Sub-centres, run by a team of an auxiliary nurse midwife, a male multi-skilled health worker and health assistants, are short of staff while primary health centres do not have enough doctors.
The acute shortage of qualified medical professionals in rural India may impact the relaunch of 150,000 health sub-centres and primary health centres (PHCs) as “health and wellness centres” under Ayushman Bharat Yojana, the national health scheme launched on September 23, 2018.
A lesser known part of the health insurance programme, also called ‘Modicare’, comprises health and wellness centres that will have a critical role in controlling the growing burden of non-communicable diseases in India. They will also offer maternal and child health services. The problem is that sub-centres, run by a team of an auxiliary nurse midwife, a male multi-skilled health worker and health assistants, are short of staff while primary health centres do not have enough doctors:
Of the 156,231 sub-centres in India, 78,569 were without male health workers, 6,371 without auxiliary nurse midwives and 4,263 without either, according to Rural Health Statistics, 2017.
PHCs require 25,650 doctors across India to tend to a minimum of 40 patients per doctor per day for outpatient care, as per Indian Public Health Standards (IPHS). If these standards are met, 1 million patients could be benefit everyday. But with a shortage of 3,027 doctors, 1,974 PHCs are without doctors. This means that 12 per cent, or 121,080 patients, go without access to primary healthcare everyday.
Healthcare in India’s villages is a three-tier structure under the National Rural Health Mission (NRHM): Sub-centres, primary health centres and community health centres.
Sub-centres are at the forefront, covering 5,000 people in the plains and 3,000 in hill or tribal areas. PHCs are equally important for the Ayushman Bharat Yojana to succeed because they are the first link to a consultation with a medical doctor and act as referral points for specialist consultations at community health centres.
Strengthening both the PHCs and sub-centres will ease the burden on secondary and tertiary health institutions.
Failure to find enough doctors will also set back universal health coverage as envisioned by successive National Health Policies in 2002 and 2017.
Seventy per cent of India’s population lives in villages and 30 per cent in urban areas. But the distribution of health workers leaves rural India with little access to healthcare — 60 per cent of the country’s 2 million strong health workforce caters to urban India, only the remaining 40 per cent services villages, as per data from a 2016 World Health Organisation (WHO) report.
There is another issue the proposed centres will have to deal with: Health-workers practising in both urban and rural areas of India are not adequately qualified, as per the WHO study. Among urban and rural allopathic doctors, only 58 and 19 percent doctors, respectively, were medically qualified.
As for nurses and midwives practising in rural areas, only 33 per cent have studied beyond secondary school and 11 per cent have medical qualification, the report estimated.
A perception survey of patients who visited healthcare facilities more than once showed that 43 per cent patients, on average, across four states were not satisfied with the medical treatment provided by the health facilities.Of the patients surveyed, 34 per cent complained of staff absenteeism, 32 per cent of shortage of medicines, 13 per cent of long waits; 3 per cent said centres were shut, 2 per cent claimed that there were no facilities at all and the remaining 5 per cent alleged different acts of corruption, according to the 2011 report by the High Level Expert Group on Universal Health Coverage.
A potential area of concern for the new wellness centres could be the reliance of rural patients on non-degree allopathic practitioners (NDAPs), or practitioners without an MBBS, according to a study carried out in Uttar Pradesh and Bihar.
Studies in rural Karnataka, Andhra Pradesh and Odisha have shown reliance on private practitioners for multiple reasons. The biggest of these is the lack of easy access to public health facilities: 73 per cent sub-centres were more than 3 km from patients, 28 per cent sub-centres and 20 per cent PHCs were not accessible by public transport, concluded an IndiaSpend analysis of a Comptroller and Auditor General report.
The easy availability and proximity of an NDAP allowed for faster consultation, according to this 2014 study carried out in north India. “Embedded in the community, the NDAPs have adapted their services to people’s needs, preferences and economic capabilities”, making them the preferred resource for “all-in-one” services, the study said.
Poor living and working conditions, irregular drug supply, weak infrastructure, professional isolation and the burden of administrative work: These are some of the challenges faced by doctors on rural postings, stated a 2017 study by the Public Health Foundation of India.
As of 2018, India has 497 medical colleges registered with the Medical Council of India (MCI) that together offer an intake capacity of 60,680 seats for MBBS. Trends in India, as well as other BRICS nations such as South Africa, suggest that most doctors prefer to sign up for hospital-based specialisations in urban areas than get into general practice at PHCs, a 2015 study published in Human Resources for Health observed.
To address this, policy frameworks in several states have mandated compulsory rural service of 1-5 years during postgraduate medical studies. Further, some states require medical officers to practise medicine in rural areas for a particular period after postgraduate studies.
Mid-level health providers could be the solution to the shortage of doctors in rural areas, according to this report of a national consultation on strengthening rural healthcare, 2018.
“A key challenge that India faces is that even after diagnosis, people continue to use health care services in secondary and tertiary settings, for conditions which can be managed at the primary care level,” said Chandrakant Lahariya, the national professional officer, Universal Health Coverage, WHO.