted across 6,354 rural and

12,339 urban households in 1992-3, and collected data on morbidity,

health care utilisation and health expenditures in considerable detail,

established the importance of the private sector in health care. For

instance, only 22 per cent of the population in Kerala, 27 per cent in

Uttar Pradesh and West Bengal, 30 per cent in Madhya Pradesh, 37

percent in Bihar and 38 per cent in Maharashtra used public health

facilities (Shariff 1995:17). While the private health markets served two

thirds and more of the sick in Uttar Pradesh, Kerala and Andhra

Pradesh. The survey found that the poorer households spent 7-8 per cent

of their household income on health care as compared to the 2 to 3 per

cent spent by the richer households. The study also noted that per capita

expenses were much higher when individuals used private facilities: for

instance, all-India per capita health expenditures on fees and medicines

only for hospitalised and non-hospitalised medical episodes based on

data from selected urban areas in a number of states was Rs. 2611 for a

public hospital and Rs. 1,115 for a private hospital, and Rs. 36 and

66

Rs.81 for non-hospital expenses in the public and private sectors

respectively. The increasing withdrawal of the State from a vital sector

of developmental activity means that health care for a growing

proportion of the population depends on private institutions and

individuals. It is not surprising, then, that recent health expenditure

studies show that household expenses on medicare are three to four

times higher than that of the government's total health expenditure.

Studies have shown that the chief beneficiaries of domestic expenditure

on health are men and children.

2.4.4: Though the number of Public Health Centres went up almost three

and a half-fold between 1981-91 as against the one and a half-fold

increase between 1971-81, field studies show that not only is there a

concentration in certain states, but also that the large majority of centres

are ill-stocked, inadequately staffed and too far from the target

population. Thus, there was already a crisis in the State-run health sector

prior to 1991; a mere enhancement of funds which are allocated without-

much thought being given to changing needs results in wastage,

underutilisation and in exacerbating already existing inequalities and

imbalances. An evaluation of the public health care infrastructure in the

country in 1996 noted that the system which "caters to the needs of 25-

30% of the population is grossly deficient" (Government of India 1996).

67

Further, a good percentage of the Central budget on health goes on

providing services for its employees through the Central Government

Health Scheme (CGHS). In a situation where about two- thirds of the

total health expenditure goes on personnel, it is not difficult to envisage

how the rest of the money is spent.

2.4.5: The 2002 Health Policy flagged declining public health

investments. It stated that the public health investment in the country

over the years has been comparatively low as a percentage of GDP

decline from 1.3 percent in 1990 to 0.9 percent in 1999. The aggregate

expenditure in the Health sector is 5.2 percent of the GDP. Out of this,

about 17 percent of the aggregate expenditure is public health spending,

the balance being out-of-pocket expenditure. The central budgetary

allocation for health over this period, as a percentage of the total Central

Budget, has been stagnant at 1.3 percent, while that in the States has

declined from 7.0 percent to 5.5 percent. The overall contribution of

Central resources to the public health funding has been limited to about

15 percent.

2.4.6: Further the 2002 Policy commended that for the outdoor medical

facilities in existence, funding is generally insufficient; the presence of

medical and para-medical personnel is often much less than that

required by prescribed norms; the availability of consumables is

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frequently negligible; the equipment in many public hospitals is often

obsolescent and unusable; and, the buildings are in a dilapidated state. In

the indoor treatment facilities, again, the equipment is often obsolescent;

the availability of essential drugs is minimal; the capacity of the

facilities is grossly inadequate, which leads to over-crowding, and

consequentially to a steep deterioration in the quality of the services. As

a result of such inadequate public health facilities, it has been estimated

that less than 20 percent of the population, which seek OPD services,

and less than 45 percent of that which seek indoor treatment, avail of

such services in public hospitals. This is despite the fact that most of

these patients do not have the means to make out-of-pocket payments

for private health services except at the cost of other essential

expenditure for items such as basic nutrition.

2.4.7: The findings of the National Health Accounts for 2001-02 also

came out with some alarming findings on the health care expenditure.

According to the report, in 2001-02, health expenditure was 4.6% of

GDP, out of this expenditure, only 20.3% was public expenditure.

