CHAPTER - II REVIEW OF LITERATURE - Shodhganga : a...
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CHAPTER - II
REVIEW OF LITERATURE
2.1: Introduction
2.2: Current Picture of the Primary Health Care System in Rural India
2.3: Rural-Urban Inequalities
2.4: Funding
2.5: Disease Profile of Rural India
2.6: Availability of Medicines in PHCs
2.7: People’s Health and Decentralised Health Care Planning in India
2.8: Primary Health Care System in Kerala
2.9: Beneficiaries’ Opinion on the PHC
2.10: Conclusion
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CHAPTER 2
REVIEW OF LITERATURE
2.1: INTRODUCTION
In this chapter, the researcher is making an attempt to critically
evaluate the existing primary health care systems by going through the
literature available on this subject. Some of the research studies in the
subject areas carried in India, the official reports by the state
government and the central government and the articles published in the
peer reviewed journals have formed sources of this literature review.
2.2: CURRENT PICTURE OF THE PRIMARY HEALTH
CARE SYSTEM IN RURAL INDIA
The report by World Bank (1996) indicated that owing to scarcity
of resources, the existing public health system has been unable to
provide care to all. At present as many as 135 million Indians do not
have access to health services. Despite the Bhore Committee‟s
recommendations in 1946 of the provision of one health centre for every
20 000 people, the country currently has one PHC per 31 000
population. Even the existing public health facilities run with abysmally
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low resources. Just for example; presently, an average Indian PHC has
as its budget only Rs 1 per capita for drugs. Since 1996, there has been
lot of improvement in organization and delivery of primary health
services in India. However, the picture is still below the standards set up
by the health authorities and agencies in the country and abroad.
2.2.1: Neesha (2005), evaluating the role of primary health centres in
India, highlighted that primary health centres are the solution to global
problems of lack of equity, lack of efficiency, lack of effectiveness and
lack of responsiveness of their health systems. Based on the results of
many international studies conducted on the primary system, Neesha
argued that primary health care is essential health care based on
practical, scientifically sound and socially acceptable methods and
technology made universally accessible to individuals in the community
through their full participation and at a low cost. According to her the
strength of a country‟s primary care system is associated with improved
population health outcomes for all-cause mortality, all-cause premature
mortality, and cause-specific premature mortality from major respiratory
and cardiovascular diseases. This relationship is significant after
controlling for determinants of population health at the macro-level
(such as GDP per capita, total physicians per one thousand population,
percentage of elderly) and micro-level (such as average number of
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ambulatory care visits, per capita income, alcohol and tobacco
consumption).
Neesha also reiterated the benefits of the improved access to
primary healthcare stating that the gate-keeping function of the primary
health care system could lead to less hospitalisation, less utilisation of
specialist and emergency centres and less chance of patients being
subjected to inappropriate health interventions. In low-income settings,
the cost effectiveness of PHC compared to other health programmes has
been reinforced by World Bank findings. Selected primary healthcare
activities such as infant and child health, nutrition programmes and
immunisation appeared as „good buys‟ compared to hospital care and
such interventions could save a large population of deaths. Thus, it is
evident that the success of health systems exists in tapping the existing
potential and making appropriate structural changes. In this context, the
role of primary care should not be defined in isolation but in relation to
the constituents of the health system.
Neesha also presented the idealistic picture of the Indian primary
health care centres as the cornerstone of rural healthcare which
characterises as the first port of call for the sick and an effective referral
system, being the main focus of social and economic development of the
community, the first level of contact, and a link between individuals and
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the national health system. Indian primary health care system brings
healthcare delivery as close as possible to where people live and work, is
promotional, preventive, curative and rehabilitative care centre and
offers a wide range of services such as health education, promotion of
nutrition, basic sanitation, the provision of mother and child family
welfare services, immunisation, disease control and appropriate
treatment for illness and injury. She also pointed a number of positive
approaches used in the developing countries in order to improve primary
care services such as capacity building and encouraging community
involvement.
Having given an idealistic picture of primary health care system
in India, Neesha also critically analysed the present health status of the
Indian population and primary health care scenario in India and
observed that fertility, mortality and morbidity are high in India. The
reasons for such a scenario are poverty and low levels of education and
poor stewardship over the health system. She stated that India‟s primary
healthcare system is based on the Primary Health Centre (PHC) which is
unable to detect diseases early due to lack of multi-disciplinary medical
expertise, laboratory facilities and insufficient quantities of general
medicines, patients usually not visiting PHCs in the early stages of their
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diseases and healthcare providers are forced to focus only on seriously
ill patients due to the volume of cases.
According to her, in India, there are not only pre-existing
inequality in healthcare provisions, but these pre-existing inequalities
are enhanced by difficulties in accessing it, which is due to
geographical, socio-economic or gender distance. Added to those are the
lack of political commitment, inadequate allocation of financial
resources to PHCs and stagnation of inter-sectoral strategies and
community participation. There are also bureaucratic approach to
healthcare provision, lack of accountability and responsiveness to the
general public and incongruence between available funding and
commitments. In this context, Neesha quoted the World Health
Organisation (WHO) by specifically pointing out that the current PHC
structure is extremely rigid, making it unable to respond effectively to
local realities and needs, political interference in the location of health
facilities often results in an irrational distribution of PHCs and sub-
centres. Government health departments are not focused on measuring
health system performance or health outcomes, lack of health
management experience among the District Health Officers, lack of
accountability, no formal feedback mechanism and incentive to treat
citizens as clients, lack of resources, which is acute in some states.
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2.2.2: In 1995, Dreze and Sen observed that “India has poor health
achievement despite spending comparatively large part of its GNP on
health when public and private spending taken together, due to
malfunctioning of the public health care system especially in the rural
areas. In some states, this system is a little more than a collection of
deserted primary health centres, filthy dispensaries, unmotivated and
chaotic hospitals‟‟.
2.2.3: Abhijit Das (2009) described the pitiable face of present primary
health care scenario in the rural India by detailing some of the health
indicators of the people in the central and northern states of India.
Abhijit observed that shark disparities exist in the health care
infrastructure and services available to the rural and urban Indians. His
findings on the rural health care infrastructure and services are of great
interest in the context of the present study. Das stated that less than 50%
of primary health centres (PHCs) had a labor room or a laboratory, and
less than 20% had a telephone. Less than a third of these centres stocked
very cheap but essential drug like iron and folic acid.
Despite major advances in medical science, people continue to
die in large numbers from preventable illnesses like tuberculosis,
gastroenteritis and malaria in the central and northern states of India.
500000 of people succumb to tuberculosis alone. Emergency services
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for delivery complications are unavailable outside cities, resulting in
maternal death rates in the northern states. He states that even this trend
is greater than maternal deaths rates in sub-Saharan African countries.
India accounts for a fourth of all maternal deaths worldwide, and the
numbers are increasing. Uttar Pradesh has a huge population base and
very poor health system. Therefore, UP contributes to a large proportion
to the overall preventable mortality and morbidity in the country.
