Describe the rural health care delivery system in India.

The Three-tier Rural Structure

• The sub-centre is the most peripheral and the first point of contact between the community and the health system
• Its norm — one per 5,000 population in plain areas and one per 3,000 in hilly, tribal and difficult areas
• Its staff — one female health worker (ANM), one male health worker (MPW-M), and, in a Health and Wellness Centre, a community health officer
• Its functions — maternal and child health; family planning; immunisation; nutrition; diarrhoeal disease control; control of communicable disease; and health education
• The sub-centre performs NO curative work of consequence and has no inpatient facility, which is both its definition and its limitation
• The primary health centre (PHC) is the first contact point between the community and a medical officer
• Its norm — one per 30,000 population in plain areas and one per 20,000 in hilly and tribal areas, covering six sub-centres
• Its staff — a medical officer (increasingly two, one being AYUSH), a pharmacist, nurse midwives, a health assistant male and female, a laboratory technician and support staff
• Its facility — 4 to 6 indoor beds, with a laboratory and a pharmacy
• Its eight functions are examinable as a list — medical care; MCH including family planning; safe water and basic sanitation; prevention and control of locally endemic disease; collection and reporting of vital statistics; health education; national health programmes as relevant; and training of health guides, workers and health assistants
• The community health centre (CHC) is the first referral unit (FRU)
• Its norm — one per 120,000 population in plain areas and one per 80,000 in hilly and tribal areas, covering four PHCs
• Its staff — four specialists — a surgeon, a physician, an obstetrician-gynaecologist and a paediatrician, with 21 paramedical and other staff
• Its facility — 30 beds, an operation theatre, labour room, X-ray, laboratory and blood storage
• The three criteria that make a CHC a functioning first referral unit must be known, since a CHC that lacks them is not one in practice — the capacity to provide round-the-clock emergency obstetric care including caesarean section; newborn care; and blood storage
• The commonest reason an Indian CHC fails to function as an FRU is the absence of an anaesthetist, without whom no caesarean section can be performed whatever else is present — which makes the anaesthetist the binding constraint on the entire emergency obstetric system
• Above the CHC — the sub-divisional hospital and the district hospital, which is the secondary-level apex of the district, followed by medical colleges and specialist institutes at the tertiary level
• The village level — the ASHA, one per about 1,000 population; the anganwadi worker under ICDS, one per about 1,000; the village health sanitation and nutrition committee; and the trained DAI

Performance, Problems and Reform

• The INDIAN public health standards (IPHS), introduced in 2007 and revised since, prescribe the minimum assured services, staff, drugs, equipment and infrastructure for each level
• Their purpose is to convert a norm about population into a standard about service — since a building with the right name is not a health centre
• The strengths of the Indian system — an extensive network reaching almost every village; free services at the point of use in the public sector; successful delivery of immunisation, family planning and national programmes, including the elimination of smallpox, polio, guinea worm, yaws and maternal and neonatal tetanus; and a large community-level workforce
• The problems, which should be stated frankly:
• Shortfall against the norms themselves, particularly of CHCs, and above all of specialists, of whom the shortfall at CHC level is very large
• Absenteeism and vacancy, especially in remote and tribal areas
• The doctor who will not stay rurally, for reasons that are understandable and must be addressed rather than deplored — housing, schooling for children, professional isolation, absence of equipment and support, personal security, and no career progression
• Shortage of drugs, equipment and diagnostics
• Poor quality of care and long waiting
• Weak referral linkages, both upward and downward
• Curative bias, with preventive work displaced by outpatient load
• Fragmentation into vertical programmes competing for the same worker’s time
• Low public health expenditure as a share of national income, which is the root of most of the above
• Consequent very high out-OF-pocket expenditure and dominance of the private sector, which provides the majority of outpatient care even to the poor
• The fact that the poor use private providers is the most telling indictment of the public system, and it reflects perceived reliability, availability and attitude rather than ignorance — a private practitioner is present, open at convenient hours and gives medicine, whatever their qualification
• The reforms:
• The national health mission, with the ASHA, untied funds, decentralised planning and flexible financing
• The IPHS
• Health and wellness centres under Ayushman Bharat, which upgrade sub-centres and PHCs and expand their mandate from selective maternal and child services to comprehensive primary care including non-communicable disease, mental health, ophthalmic, ENT, oral, elderly and palliative care
• The community health officer, a nurse or AYUSH practitioner with bridge training, placed at the sub-centre level — a mid-level provider created to fill the gap between the ANM and the medical officer
• Free drugs and free diagnostics initiatives, which address the largest single component of out-of-pocket spending
• Telemedicine (e-Sanjeevani) and digital health under the Ayushman Bharat Digital Mission
• Quality assurance through NQAS and Kayakalp
• The principle that should conclude — the structure is sound and the coverage is nearly universal; what is lacking is staff, supplies and quality at the facilities that already exist, so the priority is to make the existing network function rather than to build more of it
• The anaesthetist is the binding constraint on emergency obstetric care, whatever else the CHC has
• The poor choose private providers deliberately, because someone is present, open at convenient hours and gives medicine
• Make the existing network function rather than building more of it, since coverage is already nearly universal
• Hilly and tribal norms are roughly half the plain-area population, recognising that terrain determines access
• One sub-centre per five thousand in plains and three thousand in hilly areas, which is the figure to state
• The PHC is the first contact with a doctor, covering thirty thousand people and six sub-centres
• The CHC is the first referral unit, covering a hundred and twenty thousand and four PHCs, with thirty beds
• Four specialists staff a CHC — surgeon, physician, obstetrician and paediatrician
• An FRU needs caesarean, newborn care and blood, all round the clock, or it is not one in practice
• IPHS converts a population norm into a service standard, since a building with the right name is not a health centre
• Specialist shortfall at CHC level is very large, which is the single greatest structural weakness
• Address why doctors will not stay rurally — housing, schooling, isolation, equipment and career progression
• The community health officer fills the gap between the ANM and the medical officer, as a mid-level provider
• Free drugs address the largest out-of-pocket item, which makes the initiative more than a gesture
• India eliminated smallpox, polio and guinea worm, alongside yaws and maternal tetanus, which is worth stating
• Curative load displaces preventive work at the PHC, which is a predictable consequence of understaffing
• Low public health spending is the root of most of the other problems in the list
• Health and Wellness Centres expand the mandate to non-communicable disease, mental health, elderly and palliative care
• The sub-centre is the first point of contact between the community and the health system, with no inpatient facility
• Referral fails downward as well as upward, since patients are rarely sent back with instructions
• Telemedicine partly substitutes for absent specialists, which is why e-Sanjeevani matters more in remote districts
• The PHC has four to six indoor beds, a laboratory and a pharmacy, which defines what it can and cannot do