77.4% was private expenditure, with 2.3% originating in external

support, that is, bilateral and multilateral agencies. Classified slightly

differently, households contributed 72% of total health expenditure,

including not just expenses for treating illnesses, but also payment of

69

insurance premiums. State governments contributed 13%, the Central

government contributed 6%, 2% came from external agencies and

private firms (through medical benefits to employees) contributed 5%.

Again classified slightly differently, 70% of financial resources flowing

to health-care providers went to the “for profit” private sector, 23% went

to public providers of health services. The findings also indicated that

the level of public health spending was relatively higher in the states of

Himachal Pradesh, Jammu and Kashmir, Punjab and Kerala while lower

in Uttar Pradesh, Bihar Madhya Pradesh, Orissa and Jharkhand. Private

expenditure was relatively higher in Kerala, Punjab, Haryana and Uttar

Pradesh as compared to Assam, Rajasthan and Orissa. Per capita health

spending in Kerala was the highest while Assam was the lowest in the

country.

2.4.8: The latest GDP figures available for a complete financial year are

for 2006-07 and these show a GDP figure of Rs 37,43,472 crores in

current prices (Central Statistical Organization(2007) Public expenditure

on health is around 1% of GDP and this translates into an annual per

capita figure of around Rs 340(Hindustan Times 2008).

2.4.9: The insufficient funding and the in appropriate allocation of the

funding have caused a number of problems in the staffing patter and

infrastructure facilities in the primary care settings.

70

The number of medical practitioners in 1991 was 4.7 per 10,000

populations (as against 1.7 in 1951); however, almost 50 per cent of sub-

centres, PHCs or CHCs did not have buildings of their own. Indian

Council of Medical Research (ICMR) study on family welfare services

at the Primary Health Centre level in 1991 observed that only 22.6 per

cent of the PHCs had properly equipped operation theatres; in a majority

of PHCs in Bihar, Jammu and Kashmir, Karnataka, Kerala, Madhya

Pradesh, Maharashtra, Orissa, Rajasthan, Tamil Nadu, Uttar Pradesh and

West Bengal, operating theatres were not properly equipped. In short,

PHCs in most parts of the country are ill-equipped. In addition, water

supply was safe in only 71 per cent of the PHCs evaluated (ICMR 1991:

17, 19). A state wise look at infant mortality and poverty figures taking

in to consideration the dismal picture of PHC facilities in the states, it is

indicated that the states of Uttar Pradesh, Orissa, Madhya Pradesh,

Assam, Gujarat, Rajasthan and Bihar had above average Infant Mortality

Rates (IMRs); of these Bihar, Madhya Pradesh, Orissa and Uttar

Pradesh had a larger population living below the poverty line. In other

words, poverty, lack of facilities and high infant mortality rates are

vitally linked. This led the Government of India to admit that "the lack

of buildings, shortage of drugs, equipment etc. constituted major

impediments to full utilisation of these units" (GOI 1993a:206). Further,

71

a government document in 1994 points out that "biases in, favour of

curative vis-a-vis preventive and of secondary and tertiary health - care

facilities rather than primary, need to be corrected" (GOI 1994:153).

2.5: DISEASE PROFILE OF RURAL INDIA

2.5.1: While Park (2000), speaking on the disease profile of rural India,

stated that the majority of rural deaths, which are preventable, are due to

infections and communicable, parasitic and respiratory diseases.

Infectious diseases dominate the morbidity pattern in rural areas (40%

rural: 23.5% urban). Waterborne infections, which account for about

80% of sickness in India, make every fourth person dying of such

diseases in the world, an Indian. Annually, 1.5 million deaths and loss of

73 million workdays are attributed to waterborne diseases.

2.5.2: Deodhar NS(2001) elaborated on the groups of infections.

According to him, three groups of infections are widespread in rural

areas, as follows:

Diseases that are carried in the gastrointestinal tract, such as

diarrhoea, amoebiasis, typhoid fever, infectious hepatitis, worm

infestations and poliomyelitis. About 100 million suffer from diarrhoea

and cholera every year.

72

Diseases that are carried in the air through coughing, sneezing or

even breathing, such as measles, tuberculosis (TB), whooping cough and

pneumonia. There are 12 million TB cases (an average of 70%). Over

1.2 million cases are added every year and37 000 cases of measles are

reported every year.