According to Das, even the existing health care delivery system in Uttar
Pradesh is preoccupied with pulse polio campaign and chasing family
planning targets, rather than dealing with treating patients or controlling
diseases.18 states that have weak public health indicators, including the
seven north eastern states, and 11 states in north and eastern India.
The provision of curative services at the peripheral level is an
area of weakness in present government healthcare service delivery.
There is an acute shortage of medical officers.
2.2.4: Further, a recent study conducted by the Rural Medical College,
Loni(2002) on functioning of the PHCs has revealed the following facts
on qualification of the general practitioners in PHCs, risk to patients‟
lives due to irrational cost effective calculation by the doctor,
beneficiaries‟ lack of awareness about the PHC staff, programmes and
the facilities.
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According to the study, 80% of general practitioners in PHCs
practice western medicine (allopathic medicine) without proper training.
73% of the doctors consider cost to be the most important factor when
prescribing a drug, without considering pharmacological properties.
75% of the beneficiaries were not aware of the Government-run Primary
Health Centre (PHC) or village sub centres and also did not know the
names of the medical officer at the PHC; half (53%)of the respondents
did not know the health workers in their own area. About 67% of the
respondents had knowledge of various national health programs but only
33% participated. Over 68% received information regarding the health
programs through the media, and only 28% received information
through public health staff. About 74% of PHCs provided family
planning services, mainly oral contraceptives and condoms. General
practitioners provided services to pregnant women (65%), but only 35%
of the cases were registered. Almost all general practitioners routinely
handle cases of diarrhoea, but only 29% knew the exact composition of
oral dehydration solution (ORS); amazingly, none knew the right
method to prepare the ORS packet.
2.2.5: Lalitha‟s (2003) looked in to the availability of medicine at
primary health centres and access for the patients in the state of Tamil
Nadu and found that in 2003 there were 1411 PHCs and 8682 health sub
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centres in Tamil Nadu. According to her study, an important factor that
decided the accessibility of health services was the location of the PHC.
Lalitha also studied the infrastructure and the functioning of
PHCs in her study area along with the main objective of studying the
availability of drugs in the PHCs. In all PHCs, no positions of the doctor
and the auxiliary mid wife were vacant. The study also found that the
doctors had good rapport with the patients and the patients liked the
way, the doctors motivated them. All of the PHCs had their own
building with a few infrastructural equipments were unavailable.
Regarding the funding, the study reported that the budget
allocated for the drugs and the surgical equipments were under special
schemes and under other schemes. Department of public health allocated
the highest amount of funds. Only 5 percent of the total funds were
meant to buy the medicines. Some of the PHCs reported that if they did
not get special funds allotments under the special schemes, shortages
would occur.
In terms of drug procurement, majority of the PHCs had to travel
between 50 and 90 KMs to collect their drug from the district
warehouse. Some did not have vehicle of their own and had to depend
on the main PHCs vehicle to bring their stock. However, in reality, only
two or three PHCs stocks could be collected in one trip due to space
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constraint in vehicle. A few PHCs did not depend on the main PHCS
vehicle rather they either hired a private vehicle or depended on the
public transport services.Doctors in general observed that the drugs
available in the PHCs covered all their needs.
Further Laitha‟s observation indicated that rich and poor,
illiterate and the literate made use of the PHCs services. Women and
children attended the PHCs for their health needs. The most of them
were regular users and were able to describe the improvement in the
quality of the PHCs services from the previous times. The patients were
able to get their medicines from the PHC itself. The availability of the
doctors was almost 100 percent whenever a patient visited the PHC.
2.2.6: Ashok et al(2002), writing on the rural health scenario in rural
India, commended on the relationship existing between the socio
economic inequalities and poor health indicators of the population. They
observed that even after 54 years of independence and after a number of
urban and growth-orientated developmental programs having been
implemented, nearly 716 million rural people (72% of the total
population), half of which are below the poverty line (BPL) continue to
fight a hopeless and constantly losing battle for survival and health.
2.2.7: The authors have observed that the policies implemented so far
which concentrate only on growth of economy not on equity and
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equality have widened the gap between „urban and rural‟ and „haves and
have-nots‟. Nearly 70% of all deaths and 92% of deaths from
communicable diseases occurred among the poorest 20% of the
population. They stated that though some improvement has happened
over the last 54 years, however, interstate, regional, socioeconomic
class, and gender disparities still remain high. The authors had compared
these achievements, though significant, to the poorest nations of sub-
Saharan Africa. They blamed the socioeconomic, cultural and political
onslaughts, arising partly from the erratic exploitation of human and
material resources have endangered the naturally healthy environment
(e.g. access to healthy and nutritious food, clean air and water, nutritious
vegetation, healthy life styles, and advantageous value systems and
community harmony). The basic nature of rural health problems is
attributed also to lack of health literature and health consciousness, poor
maternal and child health services and occupational hazards.
2.3: RURAL-URBAN INEQUALITIES
2.3.1: The literature also point towards the reality that there exists rural–
urban inequalities in terms of organization and delivery of primary
health care services.
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2.3.2: Duggal (1997) observed that it is unfortunate that while the
incidence of all diseases are twice higher in rural than in urban areas, the
rural people are denied access to proper health care, as the systems and
structures were built up mainly to serve the better off. While the urban
middle class in India have ready access to health services that compare
with the best in the world, even minimum health facilities are not
available to at least 135 million of rural and tribal people, and wherever
services are provided, they are inferior. While the health care of the
urban population is provided by a variety of hospitals and dispensaries
run by corporate, private, voluntary and public sector organisations,
rural healthcare services, mainly immunisation and family planning, are
organised by ill-equipped rural hospitals, primary health centres and sub
centres.
The budgetary allocation for health programmes and services
have been always insufficient, and even the rural and urban investment
pattern has been uneven with the result of health of rural people
suffering. The total expenditure on health in India is estimated as 5.2%
of the GDP; public health investment is only 0.9%, which is by far too
inadequate to meet the requirements of poor and needy people
(Duggal,1997). The supplies in the Centres have attributed to gross
underutilisation of the infrastructure. Successive 5-year plans allocated
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less and less (in terms of per cent of total budget) to health. A major
share of the public health budget is spent on family welfare. While 75%
of India‟s population lives in rural areas, less than 10% of the total
health budget is allocated to this sector. Even here the chief interest of
the primary health care is diverted to family planning and ancillary
vertical national programs such as child survival and safe motherhood
(CSSM) which are seen more as statistical targets than as health
services. It is estimated that 85% of the PHC budget goes on personnel
salaries.
2.3.3: According to Government of India‟s report (2001), there is a
marked concentration of health personnel to maintain the heavy
structures, in the urban areas. Of the 1.1 million registered medical
practitioners of various medical systems, over 60% are located in urban
areas. In the case of modern system (allopathic) practitioners, as many
as 75% are in cities.
As a result, a large number of unqualified people (quacks) have
set up medical practice in rural areas, and the rural population as a result
exerts pressure on urban facilities. Curative care, which is the main
demand of rural people, has been ignored in terms of investment and
allocation. In addition, the percentage share of health infrastructure for
rural areas has declined from 1951 to 1993(GOI, 2000).
