With its tales of murder, intrigue and corruption, the alleged health scam in Uttar Pradesh has raised questions about accountability and transparency in the National Rural Health Mission (NRHM).
Since its launch, the NRHM budget has tripled from Rs10,040 crore in 2005-06 to Rs30,456 crore in 2011-12. However, increased allocations have done little to improve the average Indian’s chances of receiving quality healthcare.
Here’s what a patient visiting a public health facility is likely to encounter: crumbling infrastructure and no doctors. According to the 2009 concurrent evaluation of NRHM, on average only 76% primary health centres (PHCs) in India had electricity connections and 37% had piped water supply.
Crumbling infrastructure would be less of a problem if doctors were available. Vacancies, as we reported last year in this series, are high. In 2010, on average 20.7% of sanctioned doctor posts in PHCs were vacant. Specialists are harder to find. In 2010, 42% of such posts in community health centres (CHCs) were vacant. Worse still, only 35% of the required specialist posts had been created.
But filling the vacancies is unlikely to increase a patient’s chances of meeting a doctor since doctors at the centres rarely show up for work. The last national study on doctor absenteeism in 2006 placed attendance at 60%. A more recent 2009 NRHM evaluation by the Planning Commission focusing on four states found that attendance had actually declined. On a random visit to Rajasthan, only 36% and 31% of medical officers were present in PHCs and CHCs, respectively. Uttar Pradesh did marginally better with 44% attendance in CHCs and 36% in PHCs. Bihar reported attendance of 40% in CHCs and 0% in PHCs.
If a patient is lucky enough to visit a public health facility and find a doctor, there is still no guarantee that she would receive quality care. As economist Jishnu Das argues, “Getting doctors to come to work is one part of the problem; getting them to put in the effort to provide care is the other challenge." A study conducted by him and fellow economist Jeffrey Hammer on the quality of medical care in Delhi found that competence levels among MBBS doctors in a PHC were so low that there was a 50:50 chance of a doctor prescribing harmful therapy. In treating diarrhoea, for instance, a typical doctor recommended harmful treatment three quarters of the time.
This is not a consequence of poor training but lack of effort. The study found that on average, public practitioners spend less time and less effort on treating patients. When confronted with hypothetical situations, 30% doctors knew to ask the right questions but only 10% actually asked them.The contrast with private non-MBBS doctors is striking. While these doctors were far less qualified and had less professional knowledge, they put in greater effort. This is not necessarily in the patients’ favour because there is a tendency to overmedicate.
Much of the policy preoccupation with human resources is limited to the question of vacancies and shortages. The government regularly tracks these and some state governments have introduced incentives to bring doctors to rural areas. Chhattisgarh and Assam introduced a diploma course to create a new cadre of healthcare practitioners in rural areas. The discussion on human resources in the recently released report on universal health coverage by a high-level expert group focuses almost exclusively on bringing skilled professionals to public facilities. The report estimates human resource requirements, argues for the need to set up more medical colleges and knowledge centres and has even developed a potential career trajectory for front-line practitioners and health managers.
Sadly, this just misses the point. The fact is that public doctors today are governed by an incentive structure that severely compromises accountability to patients. They are paid a salary, with minimal supervision and no sanctions for poor performance. What then are the incentives to show up for work and provide quality care?
This is exacerbated by the fact that the private sector provides a lucrative alternative for public doctors. It is no secret that many public doctors run private clinics and often use public facilities as referrals for their private practice. This affects doctor behaviour in unexpected ways. As Jeffrey Hammer points out, medical officers often discourage other doctors from practising in public health facilities in the area for they see them as competition in the local market. In such a scenario, simply hiring more medical officers may not ensure results.
Acknowledging these realities is critical for identifying the right solutions. On Wednesday, the government announced its intention to boost public spending on healthcare to 2.5% of gross domestic product over the next five years (the 12th Five-Year Plan starting April). If this increased expenditure is to yield results, the focus must shift to doctor accountability and to linking incentives to quality care and improved outcomes. While solutions to these complex problems are found, simple measures such as tracking absenteeism, regular disease surveillance and providing patients with information on what doctors should and should not do (so that patients can at least question doctors’ behaviour) will serve us far better than putting more public money into the current system.
Yamini Aiyar is director, Accountability Initiative, Centre for Policy Research. Data collected and analysed by Avani Kapur and Anirvan Chowdhury, also from Accountability Initiative, Centre for Policy Research, Delhi.