Infections, which are more difficult to deal with, include malaria,

filariasis and kala-azar. These are often the result of development.

About 2.3 million episodes and over 1000 malarial deaths occur every

year in India.An estimated 45 million are carriers of microfilaria, 19

million of which are active cases and 500 million people are at risk of

developing filaria.

2.5.3: According to Government of India‟s 1996 annual health report

every third person in the world suffering from leprosy is an Indian.

Nearly, 1.2 million cases of leprosy, with 500 000 cases being added to

this figure every year.

2.5.4: According to Mukhopadhyay et al(2001) malnutrition is one of

the most dominant health related problems in rural areas. There is

widespread prevalence of protein energy malnutrition (PEM), anaemia,

vitamin A deficiency and iodine deficiency. Nearly 100 million children

do not get two meals a day. More than 85% of rural children are

undernourished (150 000 die every year).

73

2.5.5: A survey by the Rural Medical College, Loni(2002), in the

villages of Maharashtra State, has revealed some alarming facts. Illness

and deaths related to pregnancy and childbirth are predominant in the

rural areas and are due to the following reasons,

1. Very early marriage: 72.5% of women aged 25–49 years marry

before 18, where the literacy rate is 80%.

2. Very early pregnancy: 75% married women had their first

pregnancy below 18 years of age.

3. All women invariably do hard physical work until late into their

pregnancy.

4. Fifty-one per cent of deliveries are conducted at home by an

untrained traditional birth attendant.

5. Only 28% of pregnant women had their antenatal checkup before

16 weeks of pregnancy.

6. Only 67% of pregnant women had complete antenatal checks

(minimum of three checkups).

7. Only 30% of women had postnatal checkups.

In addition, agricultural- and environment-related injuries and

diseases are all quite common in rural areas, for example: mechanical

accidents, pesticide poisoning, snake, dog and insect bites, zoonotic

diseases, skin and respiratory diseases; oral health problems; socio-

74

psychological problems of the female, geriatric and adolescent

population; and diseases due to addictions.

2.5.6: According to Lalitha‟s (2003) study the morbidity pattern was

similar usual picture in the PHCs-colds, fever, cough, anaemia,

diarrhoea among the general population and hypertension, arthritis,

bronchitis among the aged. Though not common, there were cases of

skin disease, insects‟ bites and wild animal attacks and dog bites.

2.6: AVAILABILITY OF MEDICINES IN PHCs

2.6.1: While writing on the Structural Adjustment Programs on Rural

Health, Balasubramaniam et al(1996) indicated that the availability of

drugs is inadequate in all of the PHC, SC and hospitals that have been

set up by the government over the years.

2.6.2: A case study of Coimbatore and Sivaganga districts by N.Lalith

from IESE, Navara(2003), entitled „ A Access to Medicines: Initiatives

in policy making and delivery of drugs-A case study of Tamil Nadu‟

suggested that medicines were insufficient, there were lack of

equipment to transport the drugs.

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2.7: PEOPLE’S HEALTH AND DECENTRALISED HEALTH

CARE PLANNING IN INDIA

2.7.1: Involvement of the community and decentralised planning are

some of the major indicators of primary health care services. However,

there has not been much people‟s participation in India in planning for

their health. In this context, WHO(1997) commended that though the

concept of primary health care is appropriate to rural areas, it remained

sound on paper only because of the deliberate attempts of health

professionals. Further, WHO reiterated that the present system has not

left any scope for the involvement of the community, nor for grassroots

level health workers to take ownership of the programs and integrate

them with overall development. The concept of placing a community-

selected person from the village, and providing them with essential

training so that the community can cope more effectively with its health

problems, was the centrepiece of the PHC. As a result, the basic

requirements of decentralised people based, integrated curative,

preventive and promotive services have been totally undermined by the

„vertical programs‟.

