80% of the diseases can be prevented or cured at the primary level only. And that is why corporates cannot provide primary care as providing primary care would affect the profit that they can make through secondary or tertiary careA doctor in an intense discussion with medical students
These students were in Swasthya Swaraj’s clinic on an exposure visit in Kalahandi, Odisha. Coming from a city, I had never really understood the role that primary health care played in up keeping the overall health of the population. But in the last several months, it has become a term that I have been hearing and using extensively. A reference made to Alma Ata Declaration in this particular discussion led me to begin to understand what the term truly encompasses.
Post-independence, India adopted a health services system based on the recommendations of the Health Survey and Development Committee Report, 1946 under the chairmanship of Sir Joseph Bhore. The Bhore committee report, as it is popularly known, highlighted the need for developing strong basic health services at the primary level with referral linkages
The committee was clear that the inability to pay out of pocket for health services should not prevent people from accessing them. Thus, India adopted a public health system based on the principles of universality and equity. The committee also laid emphasis on the social orientation of medical practice and inter-sectoral linkages. The objectives of the first and second Five year plans were to develop the basic infrastructure and manpower as visualized by the Bhore committee. Through the third to sixth plan and committees, the focus shifted widely from family planning to vertical campaigns against communicable diseases to strengthening the health infrastructure in the rural areas.
The sixth plan was influenced by two policy documents: the Alma Ata declaration of 1978 and the 1981 ICMR-ICSSR report called ‘Health for All: An Alternative Strategy’. The Alma-Ata declaration strongly reaffirms that health is a fundamental human right whose attainment requires inter-sectoral cooperation. The ICMR-ICSSR report was in fact a move to realize the goals of the Alma Ata declaration. It reiterated the need to integrate the development of the health system with the overall plans of socio-economic and political change.
The declaration led to the formulation of India’s first National Health Policy in 1983. The National Rural Health Mission was launched in 2005 to carry out the architectural correction in the basic healthcare system. Ayushman Bharat was introduced in 2018 to give a further push to provide comprehensive primary healthcare.
All these plans, recommendations and reports highlight certain basic features of a primary healthcare system like accessibility, affordability, community participation/involvement, strong referral linkages, continuation and comprehensive care. It is in this light that I am analysing the functioning of Balisara subcentre in the Thuamul-Rampur block of Kalahandi, Odisha.
Time and again it has been reiterated that primary healthcare has to be accessible to the community. Facets of accessibility include physical accessibility, financial affordability, and accessibility beyond socio-political and cultural barriers. It also means the adequate availability of service in terms of the number of centres proportional to the population, doctors, paramedical staff, medicines, and diagnostic kits. The sub-centre under study serves 20 villages and a population of 4596 individuals. It comes under the Nakrundi Primary Healthcare Centre (PHC) in Thuamul-Rampur block, Kalahandi. There are 17 sub-centres in the Thuamul-Rampur block with two PHCs—Nakrundi and Adri.
The Balisara subcentre is on the main road connecting to the Community Health Centre (CHC). There are bus services available to reach the subcentre which improves its physical accessibility without adding excessive financial strain on patients. Both Auxiliary Nurse Midwifery (ANM) and male health worker (MHW) are available there at any time of the day. There is also an adequate stock of medicines and diagnostic kits at the centre. Under the Ayushman Bharat scheme of 2018, the primary healthcare centres (both PHCs and sub-centres) were renamed as ‘Health & Wellness Centres’ and a new post of Community Health Officer was introduced at the sub-centre level. He/she would be a staff nurse; however, the post has been vacant in the Balisara sub-centre for the past several months.
To make healthcare more accessible and closer to people, it is envisaged by the National Health Mission that there will be Village Health and Nutrition Day (VHND) and immunisation camps. The Auxiliary Nurse and Midwife (ANM) at the Balisara sub-centre said that they have grouped the villages into 7 groups and rotationally visit these 7 groups every Friday and Tuesday to put up VHND camps and every Wednesday to put up an immunisation camp.
Apart from the travel expenses to the sub-centre (which were to be addressed by the outreach camps), there are no expenses on the clinic front for a doctor consultation, medicines or other tests – they are free of cost.
Providing comprehensive care at the primary level means addressing all health problems for people of all ages and all genders while also integrating preventive, curative, promotive and rehabilitative care—all at the primary level. A major focus of Balisara subcentre has been the ANC checkups for pregnant women and growth monitoring for under-five children. When we asked the men in the villages about camps the ANM holds, they told us straight away that they don’t know anything and redirected us to the women in the village.
