Kamla is a young mother in a north Indian village. Her one-year-old, Gopi, has been suffering from high fever. She decides to visit the auxiliary nurse midwife (ANM) at a health sub-centre in the neighbouring village. Kamla and her husband are subsistence-wage farm labourers with no means of transport. In blazing sun, carrying Gopi, Kamla walks 5km to see the ANM. Realizing the severity of Gopi’s condition, the ANM advises Kamla to take him to the next higher facility.
To appreciate Kamla’s challenges, it’s important to understand India’s rural public health system. It is a tiered structure. At the bottom of the pyramid are sub-centres, catering to a population of 3,000-5,000 each, roughly five villages. Primary health centres (PHCs) are the first base for doctors, acting as referral units typically for six sub-centres. PHCs function as the core, and flow into community health centres (CHCs), followed by sub-district and district hospitals. At the apex are medical colleges and advanced research institutes such as the All India Institute of Medical Sciences.
Impressive though it looks, the system is broken for large segments of India’s population. National surveys indicate that less than half the households approach government medical institutions. Poor healthcare quality, absence of facilities nearby and long waiting times are common. Only 11% sub-centres, 13% PHCs and 16% CHCs meet the Indian Public Health Standards.
Turning back to Kamla. Her first task is simple yet challenging—getting Gopi to the PHC. The only public transport is an unreliable bus that stops far away from her village. Luckily, she manages a lift from her sympathetic neighbour. Arriving at the PHC, Kamla is in a quandary. Wading through crowded corridors, she sees the one doctor available. Gopi is critical and needs to be admitted. Sadly, this first essential point of medical care has neither the diagnostics nor beds available to handle Gopi’s case.
If Kamla does manage to reach the CHC or even the district hospital, things aren’t necessarily better. There is an 82% shortfall in total surgeons, obstetricians and gynaecologists, physicians, and paediatricians across CHCs in India, according to the government’s Rural Health Statistics 2017. I have observed run-down establishments, unhygienic labour rooms, absence of qualified doctors and unskilled nurses in numerous facilities. This may needlessly end up a tragic journey for Kamla.
Undeniably, facilities require urgent attention. There are two elements. One is fundamental—strengthen infrastructure, improve physical access and ensure adequate human resources. This itself need not take time. It’s a question of spending. What is worrying is that we don’t see adequate government health spending, and nor has that changed in recent times. Dramatic announcements in the recent Union budget included upgrading 150,000 facilities into “health and wellness centres". These would provide comprehensive healthcare including free essential drugs and diagnostics. The allocation for this is Rs1,200 crore. Assuming this is spent on revamping just half the target, it amounts to Rs1.6 lakh per centre. It will take orders of magnitude more than that to achieve transformation.
But useful things can be done in the interim. Let’s look at the crucial issue of skill gaps and staff shortages. Nurse mentoring is one recourse. A mentoring team to cascade knowledge on proper delivery, birth care and managing complications can plug gaps. In terms of infrastructure, at least basic life-saving equipment has to be the point of focus. From our experience, many primary facilities lack necessities like sterilization equipment for infection control, functional newborn care corners in labour rooms, oxygen supply and even emergency drugs.
None of this changes without political will. If there are active and aware communities, strong enough to demand health as their fundamental right, political will would be that much stronger. Media and influentials need to get involved. Their voices influence policies, and their implementation. Finally, what led Kamla to her plight? Prolonged diarrhoea ultimately caused Gopi’s critical state. This could have been identified and treated much earlier if the community was well-informed and front-line health workers were sharing data.
To sum up, five short-term actions must be carried out. Build staff capacity through nurse mentoring. Ensure availability of critical basic equipment. Raise community demand to draw political will. Influence policy through media and influentials. And improve effectiveness of grass-roots health workers.
Ashok Alexander is founder-director of Antara Foundation. His Twitter handle is @alexander_ashok