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In the case of medical research, a similar trend is observed. While
20% of research grants are allocated to studies on cancer, which is
responsible for 1% of deaths, less than 1% is provided for research in
respiratory diseases, which accounts for 20% of deaths.
In 2001, Government of India released result of Evaluation Study
conducted by the Programme Evaluation Organisation on Functioning of
Primary Health Centres (PHCs) assisted under Social Safety Net
Programme. This study comprehensively highlights the good and bad
aspects of the primary health care system in India.
2.3.4: In 1992-93, under The Social Safety Net Programme (SSNP),
World Bank initiated family welfare programmes in 90 poor performing
districts for a period of five years. Those 90 districts were characterised
by high maternal mortality rate and low levels of institutional deliveries.
The programme had envisaged to reduce the maternal mortality rate by
creating essential health infrastructural facilities including the post of
lady doctor in the identified PHCs for facilitating institutional deliveries
of pregnant mothers.
The programmes insisted that certain essential infrastructural
facilities were required to be created in each PHC which included (a)
well equipped operation theatre, (b) labour room, (c) an observation
ward, (d) two quarters, one each for auxiliary nurse mid-wife and lady
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health worker, (e) a generator, (f) provision of supply of safe drinking
water (g) an ambulance. In addition, however, the post of a lady doctor
is required to be created by the concerned state governments. The
amount sanctioned per PHC was Rs.10.00 lakh.
The study assessed the impact of SSNP simultaneously through a
combined design i.e while carrying out the field survey on CHCs,
information on relevant aspects of sample PHCs were collected. The
same methodology was adopted in the case of the study on functioning
of CHC. Both primary and secondary data were generated through
sample survey. A multi-stage sample design was adopted for the study.
The sample units at different stages were: States, Districts, PHCs and
patients. The first sample units were the six states initially selected to
represent the good and poor health status of the population by using
infant mortality rate as a stratifying parameter. However, the study
eventually was confined to the selected districts in the three states of
Haryana, Orissa and Uttar Pradesh where the programme was
implemented. The study design has adopted with and without approach
to yield therapeutic results and, therefore, two districts - one assisted and
the other not assisted under SSNP were selected from each state in the
second stage of sampling. In the third stage, four PHCs from each
district were selected. Eight patients from each PHC were selected in the
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fourth stage of sampling. In nutshell, 167 patients, 24 PHCs spread over
six sample districts of three states were selected for the study. In each
selected village, the views of the knowledgeable persons were taken for
preparation of qualitative notes on functioning of PHCs.
The evaluation study had come out with the following results
regarding the Health Infrastructure in PHCs in terms of their availability
and adequacy. During 1995-96 none of the 12 assisted sample PHCs
was found to be equipped with all the eight essential facilities; viz; well
equipped operation theatre, labour room, observation ward, two
quarters, generator, drinking water, ambulance and lady doctor that were
required to be created in each PHC. Of the eight essential
complementary facilities including the post of lady doctor, a maximum
of six facilities were created in 3 PHCs followed by five facilities in 4
PHCs, four facilities in 1 PHC and two facilities in 4 PHCs. The
facilities in PHCs have been created thinly and in an isolated manner as
against the envisaged plan of creation of a complete package of
complementary facilities in PHCs for facilitating institutional deliveries.
Among the requisite facilities, the post of lady doctor for attending on
delivery cases was envisaged to be most essential, but none of the
sample PHCs had been posted with a lady doctor. Though, a few
facilities like labour rooms, operation theatres and observation wards
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were available in many of the sample PHCs, such facilities could not be
utilised for attending delivery cases without the availability of lady
doctors. The study found mis-match between the manpower and
essential facilities. Ambulances were available in seven out of 12 sample
PHCs. Availability of Man-power especially the adequacy of doctors
against their sanctioned posts was encouraging, as 75 per cent of doctors
were in position in assisted PHCs, while 96 per cent of them were found
in position in non-assisted PHCs. However, it was observed that the
absenteeism among the doctors from their work places was very high-a
binding constraint in utilisation of health care services in sample PHCs.
On population coverage, the study reported that on an average, a
programme assisted PHC was 68386 people and it was 57705 people by
a non-assisted PHC against the prescribed norm of 20,000 to 30,000
people per PHC. As far as coverage of sub-centres by a PHC was
concerned, it was noticed that at the aggregate level, about 11 sub-
centres were served by a programme assisted PHC and the coverage of
sub-centres by a non-assisted PHC was about 12 sub-centres against the
prescribed norm of 6 sub-centres per PHC. This indicated the fact that
adequate number of PHCs have not been established against their
requirement, leading to not only a negative impact on the quality and
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delivery of health care services, but also accentuating the problem of
overcrowding in CHCs and district hospitals.
The findings on the utilisation of medical services revealed that
none of the sample PHCs had attended the delivery cases during 1995-
96, pointing out to the reality that such PHCs were not equipped with all
essential complementary facilities including the posts of lady doctors for
attending on delivery cases. The overall fining suggested that Social
Safety Net Programme had not been able to achieve the objective of
facilitating and popularisation of institutional deliveries.
The average utilisation of cases in PHCs with SSNP was 30
cases/day/doctor, while it was 25 in non-assisted PHCs. However, the
inter-PHC comparison of utilisation rate revealed a variation across the
sample states. In the contest of evaluating the utilisation rate of health
care services in PHCs in relation to true performance and functionality
of PHCs, qualitative information gathered by PEO field teams through
their in depth probing and discussions revealed that in the absence of
doctors, the cases coming to PHCs were attended by para-medical and
auxiliary para-medical staff. It was also observed by the field teams that
since the PHCs were not equipped with diagnostic facilities, the patients
preferred to visit tertiary/district hospitals for treatment of their ailments.
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Illness profile of the beneficiaries who utilised services of PHCs
and their views on services revealed that a maximum of 32.93 per cent
of beneficiaries have sought the treatment for minor ailments, like, cold,
cough and fever. This was followed by the cases suffering from water
borne diseases (14.63%), vaccine preventable diseases (8.54%),
respiratory diseases (8.53%) and gynaecological complications (4.88%)
respectively. Similar results were found for non-assisted PHCs. As
many as 51.22 % of beneficiaries belonging to programme assisted
PHCs were found to be dissatisfied with the functioning of PHCs.
Further, of the dissatisfied beneficiaries, a majority had
complained about medical and para-medical staff of PHCs. The main
reasons for their dissatisfaction included non-availability of medical and
para-medical staff (42.85%), not being examined by doctors (52.38%)
and proper attention not given (35.71%). The second important reason
for dissatisfaction of beneficiaries was the non availability of medicines
in PHCs. About 66.67 per cent of the beneficiaries expressed this view.