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2.8: PRIMARY HEALTH CARE SYSTEM IN KERALA

2.8.1: Health Development indicators - Kerala & India - 2007 (a report

by the directorates of Health services) revealed that Kerala's remarkable

achievements in health in spite of its economic backwardness has

described "Kerala Model of Health" which is worth emulating by other

developed countries. The hall mark of Kerala model is low cost of health

care, universal accessibility and availability even to the poor sections of

the society along with many socio-economic conditions unique to the

state such as high female literacy rate (87.72%). The widely accepted

health indication viz death rate, Infant Mortality Rate (IMR) and

expectation of life at birth too are far advanced than the rest of the states

in India and are even comparable with developed countries. Such that in

Kerala, the expectation of life has increased, infant mortality rate is very

low and there is decline in death rate. Also the health awareness among

the citizens of the state maintains to be at a very high level.

In the state, there exist 7831 public health institutions. Of this,

71.8% are PHCs (including sub centres), 8.2% are CHCs and 11% are

hospitals (censes 2001). Apart from this there are 81 co-operative

hospitals functioning effectively in Kerala. The number of sub-centres

continuous to be 5074 for the last 12 years and there is a sub-centre for

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every 6.16 sq.km and a primary health centres for every 33.3 sq.km

there by assuring the accessibility of health care to the downtrodden

section of the society. In terms of health personnel, there are 25225

medical and para medical personnel and there is one medical officer for

every 8244 population in Kerala.

Despite, better health outcomes, the much-proclaimed Kerala

model of health have started showing a number of disturbing trends.

Although mortality is low, the morbidity (those suffering from diseases)

both from urban and rural Kerala is high in Kerala compared to other

Indian states. Thus the paradox is that on the one side Kerala stands as

the state with all indicators of better health care development in terms of

IMR,MMR, birth rate, death rate etc. on the other it outstrips all other

Indian states in terms of morbidity especially the chronic illness.

The morbidity analysis of Kerala reveals that the attack of acute

diarrhoeal diseases, measles, pneumonia, pulmonary tuberculosis,

dengue fever etc is the major diseases dominating the health profile of

the state. The attack and death of a mammoth of population has

happened due to vital illness - chikungunyas. Moreover, many

epidemics that were supposed to be eliminated from kerala are staging a

come back. Higher prevalence of mental health problems including

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higher suicide rates, health problems and death due to road traffic

accidents and other traumas comprise the health picture of Kerala.

Ageing is another area of concern of Kerala health that accounts

for hike in morbidity. As life expectancy increases there is high

incidence of disease associated with aging and life style diseases.

Sedentary life styles, lack of physical activities and obesity increases the

risk of chronic and life style diseases.

In terms of the health care funding, Kerala spends fairly

substantial amount on medical and public health compared to other

Indian states {Rs. 96049.66/- (2005-06)}, yet public health system is

getting alienated from the common man due to lack of medicines and

sophisticated infrastructure facilities in the government hospitals. Thus,

public health centres are being utilised mostly for maternal and child

health care programmes especially for immunisation schemes. This has

led to the impetus growth of the private medical care set up in the state

and the dependence on private health care is quite high even among the

lower expenditure classes and rural areas. In the changing scenario, the

private sector reigns supremacy in the infrastructure and health

manpower development than public sector in the state.

As the state is moving into a consumerist society, the

commercialization and the commoditisation of health care are rampant

79

in the state. Thus the state's health scenario is slowly drifting towards

the decay of public health system, uncontrolled growth of private sector,

escalation of health care cost and the presence of communicable, non-

communicable and life-style diseases. (Human Development Report –

2005).

2.8.2: Varatharajan et al (2004) evaluated the Performance of Primary

Health Centres under decentralized government in Kerala, India,

through a rigorous research methodology.

The overall methodology of the study indicated that the study

was conducted in three stages. The first stage included all 990 village

panchayats in Kerala. The second stage covered 10 panchayats (their

respective 10 PHCs and 65 sub-centres) occupying the top five and

bottom five ranks in terms of resource allocation to health. Two

panchayats (their respective PHCs and sub-centres), one each from the

top five and the bottom five, were chosen for the third stage.

The date collection was done using the published and unpublished

government data, panchayat development reports, panchayat and PHC

records, and facility checklist. Additionally, the key informant and client

exit interviews were also used for data collection. The study took also in

to account the intermediary changes in a PHC, such as access, quality of

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infrastructure and machinery, cost-effectiveness, services offered and

quality of care.

