Ever wondered why our government hospitals look like homeless shelters? Why are there so many people sleeping in their corridors? Do we have too few hospitals? Or too few doctors? The reasons are aplenty; one of the main ones is the poor realisation of a theoretically sound policy.
India’s current public health set-up is often traced to the Bhore committee of 1946. The committee’s continued relevance signifies its foresight, and our inability to achieve its recommendations. For instance, it recommended setting up 75-bedded hospitals for a population of 10,000 to 20,000. The bed to population ratio, 70 years later, is 9 per 10,000.
The three-tiered government health centre model that forms the core of the National Health Mission (NHM), has evolved from the committee’s recommendations. There is a base of sub-centres and primary health centres which are the first points of contact for the patient with the government health system. These centres are capable of a basic set of services, which includes conducting normal (vaginal) deliveries.
If the patient’s needs are beyond the services available, she is referred to a higher centre which houses specialists. These community health centres (CHC) cover 80,000 to 1,20,000 people, and have a physician, a gynaecologist, a surgeon, and a paediatrician.
Health and Medical Care
For even more complicated procedures and diseases, the patient is further referred to district hospitals (DH; also called tertiary centres). This system of graded care with referral linkages helps to bring health and medical care close to a patient’s home and ensures timely treatment.
The network of this infrastructure comprises 1.5 lakh SC, 25,000 PHC, 5,600 CHC and 760 DH. This still falls short of the population norms mentioned above, by 19-30%. While the brick-and-mortar gap should be plugged, it is worthwhile to take stock of whether these 2 lakh institutions are working efficiently. If they were, our public health pyramid would not currently be balancing on its tip.
Studies show that more than 50% of patients at tertiary centres are only in need of primary care. One can also use this inverted pyramid to partially explain why so many patients choose to visit quacks, euphemistically referred to as rural medical practitioners.
The latest round of National Family Health Survey 2015-16 which had a sample of 5.7 lakh households, shows that the most common reasons for non-availing of services at government health centres are poor quality of services, no nearby health facility, and long waiting lines.
To address these issues, firstly, the public healthcare system in India needs to build a reputation for credibility. SCs are being transformed to health and wellness centres (HWCs) under the Ayushmaan Bharat programme. This transformation will entail a reorientation of SC from beyond the historic focus on reproductive and child health to include non-communicable diseases, oral health, emergency medical care, etc.
Secondly, a humble acknowledgement of the limitations of the public healthcare sector needs to be made and an assessment of the complementarities of the private sector should be done. While Niti Aayog has been encouraging states to take up a PPP model for setting up hospitals, the regulatory environment must also incentivise more single doctor clinics to plug the rural-urban inequality.
Thirdly, technology has been tested to improve access and its quality. Tata Trusts and the Karnataka government put forth the ‘Digital Nerve Centre’ which merges the last two suggestions. It uses tele-medicine, video-conferencing and e-appointments systems to improve patients’ experience. While there may be limitations in its scalability, such innovative interventions need to be tried out across the country.
With government spending on health stagnating at 1% of GDP, capacity building of the existing institutional framework will be a challenge. Much hinges on creating an ecosystem of partnership and innovation which brings to the fore a renewed vigour for improving India’s healthcare system.