At a public hearing in Karjat, Sushila Bhoir from Jambhulwadi village stood up with a string of complaints. “The health centre near our village does not have medicines, nor does it have water,” she said. “Even for deliveries, they refer pregnant women far away.”
Held in March, the meeting was a part of a Maharashtra government exercise to bring health officers, non-governmental organisations, government workers, and local residents together to discuss health issues. Several people had travelled from rural and tribal villages in Karjat, Raigad district, to be part of this hearing.
The centre Bhoir referred to is an Arogya Mandir in Kadav village.
In 2018, it was upgraded from a primary health centre into a health and wellness centre under the ambitious Ayushman Bharat scheme launched by Prime Minister Narendra Modi that year. On paper, the upgrade meant that the centre could now provide a list of 12 specialised healthcare services.
Bhoir remembers a fresh coat of yellow paint was applied on its walls that year. In 2022, the centre was renamed Arogya Mandir and a second coat of paint was applied last year as part of the rebranding exercise. Each centre was allotted Rs 3,000 for the rebranding.
That was all. “The services did not improve then,” said Bhoir, who is in her 60s. “It has not improved now.”
Ujjain Shirsathe, a social worker with Disha, an NGO that works on health issues in Raigad, pointed out that Arogya Mandirs across Karjat are struggling. “If you go there, only basic treatment for fever and cold is provided,” he said. “The biggest problem is that doctors work only for a few hours and leave early.”
The promise: ‘Your family doctor’
In April 2018, while inaugurating the first health and wellness centre under the Ayushman Bharat programme in Bastar’s Bijapur, Prime Minister Narendra Modi had promised that India will have 1.5 lakh such centres by 2022 “which will not only treat illnesses but also prevent them”.
“Diabetes and blood pressure patients are in large numbers, so are heart and cancer patients…Through health and wellness centres, we will diagnose these diseases,” Modi said. “Health and wellness centres will be like your family doctor.”
As Modi promised, India did create 1.5 lakh health and wellness centres, by converting existing healthcare facilities. They were subsequently renamed as Ayushman centres or Arogya Mandirs.
In a response to a Right to Information query from Scroll, the Union health ministry on April 9 said that India has 1.70 lakh Arogya Mandirs, created by upgrading existing 23,744 primary health centres, 1.37 lakh sub-centres in rural areas, and 9,833 urban centres.
As its leaders canvass for the Lok Sabha elections, the Bharatiya Janata Party and its allies have cited the numbers to claim the success of the Ayushman Bharat scheme. In multiple election speeches, PM Modi has claimed that Ayushman Bharat centres have taken healthcare services to all villages.
But as Scroll found out in Karjat and elsewhere, the claims do not square with the reality on the ground.
Ghost centers, missing doctors
About two years ago, residents of Bhalivadi demanded that the district administration set up a sub-centre in their village, said Rekha Bhalerao, a local health activist.
But they were shocked to know that Bhalivadi already had a functional Arogya Mandir, according to the records of the Raigad health office.
“We wrote to the district office telling them that no centre exists here. But they said funds have been disbursed and a centre has been constructed in their records,” Bhalerao said.
The address of the centre is of a plot next to the village panchayat office. Instead of an Arogya Mandir, a dilapidated empty room stands there, with garbage and empty glass bottles strewn across the floor. This room, Bhalerao said, has existed for several years and was previously used as an anganwadi.
Prabhavati Gurau, a senior citizen, said the village lacks government health services and villagers are not aware that officially an Arogya Mandir has been allocated to their village. “If there was one, access to immunisation and delivery would be easier,” she said.
For now, villagers travel four kilometres to the Arogya Mandir in Kadav.
When Scroll reached Kadav, Rasika Borke and her husband stood outside, deliberating what to do next.
Borke had a fever and headache and complained of weakness. In her last visit, she was advised to have her blood tested. She had returned to show the reports to the doctor. Her husband had skipped daily-wage work in a factory to bring her to the centre.