The facility checklist covered availability, functioning and

financial source of 41 routine items within the PHCs and sub-centres,

including equipment, drugs, supplies, staff, access and quality of

infrastructure. Infrastructure included six items: building structure,

toilet, clean running water, electricity, communication and wash basin.

Access included eight items: size of the building vis-à-vis patient

load, home visits by the PHC staff, facility hours, patient records,

waiting area, patient privacy, and distribution/display of health

education materials and display of community statistics. The checklist

was filled by using PHC and sub-centre records, by actual observation

of facilities and by questioning health-care delivery staff. Items such as

buildings, toilet, drinking water, electricity, communication, washbasin,

waiting area, patient privacy, and display of community statistics and

distribution of health education materials were observed and graded for

their quality. The choice of panchayats and subsequently PHCs were

based on the ranking of panchayats according to resource allocation to

health per se. Meanwhile actual PHC receipts were taken into account in

order to assess the impact of panchayat support.In the second stage data

collection consisted of perusal of records, and key informant and client

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exit interviews. Structured and pre-tested schedules (separate for

panchayats, PHCs and sub-centres) were used for interviews. Key

informant interviews elicited information on budget, cost, financial

sources, PHC and panchayat characteristics, panchayat–PHC linkages,

and steps to improve PHC performance. Client exit interview, on the

other hand, focused on illness, services received, access frequency, staff

behaviour, diagnosis and measures to improve efficiency.

The study also brought out some significant findings regarding

the beneficiaries‟ opinion on the determining factors of a well

functioning PHC, budget and cost components of PHC. The majority of

the informants participated in this study opined that strength of a PHC is

indicated by:

1. Uninterrupted supply of medicines and water

2. Presence of doctor for longer time and extended out patient hours

3. Provision of adequate facilities

4. Good doctor-client relationship

5. Good doctor-staff relationship and participatory PHC management

6. High quality care

7. Intense field activities

The informants were also of the opinion that the efficiency of a

PHC has to be judged by the level of supply of medicines and that

82

prescriptions to buy medicines from outside should be viewed as

indicative of inefficiency.

All major cost components (salary, investment, maintenance, patient

care, building, furniture and equipment) were included in the cost

estimation after converting non-recurrent items into annualized figures.

Equipment, instruments and furniture items were first listed and expert

opinion was sought to find out the value and expected life of each item

in order to arrive at the annualized figures. A cross-sectional analysis of

two contrasting scenarios of high and low resource (monetary and

material) support from panchayats was employed to demonstrate impact,

because the panchayats‟ control over PHCs is essentially derived from

the amount of resources they allocate to them. The result indicated that

all the panchayat and PHC informants felt that panchayat intervention

would strengthen PHCs and listed five possible roles for panchayats in

strengthening PHC such as

1. Providing medicines

2. Facilitating the implementation of national health programmes

3. Constructing buildings

4. Conducting routine maintenance work

5. Improving (clinical and non-clinical) facilities.

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The overall results indicated that:

1. Panchayats in Kerala allocated a lower proportion of resources to

health than that allocated by the state government prior to

decentralization; while panchayat resources grew at an annual

rate of 30.7% and health resources grew at 7.9%.

2. PHCs were funded to the extent of 0.7–2.7% of the total cost. An

additional 2% in PHC resources was associated with improved

patient load (63.5%), cost-effectiveness (50.8%), medicine

supply (49.4%), information (32.8%) and patient satisfaction

(12.7%).

3. And suggested an annual increase of US$940 in PHC resources

would help to extend primary care facilities to 3000 (15.5%)

more users.

The authors have concluded their study by establishing that

decentralization brought no significant change to the health sector.

However, saying that active panchayat support to PHCs existed in only a

few places, but wherever it was present, the result was positive. The

authors had also suggested an action plan for the improvement of the

primary health centres, that Kerala should find an alternative strategy to

channel panchayats towards health before health loses its battle for

resources.