Similar results were obtained for non-assisted PHCs also. Despite
inadequacies in the delivery of health care services by PHCs, a vast
majority of about 89 per cent of beneficiaries belonging to programme
assisted PHCs and about 96 per cent beneficiaries from non-assisted
PHCs had still expressed their preferences for PHCs for seeking health
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care services over other alternative sources of treatment. It was revealed
that 54.88 per cent of beneficiaries belonging to assisted PHCs and
94.12 percent belonging to non-assisted PHCs had incurred private
expenditure on various items while seeking treatment in PHCs. A
majority of 73.33 per cent beneficiaries belonging to assisted PHCs and
52.50 per cent belonging to non-assisted PHCs had incurred private
expenditure below Rs.100 per illness episode. Besides, major chunk of
expenditure made by the sample beneficiaries of all categories was on
purchasing medicines. The income profile of beneficiaries belonging to
programme assisted PHCs revealed that the beneficiaries whose average
monthly income was below Rs.500 have formed a small percentage of
3.66, while a majority (63.41%) of the beneficiaries are from the
monthly income group of above Rs.1000.. Similar results are obtained
for non-assisted PHCs also. The low-income group households seemed
to stay away from the public health care delivery system primarily
because of non-availability of medicine, indirect cost on transport and
high opportunity cost in terms of foregone income (due to loss of wage
income say). They, therefore, seemed to depend on cheaper alternatives,
such as traditional Indian medicines or unqualified medical practitioners.
It was interesting to note that large majority beneficiaries of the public
health delivery system have expressed willingness to pay for the
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services if the quality of delivery improved. The beneficiaries were
willing to pay 25% of the market cost of treatment if the quality of
delivery improved. About 62% of the beneficiaries replied in the
affirmative.
2.3.5: Primary Health Care system in urban area
The Eighth Plan pointed out that it is not only the rural poor who
are deprived: in large cities, where about 40-50 per cent of urban
dwellers live in slums, their health status "is as bad, if not worse than in
rural areas". Further, "the infrastructure for primary health care in urban
areas hardly exists" (VHAI. 1998).
The following three studies depict the deplorable situation of
urban primary health care system and factors that influence their health
seeking behaviour and the personalised spending for their health
problems.
2.3.5.1: Sonya et all(1996) looked in to whether primary health care is
accessible, available and affordable to the urban dwellers by
interviewing OPD users in Mumbai‟s KEM Hospital, a tertiary care
centre in the middle of the city. Their results of their study revealed that
54% of the patients who attended the OPD came from the urban
unorganized sector. Over two-thirds had earlier gone to a private doctor
but shifted because the treatment didn‟t work, or it became too costly.
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They did not go to the urban health centre because there was just one
municipal dispensary for a population of 50,000 compared to a private
practitioner for less than 2,000 people in the municipal ward where the
hospital was located. The dispensary could hardly match the coverage of
the private sector or consider itself the main provider of first –level care.
2.3.5.2: Study by Aditi and others (1996) throw some insights in to the
affordability and the accessibility aspects of health seeking behavior.
They surveyed inhabitants of a densely populated ward in Greater
Mumbai with a predominantly lower middle class population to study
the reason for why people travel to distant public health centre to seek
treatment for their illness. They found that financial reasons forced 30%
of those surveyed to travel to another ward for public sector in patient
care. Fifteen per cent went outside for outpatient public care. Apparently
for this group, the cost and inconvenience of travel was less than the
cost of a private hospital. Though the majority of households used the
private sector for outpatient care and slightly fewer for in patient care, a
substantial percentage of households said they would rather go to the
public sector if it were available in the locality.
2.3.5.3: In another study by Garg in 1995 in Dharavi revealed that the
patients of Dharavi rarely used the urban health centre due to lack of
facilities, not being accessible and affordable. Rather they went to
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private doctors for minor problems or the public tertiary hospital for
major illnesses. When these researchers interviewed patients in that
tertiary hospital to know the reasons retrospectively as to why the
patients came to the tertiary hospital, they found 3.2% of the patients
were not provided with beds, 19.5% were not provided with linen, and
16.3% were not given hospital clothing and 21.1% of them did not have
linen and 27.6% of hospital clothes had never been changed. 68.1% of
the patients had to buy medicines from outside pharmacies. One out of
three had to get tests done outside. Only the poor come to public
hospitals, many of them after being exploited and neglected at private
hospitals.
2.4: FUNDING
2.4.1: Lack of funding has been a fundamental problem to the primary
health care system in India. Funding for the health care in India has
always been insufficient throughout the period since independence even
after the economic reforms introduced from the nineties. In the
following part of the literature review will focus on the funding and the
impact of lack of funding has on the primary health care system in India.
Insufficient funding and consequential use of private health care sector
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by people made the Eighth Plan to support the philosophy of a
minimalist State position in health (Malavika Karlekar).
2.4.2: A longitudinal analysis by K.N. Reddy and V. Selvaraju(1994) of
GDP, health expenditure between 1974-1991 indicates that though
spending under the heads of family welfare, nutrition, water supply and
sanitation - all clubbed under the health budget -increased, that of
medical and public health declined. Also during the period from 1974-5
to 1990-1, the total expenditure on medical and public health declined
from 62.14% of the relevant budgetary head to 48.62% (Reddy and
Selvaraju 1994).In addition, while salaries accounted for a large
percentage of the outlay, non-salary components such as medicines,
equipment and fuel were inadequately funded (Duggal, 1995).
2.4.3: The Economic Survey presented to the Parliament in 1996 states
that after the introduction of economic reforms, the Central Plan outlay
for programmes of the Department of Health has been stepped up from
Rs. 302 crores in 1992-3 to Rs.670 crores in the 1995-6 period. A large
percentage of these funds are ear-marked for the control of
communicable diseases such as malaria, tuberculosis, leprosy, blindness
and now AIDS (Rs. 421 crores) as well as salaries and maintenance
(GOI 1996).
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A nation-wide survey conducted by the National Council for
Applied Economic Research to establish the market structures for a
variety of consumer goods revealed a number of things in relation to the
health care funding and people‟s utilization of public and private health
care services. The survey, which was conducted across 6,354 rural and
12,339 urban households in 1992-3, and collected data on morbidity,
health care utilisation and health expenditures in considerable detail,
established the importance of the private sector in health care. For
instance, only 22 per cent of the population in Kerala, 27 per cent in
Uttar Pradesh and West Bengal, 30 per cent in Madhya Pradesh, 37
percent in Bihar and 38 per cent in Maharashtra used public health
facilities (Shariff 1995:17). While the private health markets served two
thirds and more of the sick in Uttar Pradesh, Kerala and Andhra
Pradesh. The survey found that the poorer households spent 7-8 per cent
of their household income on health care as compared to the 2 to 3 per
cent spent by the richer households. The study also noted that per capita
expenses were much higher when individuals used private facilities: for
instance, all-India per capita health expenditures on fees and medicines
only for hospitalised and non-hospitalised medical episodes based on
data from selected urban areas in a number of states was Rs. 2611 for a
public hospital and Rs. 1,115 for a private hospital, and Rs. 36 and
66
Rs.81 for non-hospital expenses in the public and private sectors
respectively. The increasing withdrawal of the State from a vital sector
of developmental activity means that health care for a growing
proportion of the population depends on private institutions and
individuals. It is not surprising, then, that recent health expenditure
studies show that household expenses on medicare are three to four
times higher than that of the government's total health expenditure.