The primary focus of the centres has been pregnant women and under-five children with little regard to other genders or age groups. Vertical programmes related to mothers and children are given the utmost importance. Essential medicines for fever, diarrhoea and other illnesses are handed over to the patients who come to the centre. Even though malaria is endemic to the region, TB rates are really high; there is no rampant testing and preventive counselling given in this aspect. The disease load of other communicable diseases is also high in the region. Other services related to childhood and adolescent health care services, family planning and other reproductive health care services are not addressed in the sub-centre. Preventive counselling is provided in the camps and the centre mainly related to ante and postnatal care. Rehabilitative care is out of question at this level.
The Alma-Ata Declaration and the Bhore Committee report both have emphasized community participation and cooperation for achieving the goal of ‘Health For All’. Community participation is assessed through their participation in the camps held, how the ANM are held responsible for their work, people following the advice given, and the ability of the patients to identify the primary healthcare provider and locate the centre.
The men in the villages under study were aloof about the camps held, while all the women respondents were quite sure of the dates when they mostly come for the camps. All of them were able to locate the sub-centre quite clearly and identify the ANM/MHW.
Consider, in comparison, a village served by a different subcentre; when the community was asked to locate the subcentre, they were neither able to locate it nor identify the service provider. This can be a function of both poor community participation and the dysfunctionality of the centre. From my interactions with the healthcare providers, it was clear that whenever a camp is held, the participation of women and children has always been high except during harvesting season or other festivities.
For receiving curative care, most of the community members mentioned that they don’t get good quality care at the PHC and therefore they go to the Kaniguma clinic run by the NGO, Swasthya Swaraj. The community itself determining what is the quality of healthcare they require indicates higher levels of community involvement. While we focus on providing comprehensive health care at the primary level, having a strong referral system and following up of the patients both ways is also important. Early detection of any complex illness, prevention of a disease from worsening, reducing the OOP expense for visiting the higher level care centres frequently are some of the benefits of providing comprehensive care at the primary level.
The Balisara sub-centre has a very strong referral system. They refer patients to either the CHC in Th Rampur or the District Hospital in Bhawanipatna. The Nakrundi PHC under which the sub-centre functions is run in PPP model and it is dysfunctional. This was agreed by both the sub-centre staff and the community. Though the referral system is strong, following up with patients or ensuring the continuity of their treatments are hardly given any preference.
One of the important factors determining the utilisation of health care services is how the patients are treated, their interaction with the staff and their satisfaction. Most of the women unanimously agreed that there was absolute warmth and care that they receive from the ANM and other staffs at the CHC or DH. The men, however, disagreed, saying that they had not been treated well, mostly been shouted at. Some of them added that they were given the same tablets for all the illnesses and that they were dissatisfied with the service. There were instances when few members of the community spoke of the caste-based discriminatory treatment they received as the staff members were of upper castes.
The Balisara subcentre under the Nakrundi PHC of Th Rampur block functions much better than the other subcentres and the PHC itself. The Kerpai subcentre under the same PHC functions as a storehouse for the Panchayat office. The state of the PHC is even more pathetic. The ANM of both the Saisurni and Balisara subcentres themselves stated that they have no links with the PHC. All the reporting and referrals happens directly to the CHC. The unavailability of doctors at the PHC is an open secret. On further enquiry, we got to know that both the PHCs in this block have been run in a public-private partnership (PPP) model for more than five years. Unpacking this model and its on-ground realities will be explored in future blogs.
Primary healthcare is the backbone of the health system in our country. It is the day-to-day care needed to protect, maintain or restore health. It is mostly utilised by people of middle to low-income groups for whom it becomes the first point of contact and most frequently used health service. When a majority of cases are diagnosed and treated at the primary level, the caseload in general hospitals/medical colleges or any tertiary care hospitals will be reduced; which will in turn improve the quality of care received at these tertiary centres. Comprehensive primary healthcare also improves the performance of health systems by lowering health care expenditure while improving the overall health of the population.
Structural deficiency, staff vacancy, the pressure for political leaders to not report the actual data, the reluctance of doctors to be at the primary healthcare level, target-oriented vertical programmes are the other contextual complexities in the implementation of primary health care system that came up in the discussions with public health professionals and doctors.
Through the Balisara sub-centre, the blog tries to illustrate the functioning of a sub-centre in a tribal area. Though we cannot generalise the status of all sub-centres across rural areas, the realities the community contends with at the Balisara sub-centre surely point to certain similarities. These ground realities caution us against a blind belief in the successes of our public healthcare system. What exists today is a far cry from the original philosophy of primary healthcare approach. Indicators that measure the effectiveness and efficiency of primary healthcare need to be developed and analysed. Monitoring these indicators will help in making course corrections and appreciating the contributions of primary health care toward the attainment of ‘Health for All’.