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2.8.3: Mala Ramanathan (2003) studied the Structure, facilities and

service delivery context of primary health care system in Kerala . The

indicated that there are 944 PHCs and 5,094 sub-centres in Kerala, PHC

serves 30,732 people and covers a radial distance of 3.4 km, utilisation

remained steady at 40% during 1987-97. The study covered 50 taluks,

250 block public health centres, 15 PHCs, 230 reproductive health

centre, 20 patients per day, and 100 health centre. According to the

study, in RH – 1, One PHC did not have a doctor for several months

during the previous year, Facility for Medical Termination of Pregnancy

(MTP) was available at one Block PHC and the Taluk hospitals and two

of these had indoor facilities for recovery, Surgical sterilisation for

women was available at one Block PHC and both Taluk Hospitals.

Vasectomy for men was possible only at one Taluk Hospital, Available

Facilities for RH - 2, Contraceptive commodities like oral pills,IUDs

and condoms were available, 4 PHCs, BPHCs & taluk hospitals had

store for contraceptive commodities, Some drugs for treatment of RTI

were available during the previous year.

About the Infrastructure, the study revealed that The patient

examining rooms in all the facilities were clean and had adequate

lighting, Two PHCs and the block PHCs and the Taluk Hospitals had

seating arrangements for the patients where as four of the PHCs did not

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have adequate seating arrangements, Only three PHCs (3/10) lacked

clean drinking water and toilets, Electricity supply was interrupted in

most Health centres and standby arrangement available in block PHC

and taluk hospitals.

Regarding equipments, all the study units had sterilising

equipment of some kind, except for one block PHC and one PHC all

others had disposable syringes available for use , all the units in the

study had blood pressure gauge available , Nine of the 10 facilities had

ILRs available.

With regard to the Equipments and records, 3 PHCs had height &

weight scales of infants and adults,1 PHC had operation theatre

(furnished & equipped) but was never used, All PHCs maintained

records of eligible couples and 4 of them updated them recently. She

concluded that PHCs less equipped for many reproductive health needs,

Taluk hospitals – 50 patients /day, Taluk hospitals - Better equipped,

Women doctors were available , Quality service and heavy patient load,

inadequate waiting space in PHC.

2.8.4: Baburajan PK Verma RK (1991) studied Job satisfaction among

health and family welfare personnel in Kerala by interviewing 88 staff

members from 2 Public Health Centres (PHCs) in Kerala State through a

job satisfaction questionnaire (Paliwal and Sawhney Scale). The PHCs

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were selected as better as and worse than average in family welfare

performance. They were similar in socioeconomic and topological

features, but PHC I had twice the population, proportionally more staff,

and a medical officer with a degree in management. PHC I averaged 8

staff meetings monthly to update training in hygiene, immunization, oral

rehydration therapy, and maternal and child care. PHC I kept records

and charts such as maps of disease occurrence, lists of personnel

assignments, daily record flow, and program monitoring charts. PHC II

held monthly meetings only. Interviews of doctors from PHC I revealed

concern for quality of care and incentives for family planning acceptors,

training, teamwork, and supervision of staff; PHC II doctors saw

problems in the infrastructure, and commitment of local leaders.

Paramedical staff concerns were similar at the 2 centers. The mean

scores on the job satisfaction scale were 50.7 for PHC I and 50.5 for

PHC II. 25% of staff from both centers combined were not satisfied

with their jobs. Those expressing dissatisfaction tended to be older, with

longer work experience, or not to be given housing. Of all the variables

analysed, chance of being promoted explained 58% of the variance in

job satisfaction, proper facilities explained 15%, but salary was not

significant.

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2.9: BENEFICIARIES’ OPINION ON THE PHC

2.9.1: The primary health care system in India has been dysfunctional

and not geared suitably to serve the health needs of the people due to

many reasons as has been established above with the help of available

literature. There have been many studies which looked in the popularity

and the satisfaction of service beneficiaries of PHCs in the context of

scare resources and poor quality of the services provided.

2.9.2: Kamat (1995) looked in to the popularity of primary health

centres in India by assessing a village in rural Maharashtra using case

study method. The findings of the study indicated that:

1. The popularity of the primary health centre is centered around the

popularity of the doctor, and the popularity of the doctor is

centered around the doctor‟s ability to manage the PHC situation

and the patients rather than his clinical expertise or medical

degrees.

2. PHC doctor engages in private practice along with the

government job, and there is a lot of interfacing between the

private and the government practice irrespective of the places

where the doctor sit for consultation whether it is his private

residence , government quarters and the PHC.