Studies have shown that the chief beneficiaries of domestic expenditure
on health are men and children.
2.4.4: Though the number of Public Health Centres went up almost three
and a half-fold between 1981-91 as against the one and a half-fold
increase between 1971-81, field studies show that not only is there a
concentration in certain states, but also that the large majority of centres
are ill-stocked, inadequately staffed and too far from the target
population. Thus, there was already a crisis in the State-run health sector
prior to 1991; a mere enhancement of funds which are allocated without-
much thought being given to changing needs results in wastage,
underutilisation and in exacerbating already existing inequalities and
imbalances. An evaluation of the public health care infrastructure in the
country in 1996 noted that the system which "caters to the needs of 25-
30% of the population is grossly deficient" (Government of India 1996).
67
Further, a good percentage of the Central budget on health goes on
providing services for its employees through the Central Government
Health Scheme (CGHS). In a situation where about two- thirds of the
total health expenditure goes on personnel, it is not difficult to envisage
how the rest of the money is spent.
2.4.5: The 2002 Health Policy flagged declining public health
investments. It stated that the public health investment in the country
over the years has been comparatively low as a percentage of GDP
decline from 1.3 percent in 1990 to 0.9 percent in 1999. The aggregate
expenditure in the Health sector is 5.2 percent of the GDP. Out of this,
about 17 percent of the aggregate expenditure is public health spending,
the balance being out-of-pocket expenditure. The central budgetary
allocation for health over this period, as a percentage of the total Central
Budget, has been stagnant at 1.3 percent, while that in the States has
declined from 7.0 percent to 5.5 percent. The overall contribution of
Central resources to the public health funding has been limited to about
15 percent.
2.4.6: Further the 2002 Policy commended that for the outdoor medical
facilities in existence, funding is generally insufficient; the presence of
medical and para-medical personnel is often much less than that
required by prescribed norms; the availability of consumables is
68
frequently negligible; the equipment in many public hospitals is often
obsolescent and unusable; and, the buildings are in a dilapidated state. In
the indoor treatment facilities, again, the equipment is often obsolescent;
the availability of essential drugs is minimal; the capacity of the
facilities is grossly inadequate, which leads to over-crowding, and
consequentially to a steep deterioration in the quality of the services. As
a result of such inadequate public health facilities, it has been estimated
that less than 20 percent of the population, which seek OPD services,
and less than 45 percent of that which seek indoor treatment, avail of
such services in public hospitals. This is despite the fact that most of
these patients do not have the means to make out-of-pocket payments
for private health services except at the cost of other essential
expenditure for items such as basic nutrition.
2.4.7: The findings of the National Health Accounts for 2001-02 also
came out with some alarming findings on the health care expenditure.
According to the report, in 2001-02, health expenditure was 4.6% of
GDP, out of this expenditure, only 20.3% was public expenditure.
77.4% was private expenditure, with 2.3% originating in external
support, that is, bilateral and multilateral agencies. Classified slightly
differently, households contributed 72% of total health expenditure,
including not just expenses for treating illnesses, but also payment of
69
insurance premiums. State governments contributed 13%, the Central
government contributed 6%, 2% came from external agencies and
private firms (through medical benefits to employees) contributed 5%.
Again classified slightly differently, 70% of financial resources flowing
to health-care providers went to the “for profit” private sector, 23% went
to public providers of health services. The findings also indicated that
the level of public health spending was relatively higher in the states of
Himachal Pradesh, Jammu and Kashmir, Punjab and Kerala while lower
in Uttar Pradesh, Bihar Madhya Pradesh, Orissa and Jharkhand. Private
expenditure was relatively higher in Kerala, Punjab, Haryana and Uttar
Pradesh as compared to Assam, Rajasthan and Orissa. Per capita health
spending in Kerala was the highest while Assam was the lowest in the
country.
2.4.8: The latest GDP figures available for a complete financial year are
for 2006-07 and these show a GDP figure of Rs 37,43,472 crores in
current prices (Central Statistical Organization(2007) Public expenditure
on health is around 1% of GDP and this translates into an annual per
capita figure of around Rs 340(Hindustan Times 2008).
2.4.9: The insufficient funding and the in appropriate allocation of the
funding have caused a number of problems in the staffing patter and
infrastructure facilities in the primary care settings.
70
The number of medical practitioners in 1991 was 4.7 per 10,000
populations (as against 1.7 in 1951); however, almost 50 per cent of sub-
centres, PHCs or CHCs did not have buildings of their own. Indian
Council of Medical Research (ICMR) study on family welfare services
at the Primary Health Centre level in 1991 observed that only 22.6 per
cent of the PHCs had properly equipped operation theatres; in a majority
of PHCs in Bihar, Jammu and Kashmir, Karnataka, Kerala, Madhya
Pradesh, Maharashtra, Orissa, Rajasthan, Tamil Nadu, Uttar Pradesh and
West Bengal, operating theatres were not properly equipped. In short,
PHCs in most parts of the country are ill-equipped. In addition, water
supply was safe in only 71 per cent of the PHCs evaluated (ICMR 1991:
17, 19). A state wise look at infant mortality and poverty figures taking
in to consideration the dismal picture of PHC facilities in the states, it is
indicated that the states of Uttar Pradesh, Orissa, Madhya Pradesh,
Assam, Gujarat, Rajasthan and Bihar had above average Infant Mortality
Rates (IMRs); of these Bihar, Madhya Pradesh, Orissa and Uttar
Pradesh had a larger population living below the poverty line. In other
words, poverty, lack of facilities and high infant mortality rates are
vitally linked. This led the Government of India to admit that "the lack
of buildings, shortage of drugs, equipment etc. constituted major
impediments to full utilisation of these units" (GOI 1993a:206). Further,
71
a government document in 1994 points out that "biases in, favour of
curative vis-a-vis preventive and of secondary and tertiary health - care
facilities rather than primary, need to be corrected" (GOI 1994:153).
2.5: DISEASE PROFILE OF RURAL INDIA
2.5.1: While Park (2000), speaking on the disease profile of rural India,
stated that the majority of rural deaths, which are preventable, are due to
infections and communicable, parasitic and respiratory diseases.
Infectious diseases dominate the morbidity pattern in rural areas (40%
rural: 23.5% urban). Waterborne infections, which account for about
80% of sickness in India, make every fourth person dying of such
diseases in the world, an Indian. Annually, 1.5 million deaths and loss of
73 million workdays are attributed to waterborne diseases.
2.5.2: Deodhar NS(2001) elaborated on the groups of infections.
According to him, three groups of infections are widespread in rural
areas, as follows:
Diseases that are carried in the gastrointestinal tract, such as
diarrhoea, amoebiasis, typhoid fever, infectious hepatitis, worm
infestations and poliomyelitis. About 100 million suffer from diarrhoea
and cholera every year.
