Primary concerns

Strap: The time for goal-setting is over. We need actionable plans at the local level if we want to ensure Universal Health Coverage

There is always a chasm between goal and reality when it comes to accessing healthcare in India. So though the theme of this World Health Day is Universal Health Coverage: Everyone, Everywhere and focusses on primary health care and party manifestoes talk about free services and treatment, fact is altruistic desires seem vapid when confronted with reports that our public hospitals lack basic infrastructure and most importantly doctors. The time for introspection is now over, it is now time to address this gap permanently.

The new World Health Organisation (WHO) report — the World Health Statistics 2019, published to coincide with World Health Day — highlights the need to improve access to primary health care worldwide and to increase uptake. India has recognised this gap realistically with the Union Ministry of Health and Family Welfare and the WHO forming a ‘Solidarity Human Chain’ on April 4 to reaffirm their commitment to bridging gaps and working collaboratively towards Universal Health Coverage.

The current state of affairs

It’s is a disturbing fact that  even after 72 years of Independence, the country’s fundamental aspects of primary health care lie in shambles if the Comptroller and Auditor General (CAG) India’s assessment of The National Health Mission (NHM) is anything to go by. The mission was launched in 2005 as India’s largest health programme aimed at providing universal access to healthcare. The CAG came out with its report in 2017 which was based on a survey across 1,443 sub-centres, 514 primary health centres, 300 community health centres and 134 district hospitals.

  1. The CAG reports say most healthcare clinics (primary health centres, sub-centres and community health centres) across 28 states and union territories of India face 24 to 38 per cent medical staff crunch. Observers noted a shortfall of 50 per cent in availability of staff at health centres in Bihar, Jharkhand, Sikkim, Uttarakhand and West Bengal. Bihar reported shortages in community health centres by as much as 92 per cent.
  2.  Almost 73 per cent of sub-centres were more than three kilometres from the remotest village, 28 per cent were not accessible by public transport and 17 per cent were in an unhygienic condition.
  3. In 24 states, instances of non-availability of essential drugs were also observed. In eight of these states, essential medicines and consumables such as vitamin-A, contraceptive pills, oral rehydration solution (ORS) packets and essential obstetric kits were not available at some health facilities.
  4. The report also suggests that 77 per cent to 87 per cent of community health centres have been functioning without specialist doctors like gynaecologists and paediatricians.
  5. The CAG also noted that 17 states had not used equipment for the ultrasound, X-ray, ECG, cardiac monitoring machines due to the non-availability of doctors and trained professionals.

The World Bank has further estimated that 90 per cent of all health needs can be met at the primary healthcare level. But India has grossly neglected the area that should matter the most.


The Government rolled out the biggest publicly funded healthcare plan (Ayushman Bharat) last September. It has two components, the Health and Wellness Centres (HWCs) for primary health care and Pradhan Mantri Jan Arogya Yojana (PMJAY) for secondary and tertiary care. Under the scheme, 1,50,000 HWCs need to be operationalised by 2022 closer to where people live in the rural and urban areas. At the launch of the ‘Solidarity Human Chain’, Union Health Secretary Preeti Sudan said that more than 17,000 HWCs are operational across the country and are providing services for non-communicable diseases in addition to existing services for reproductive and child health, communicable diseases etc.

The government claims that operationalisation of HWCs in some pockets has started showing results and has reduced out of pocket expenditure (OOPE) incurred by the patients. It cited a study conducted by IIT-Madras in the HWC pilot district in Tamil Nadu where OOPE was as low as Rs 3 per outpatient visit. However, some ground reports say that operational H&WCs are not able to provide all services promised at centres which include non-communicable diseases and maternal and child health among others.


Apprehensions are that the acute shortage of qualified medical professionals in rural India may impact the relaunch of 150,000 health sub-centres and primary health centres as HWCs. Second, the distribution of health professionals is skewed in favour of cities. A report of WHO (2016) says that against the needy 70% population in rural areas, only 40% pf the country’s 2-million strong health workforce caters to rural India. Third, India’s health spending at present is only 1.15-1.5 of GDP, woefully short of its ambition to increase public health spending to 2.5% of GDP as recommended by National Health Policy 2017. This is far-far less than the world average of 6%.

One of WHO’s triple billion goals is for 1 billion more people to have universal health coverage by 2023. But, filling the huge gap of trained human resources in healthcare, justifying their distribution and developing attendant infrastructure are the biggest hurdles for India in achieving WHO’s goal. Much has been talked about making the health a fundamental right. But, right without resources cannot be of any use.


Experts suggest some drastic changes in public health policies. Former Union Health Secretary (Retd) and public health expert P K Hota says that since Independence, “we have provided substandard health services in the name of social sector responsibilities and not factored in hidden costs that have allowed the private sector to reap the benefit.” He says instead of relying on foreign research works and agencies, India needs its own goal and solutions, keeping in the mind its own unique problems.

Vouching for standard services at standard cost, he terms Ayushman Bharat as a cart put before horses. “When standard services are assured at standard costs, only then will Ayushman Bharat be realistic. Otherwise it would be diverting hard earned public money to the private sector”, says Hota.

Advocating a separate health services cadre and a health corporation of India, Hota says, “The health sector has more governance than investment issues. We need to increase governance in health sector and bringing the managerial talent so that doctors can be assisted to do their best.” Hota suggests the inflow of institutional finances into the health sector.

Shailaja Chandra, independent policy analyst and former secretry to the Government of India & former chief secretary of Delhi, says that her research paper (Unqualified Medical Practitioners- The legal, Medical and Social Dimension of Their Practice) shows that in majority of rural areas, people are dependent on jhola chaap (quacks) doctors and roughly 20 per cent people are able to access primary health centres (PHCs) as they are at least 5 km away from the village of the affected. But then these lack doctor, staff, medicine, and facilities.

To provide last mile connectivity and mimise the risk of wrong diagnosis and medication, Chandra suggests that a system be evolved where locals (including jhola chaap doctors) should be invited, tested by experts and get enrolled as auxilliary medical workers after two years of training. “There should be a model where four-five such auxilliary medical workers be put under supervision of a PHC doctor or any authorised private doctor. This can bring some standard primary health services to a community,” says Chandra. This connect between end-use and resource base must be reconciled before any more ambitious targets are set.

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