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3. The reported illness and frank symptoms in the PHC fell in to 12

broad categories, ranging from cough/ cold, diarrhea to TB and

leprosy.

4. Regarding the utilization of the health care facility and the

preventive health care services, the majority of the people who

were affected by these illnesses were found to be using the PHC

doctor as the first resort to deal with these illnesses. As for the

utilization of the preventive health services in the PHC, majority

of household had at least one member who utilized immunization

services, anti natal and post natal services, taken treatment for

malaria, received oral rehydration therapy, and undergone

sterilization. However, attendance at eye camp organized by the

PHC, maternity services, treatment for snake bite and scorpion

sting, dog bite, leprosy, acceptance for contraceptives, and

seeking treatment for tuberculosis were below fifty percent. The

reason for non utilization of the services was associated with non

perception of such need for treatment and the lack of awareness

about such services.

5. Seventy four percent of the respondents felt that PHC had

brought some good benefits to the house hold, while the

remaining felt that PHC was a show piece of the government that

89

did not serve the real needs of the people. Sixty two percent of

the people felt that the health activities in the centre would bring

benefits to the people in the future. 56% evaluated the PHC staff

as hard working and efficient. According to the majority of the

respondents, the accessibility, availability and the affordability

were the main of the reasons for the popularity of the PHC.

Community participation in the PHC activities was very low and

reported that they had no opportunities provided to them to do so.

The most of the participation were politically motivated and the

PHC activities were controlled by the politicians.

2.9.3: Government of India (2001)‟s result of Evaluation Study

conducted by the Programme Evaluation Organisation on Functioning of

Primary Health Centres(PHCs) assisted under Social Safety Net

Programme revealed that as many as 51.22 % of beneficiaries belonging

to programme assisted PHCs were found to be dissatisfied with the

functioning of PHCs. Further, of the dissatisfied beneficiaries, a

majority had complained about medical and para-medical staff of PHCs.

The main reasons for their dissatisfaction included non-availability of

medical and para-medical staff (42.85%), not examined by doctors

(52.38%) and proper attention not given (35.71%). The second

important reason for dissatisfaction of beneficiaries was the non

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availability of medicines in PHCs. About 66.67 per cent of the

beneficiaries expressed this view. Similar results were obtained for non-

assisted PHCs also. Despite inadequacies in the delivery of health care

services by PHCs, a vast majority of about 89 per cent of beneficiaries

belonging to programme assisted PHCs and about 96 per cent

beneficiaries from non-assisted PHCs had still expressed their

preferences for PHCs for seeking health care services over other

alternative sources of treatment.

2.10: CONCLUSION

This literature review has covered a wide variety of topics on

primary health care system in India. The review of literature done so

far over all indicates that the primary health care system in India is

dysfunctional. While extensive, it is wasteful, inefficient and delivers

very low quality health services, so much so that the private sector has

become the de facto provider of health services in India (Nirupam

Bajpay et al(2009). The geographical and quantitative availability of

primary health care facilities, though extensive, is far less than the

guidelines laid down by the government. As has been pointed out,

people are more likely to use a medical facility if it is closely located,

especially in rural areas. Access is important but people‟s experiences of

what the facility has to offer in terms of medical care and whether it is

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worth their while to use it are equally important in terms of their

incentives to utilize health care facilities. People‟s perceptions of „free‟

care is that of it being of low quality, and therefore, even the available

infrastructure is grossly underutilized, i.e. the public health care system

in India suffers from gross supply side distortions that go beyond

physical availability. This affects the delivery of basic services to its

large population of poor whose quality of life depends in crucial ways

on public goods. Though buildings are available, the simple availability

of a building designated as a public health facility is no guarantee that it

is functional, and if functional, it is inaccessible to groups of people who

may be restricted in their use of public health care services on account of

their caste, religion, gender and language. Even setting aside socio-

economic barriers to access and assuming the presence of a public health

facility close at hand, the delivery of quality health care services is not

guaranteed. The infrastructure is of poor quality and there is severe lack

of even basic drugs and equipment. This is especially true for rural

areas, and with regard to women‟s and children‟s health. Maternal,

infant and child morbidity and mortality rates are intolerably high in

India. Not only social justice but economic efficiency ie to protect the

health and well-being of its future generations.