72
Diseases that are carried in the air through coughing, sneezing or
even breathing, such as measles, tuberculosis (TB), whooping cough and
pneumonia. There are 12 million TB cases (an average of 70%). Over
1.2 million cases are added every year and37 000 cases of measles are
reported every year.
Infections, which are more difficult to deal with, include malaria,
filariasis and kala-azar. These are often the result of development.
About 2.3 million episodes and over 1000 malarial deaths occur every
year in India.An estimated 45 million are carriers of microfilaria, 19
million of which are active cases and 500 million people are at risk of
developing filaria.
2.5.3: According to Government of India‟s 1996 annual health report
every third person in the world suffering from leprosy is an Indian.
Nearly, 1.2 million cases of leprosy, with 500 000 cases being added to
this figure every year.
2.5.4: According to Mukhopadhyay et al(2001) malnutrition is one of
the most dominant health related problems in rural areas. There is
widespread prevalence of protein energy malnutrition (PEM), anaemia,
vitamin A deficiency and iodine deficiency. Nearly 100 million children
do not get two meals a day. More than 85% of rural children are
undernourished (150 000 die every year).
73
2.5.5: A survey by the Rural Medical College, Loni(2002), in the
villages of Maharashtra State, has revealed some alarming facts. Illness
and deaths related to pregnancy and childbirth are predominant in the
rural areas and are due to the following reasons,
1. Very early marriage: 72.5% of women aged 25–49 years marry
before 18, where the literacy rate is 80%.
2. Very early pregnancy: 75% married women had their first
pregnancy below 18 years of age.
3. All women invariably do hard physical work until late into their
pregnancy.
4. Fifty-one per cent of deliveries are conducted at home by an
untrained traditional birth attendant.
5. Only 28% of pregnant women had their antenatal checkup before
16 weeks of pregnancy.
6. Only 67% of pregnant women had complete antenatal checks
(minimum of three checkups).
7. Only 30% of women had postnatal checkups.
In addition, agricultural- and environment-related injuries and
diseases are all quite common in rural areas, for example: mechanical
accidents, pesticide poisoning, snake, dog and insect bites, zoonotic
diseases, skin and respiratory diseases; oral health problems; socio-
74
psychological problems of the female, geriatric and adolescent
population; and diseases due to addictions.
2.5.6: According to Lalitha‟s (2003) study the morbidity pattern was
similar usual picture in the PHCs-colds, fever, cough, anaemia,
diarrhoea among the general population and hypertension, arthritis,
bronchitis among the aged. Though not common, there were cases of
skin disease, insects‟ bites and wild animal attacks and dog bites.
2.6: AVAILABILITY OF MEDICINES IN PHCs
2.6.1: While writing on the Structural Adjustment Programs on Rural
Health, Balasubramaniam et al(1996) indicated that the availability of
drugs is inadequate in all of the PHC, SC and hospitals that have been
set up by the government over the years.
2.6.2: A case study of Coimbatore and Sivaganga districts by N.Lalith
from IESE, Navara(2003), entitled „ A Access to Medicines: Initiatives
in policy making and delivery of drugs-A case study of Tamil Nadu‟
suggested that medicines were insufficient, there were lack of
equipment to transport the drugs.
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2.7: PEOPLE’S HEALTH AND DECENTRALISED HEALTH
CARE PLANNING IN INDIA
2.7.1: Involvement of the community and decentralised planning are
some of the major indicators of primary health care services. However,
there has not been much people‟s participation in India in planning for
their health. In this context, WHO(1997) commended that though the
concept of primary health care is appropriate to rural areas, it remained
sound on paper only because of the deliberate attempts of health
professionals. Further, WHO reiterated that the present system has not
left any scope for the involvement of the community, nor for grassroots
level health workers to take ownership of the programs and integrate
them with overall development. The concept of placing a community-
selected person from the village, and providing them with essential
training so that the community can cope more effectively with its health
problems, was the centrepiece of the PHC. As a result, the basic
requirements of decentralised people based, integrated curative,
preventive and promotive services have been totally undermined by the
„vertical programs‟.
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2.8: PRIMARY HEALTH CARE SYSTEM IN KERALA
2.8.1: Health Development indicators - Kerala & India - 2007 (a report
by the directorates of Health services) revealed that Kerala's remarkable
achievements in health in spite of its economic backwardness has
described "Kerala Model of Health" which is worth emulating by other
developed countries. The hall mark of Kerala model is low cost of health
care, universal accessibility and availability even to the poor sections of
the society along with many socio-economic conditions unique to the
state such as high female literacy rate (87.72%). The widely accepted
health indication viz death rate, Infant Mortality Rate (IMR) and
expectation of life at birth too are far advanced than the rest of the states
in India and are even comparable with developed countries. Such that in
Kerala, the expectation of life has increased, infant mortality rate is very
low and there is decline in death rate. Also the health awareness among
the citizens of the state maintains to be at a very high level.
In the state, there exist 7831 public health institutions. Of this,
71.8% are PHCs (including sub centres), 8.2% are CHCs and 11% are
hospitals (censes 2001). Apart from this there are 81 co-operative
hospitals functioning effectively in Kerala. The number of sub-centres
continuous to be 5074 for the last 12 years and there is a sub-centre for
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every 6.16 sq.km and a primary health centres for every 33.3 sq.km
there by assuring the accessibility of health care to the downtrodden
section of the society. In terms of health personnel, there are 25225
medical and para medical personnel and there is one medical officer for
every 8244 population in Kerala.
Despite, better health outcomes, the much-proclaimed Kerala
model of health have started showing a number of disturbing trends.
Although mortality is low, the morbidity (those suffering from diseases)
both from urban and rural Kerala is high in Kerala compared to other
Indian states. Thus the paradox is that on the one side Kerala stands as
the state with all indicators of better health care development in terms of
IMR,MMR, birth rate, death rate etc. on the other it outstrips all other
Indian states in terms of morbidity especially the chronic illness.
The morbidity analysis of Kerala reveals that the attack of acute
diarrhoeal diseases, measles, pneumonia, pulmonary tuberculosis,
dengue fever etc is the major diseases dominating the health profile of
the state. The attack and death of a mammoth of population has
happened due to vital illness - chikungunyas. Moreover, many
epidemics that were supposed to be eliminated from kerala are staging a
come back. Higher prevalence of mental health problems including
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higher suicide rates, health problems and death due to road traffic
accidents and other traumas comprise the health picture of Kerala.
Ageing is another area of concern of Kerala health that accounts
for hike in morbidity. As life expectancy increases there is high
incidence of disease associated with aging and life style diseases.
Sedentary life styles, lack of physical activities and obesity increases the
risk of chronic and life style diseases.
In terms of the health care funding, Kerala spends fairly
substantial amount on medical and public health compared to other
Indian states {Rs. 96049.66/- (2005-06)}, yet public health system is
getting alienated from the common man due to lack of medicines and
sophisticated infrastructure facilities in the government hospitals. Thus,
public health centres are being utilised mostly for maternal and child
health care programmes especially for immunisation schemes. This has
led to the impetus growth of the private medical care set up in the state
and the dependence on private health care is quite high even among the
lower expenditure classes and rural areas. In the changing scenario, the
private sector reigns supremacy in the infrastructure and health
manpower development than public sector in the state.
As the state is moving into a consumerist society, the
commercialization and the commoditisation of health care are rampant
79
in the state. Thus the state's health scenario is slowly drifting towards
the decay of public health system, uncontrolled growth of private sector,
escalation of health care cost and the presence of communicable, non-
communicable and life-style diseases. (Human Development Report –
2005).
2.8.2: Varatharajan et al (2004) evaluated the Performance of Primary
Health Centres under decentralized government in Kerala, India,
through a rigorous research methodology.
The overall methodology of the study indicated that the study
was conducted in three stages. The first stage included all 990 village
panchayats in Kerala. The second stage covered 10 panchayats (their
respective 10 PHCs and 65 sub-centres) occupying the top five and
bottom five ranks in terms of resource allocation to health. Two
panchayats (their respective PHCs and sub-centres), one each from the
top five and the bottom five, were chosen for the third stage.
The date collection was done using the published and unpublished
government data, panchayat development reports, panchayat and PHC
records, and facility checklist. Additionally, the key informant and client
exit interviews were also used for data collection. The study took also in
to account the intermediary changes in a PHC, such as access, quality of
80
infrastructure and machinery, cost-effectiveness, services offered and
quality of care.
The facility checklist covered availability, functioning and
financial source of 41 routine items within the PHCs and sub-centres,
including equipment, drugs, supplies, staff, access and quality of
infrastructure. Infrastructure included six items: building structure,
toilet, clean running water, electricity, communication and wash basin.
Access included eight items: size of the building vis-à-vis patient
load, home visits by the PHC staff, facility hours, patient records,
waiting area, patient privacy, and distribution/display of health
education materials and display of community statistics. The checklist
was filled by using PHC and sub-centre records, by actual observation
of facilities and by questioning health-care delivery staff. Items such as
buildings, toilet, drinking water, electricity, communication, washbasin,
waiting area, patient privacy, and display of community statistics and
distribution of health education materials were observed and graded for
their quality. The choice of panchayats and subsequently PHCs were
based on the ranking of panchayats according to resource allocation to
health per se. Meanwhile actual PHC receipts were taken into account in
order to assess the impact of panchayat support.In the second stage data
collection consisted of perusal of records, and key informant and client
81
exit interviews. Structured and pre-tested schedules (separate for
panchayats, PHCs and sub-centres) were used for interviews. Key
informant interviews elicited information on budget, cost, financial
sources, PHC and panchayat characteristics, panchayat–PHC linkages,
and steps to improve PHC performance. Client exit interview, on the
other hand, focused on illness, services received, access frequency, staff
behaviour, diagnosis and measures to improve efficiency.
The study also brought out some significant findings regarding
the beneficiaries‟ opinion on the determining factors of a well
functioning PHC, budget and cost components of PHC. The majority of
the informants participated in this study opined that strength of a PHC is
indicated by:
1. Uninterrupted supply of medicines and water
2. Presence of doctor for longer time and extended out patient hours
3. Provision of adequate facilities
4. Good doctor-client relationship
5. Good doctor-staff relationship and participatory PHC management
6. High quality care
7. Intense field activities
The informants were also of the opinion that the efficiency of a
PHC has to be judged by the level of supply of medicines and that
82
prescriptions to buy medicines from outside should be viewed as
indicative of inefficiency.
All major cost components (salary, investment, maintenance, patient
care, building, furniture and equipment) were included in the cost
estimation after converting non-recurrent items into annualized figures.
Equipment, instruments and furniture items were first listed and expert
opinion was sought to find out the value and expected life of each item
in order to arrive at the annualized figures. A cross-sectional analysis of
two contrasting scenarios of high and low resource (monetary and
material) support from panchayats was employed to demonstrate impact,
because the panchayats‟ control over PHCs is essentially derived from
the amount of resources they allocate to them. The result indicated that
all the panchayat and PHC informants felt that panchayat intervention
would strengthen PHCs and listed five possible roles for panchayats in
strengthening PHC such as
1. Providing medicines
2. Facilitating the implementation of national health programmes
3. Constructing buildings
4. Conducting routine maintenance work
5. Improving (clinical and non-clinical) facilities.
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The overall results indicated that:
1. Panchayats in Kerala allocated a lower proportion of resources to
health than that allocated by the state government prior to
decentralization; while panchayat resources grew at an annual
rate of 30.7% and health resources grew at 7.9%.
2. PHCs were funded to the extent of 0.7–2.7% of the total cost. An
additional 2% in PHC resources was associated with improved
patient load (63.5%), cost-effectiveness (50.8%), medicine
supply (49.4%), information (32.8%) and patient satisfaction
(12.7%).
3. And suggested an annual increase of US$940 in PHC resources
would help to extend primary care facilities to 3000 (15.5%)
more users.
The authors have concluded their study by establishing that
decentralization brought no significant change to the health sector.
However, saying that active panchayat support to PHCs existed in only a
few places, but wherever it was present, the result was positive. The
authors had also suggested an action plan for the improvement of the
primary health centres, that Kerala should find an alternative strategy to
channel panchayats towards health before health loses its battle for
resources.
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2.8.3: Mala Ramanathan (2003) studied the Structure, facilities and
service delivery context of primary health care system in Kerala . The
indicated that there are 944 PHCs and 5,094 sub-centres in Kerala, PHC
serves 30,732 people and covers a radial distance of 3.4 km, utilisation
remained steady at 40% during 1987-97. The study covered 50 taluks,
250 block public health centres, 15 PHCs, 230 reproductive health
centre, 20 patients per day, and 100 health centre. According to the
study, in RH – 1, One PHC did not have a doctor for several months
during the previous year, Facility for Medical Termination of Pregnancy
(MTP) was available at one Block PHC and the Taluk hospitals and two
of these had indoor facilities for recovery, Surgical sterilisation for
women was available at one Block PHC and both Taluk Hospitals.
Vasectomy for men was possible only at one Taluk Hospital, Available
Facilities for RH - 2, Contraceptive commodities like oral pills,IUDs
and condoms were available, 4 PHCs, BPHCs & taluk hospitals had
store for contraceptive commodities, Some drugs for treatment of RTI
were available during the previous year.
About the Infrastructure, the study revealed that The patient
examining rooms in all the facilities were clean and had adequate
lighting, Two PHCs and the block PHCs and the Taluk Hospitals had
seating arrangements for the patients where as four of the PHCs did not
85
have adequate seating arrangements, Only three PHCs (3/10) lacked
clean drinking water and toilets, Electricity supply was interrupted in
most Health centres and standby arrangement available in block PHC
and taluk hospitals.
Regarding equipments, all the study units had sterilising
equipment of some kind, except for one block PHC and one PHC all
others had disposable syringes available for use , all the units in the
study had blood pressure gauge available , Nine of the 10 facilities had
ILRs available.
With regard to the Equipments and records, 3 PHCs had height &
weight scales of infants and adults,1 PHC had operation theatre
(furnished & equipped) but was never used, All PHCs maintained
records of eligible couples and 4 of them updated them recently. She
concluded that PHCs less equipped for many reproductive health needs,
Taluk hospitals – 50 patients /day, Taluk hospitals - Better equipped,
Women doctors were available , Quality service and heavy patient load,
inadequate waiting space in PHC.
2.8.4: Baburajan PK Verma RK (1991) studied Job satisfaction among
health and family welfare personnel in Kerala by interviewing 88 staff
members from 2 Public Health Centres (PHCs) in Kerala State through a
job satisfaction questionnaire (Paliwal and Sawhney Scale). The PHCs
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were selected as better as and worse than average in family welfare
performance. They were similar in socioeconomic and topological
features, but PHC I had twice the population, proportionally more staff,
and a medical officer with a degree in management. PHC I averaged 8
staff meetings monthly to update training in hygiene, immunization, oral
rehydration therapy, and maternal and child care. PHC I kept records
and charts such as maps of disease occurrence, lists of personnel
assignments, daily record flow, and program monitoring charts. PHC II
held monthly meetings only. Interviews of doctors from PHC I revealed
concern for quality of care and incentives for family planning acceptors,
training, teamwork, and supervision of staff; PHC II doctors saw
problems in the infrastructure, and commitment of local leaders.
Paramedical staff concerns were similar at the 2 centers. The mean
scores on the job satisfaction scale were 50.7 for PHC I and 50.5 for
PHC II. 25% of staff from both centers combined were not satisfied
with their jobs. Those expressing dissatisfaction tended to be older, with
longer work experience, or not to be given housing. Of all the variables
analysed, chance of being promoted explained 58% of the variance in
job satisfaction, proper facilities explained 15%, but salary was not
significant.
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2.9: BENEFICIARIES’ OPINION ON THE PHC
2.9.1: The primary health care system in India has been dysfunctional
and not geared suitably to serve the health needs of the people due to
many reasons as has been established above with the help of available
literature. There have been many studies which looked in the popularity
and the satisfaction of service beneficiaries of PHCs in the context of
scare resources and poor quality of the services provided.
2.9.2: Kamat (1995) looked in to the popularity of primary health
centres in India by assessing a village in rural Maharashtra using case
study method. The findings of the study indicated that:
1. The popularity of the primary health centre is centered around the
popularity of the doctor, and the popularity of the doctor is
centered around the doctor‟s ability to manage the PHC situation
and the patients rather than his clinical expertise or medical
degrees.
2. PHC doctor engages in private practice along with the
government job, and there is a lot of interfacing between the
private and the government practice irrespective of the places
where the doctor sit for consultation whether it is his private
residence , government quarters and the PHC.
88
3. The reported illness and frank symptoms in the PHC fell in to 12
broad categories, ranging from cough/ cold, diarrhea to TB and
leprosy.
4. Regarding the utilization of the health care facility and the
preventive health care services, the majority of the people who
were affected by these illnesses were found to be using the PHC
doctor as the first resort to deal with these illnesses. As for the
utilization of the preventive health services in the PHC, majority
of household had at least one member who utilized immunization
services, anti natal and post natal services, taken treatment for
malaria, received oral rehydration therapy, and undergone
sterilization. However, attendance at eye camp organized by the
PHC, maternity services, treatment for snake bite and scorpion
sting, dog bite, leprosy, acceptance for contraceptives, and
seeking treatment for tuberculosis were below fifty percent. The
reason for non utilization of the services was associated with non
perception of such need for treatment and the lack of awareness
about such services.
5. Seventy four percent of the respondents felt that PHC had
brought some good benefits to the house hold, while the
remaining felt that PHC was a show piece of the government that
89
did not serve the real needs of the people. Sixty two percent of
the people felt that the health activities in the centre would bring
benefits to the people in the future. 56% evaluated the PHC staff
as hard working and efficient. According to the majority of the
respondents, the accessibility, availability and the affordability
were the main of the reasons for the popularity of the PHC.
Community participation in the PHC activities was very low and
reported that they had no opportunities provided to them to do so.
The most of the participation were politically motivated and the
PHC activities were controlled by the politicians.
2.9.3: Government of India (2001)‟s result of Evaluation Study
conducted by the Programme Evaluation Organisation on Functioning of
Primary Health Centres(PHCs) assisted under Social Safety Net
Programme revealed that as many as 51.22 % of beneficiaries belonging
to programme assisted PHCs were found to be dissatisfied with the
functioning of PHCs. Further, of the dissatisfied beneficiaries, a
majority had complained about medical and para-medical staff of PHCs.
The main reasons for their dissatisfaction included non-availability of
medical and para-medical staff (42.85%), not examined by doctors
(52.38%) and proper attention not given (35.71%). The second
important reason for dissatisfaction of beneficiaries was the non
90
availability of medicines in PHCs. About 66.67 per cent of the
beneficiaries expressed this view. Similar results were obtained for non-
assisted PHCs also. Despite inadequacies in the delivery of health care
services by PHCs, a vast majority of about 89 per cent of beneficiaries
belonging to programme assisted PHCs and about 96 per cent
beneficiaries from non-assisted PHCs had still expressed their
preferences for PHCs for seeking health care services over other
alternative sources of treatment.
2.10: CONCLUSION
This literature review has covered a wide variety of topics on
primary health care system in India. The review of literature done so
far over all indicates that the primary health care system in India is
dysfunctional. While extensive, it is wasteful, inefficient and delivers
very low quality health services, so much so that the private sector has
become the de facto provider of health services in India (Nirupam
Bajpay et al(2009). The geographical and quantitative availability of
primary health care facilities, though extensive, is far less than the
guidelines laid down by the government. As has been pointed out,
people are more likely to use a medical facility if it is closely located,
especially in rural areas. Access is important but people‟s experiences of
what the facility has to offer in terms of medical care and whether it is
91
worth their while to use it are equally important in terms of their
incentives to utilize health care facilities. People‟s perceptions of „free‟
care is that of it being of low quality, and therefore, even the available
infrastructure is grossly underutilized, i.e. the public health care system
in India suffers from gross supply side distortions that go beyond
physical availability. This affects the delivery of basic services to its
large population of poor whose quality of life depends in crucial ways
on public goods. Though buildings are available, the simple availability
of a building designated as a public health facility is no guarantee that it
is functional, and if functional, it is inaccessible to groups of people who
may be restricted in their use of public health care services on account of
their caste, religion, gender and language. Even setting aside socio-
economic barriers to access and assuming the presence of a public health
facility close at hand, the delivery of quality health care services is not
guaranteed. The infrastructure is of poor quality and there is severe lack
of even basic drugs and equipment. This is especially true for rural
areas, and with regard to women‟s and children‟s health. Maternal,
infant and child morbidity and mortality rates are intolerably high in
India. Not only social justice but economic efficiency ie to protect the
health and well-being of its future generations.