“The clerk said there is no doctor inside,” Borke said. “The doctor leaves early almost every day.”
Less than 10 km away, patients faced a similar situation in Vaijnath Arogya Mandir. The community health officer there had left early after a morning meeting. Patients who came with fever and cold were turned away.
Each sub-centre that is now an Arogya Mandir – like the Vaijnath one – must have a community health officer, a multi-purpose worker and an auxiliary nurse midwife.
But at the Vaijnath centre, auxiliary nurse midwife Kranti Kalyankar has been manning three Arogya Mandirs for 18 months because of vacancies in the other two.
According to the RTI response from the Union health ministry, the situation across India is similar. Of the 1.70 lakh Arogya Mandirs, only 44,603 or 26.1% centres have a nurse.
“I handle delivery, maternal health and immunisation in all these centres,” Kalyankar said. “The workload is too much.”
The reality check
The Arogya Mandir is supposed to provide palliative and rehabilitative care, oral, eye and ENT care, mental health, maternal and child care, diagnosis and management of non-communicable diseases, and first-level care for emergencies and trauma, including free essential drugs and diagnostic services.
On its website, the health ministry says the idea of this centre “is to not just provide basic primary health care but an expanded range of services”.
The health ministry in its RTI response claimed that all 1.70 lakh Arogya Mandirs provide ENT care, palliative care, mental health and emergency care.
But in several states, the centres are struggling to provide the listed services despite massive funds pumped into them. Between 2018 and 2022, the health ministry budgeted Rs 6,300 crore for these centres.
A recent Niti Aayog report from 13 states has flagged huge gaps in cancer screening in these centres, citing lack of staff training.
In Maharashtra, Dr Vijay Bawaskar, who oversees Arogya Mandirs in the state, told Scroll that doctors have not yet been trained to provide mental health support and palliative care.
In Bihar, Jan Jagran Shakti Sangathan activist Shohini said they found community health officers were routinely skipping work in rural Arogya Mandirs.
In Karnataka, activist Gopal Dabhade said the services listed are not provided in most centres. Even centres in Madhya Pradesh face the same problem, according to activist Amulya Nidhi.
According to activists, patients and health workers, most of the Arogya Mandirs suffer from medicine and staff shortage. Doctors and nursing graduates posted there do not have the skill to provide specialised diagnosis, they told Scroll.
Lack of specialised care
In several centres, the staff said they were unable to provide specialised healthcare – because they did not have the necessary skills.
The community health officers recruited for the task mostly had a bachelor’s degree in ayurvedic medicine and surgery, or in pharmacy and nursing. With those qualifications, several admitted that their duties go beyond their skill set.
Dr Tejal Harpude, medical officer in Kadav Arogya Mandir, was posted at the Kadav centre six months ago. With a degree in ayurvedic medicine and surgery, she said she can handle cases of childbirth, and treatment of basic cough, cold and fever.
But for other services the centre is meant to provide, such as ENT, oral, ophthalmology, palliative care, mental health, and diagnosis of cancer, Harpude says she neither has the training nor the skill.
“For an ENT examination, we don’t have an otoscope,” she said. “For cervical cancer, we don’t have the required testing means. For an eye test, we don’t have a reading chart. We use a torch light to examine the eye and ear.”
So far, she said, she has not diagnosed cases for mental health since there has been no training. “I refer such cases to a sub-district hospital or a district hospital,” she said.
The Union health ministry, however, in its RTI response listed Kadav as a centre that provides mental health services.
The situation is similar elsewhere. In Ambivali Arogya Mandir, Karjat, community health officer Dr Deep Mala’s many responsibilities also include home visits for palliative care. “But frankly, I can only provide moral support,” she said. “For any symptom management, I have to refer to the rural hospital.”
Mala said the rural hospital also usually refers terminally ill patients further ahead to the district hospital in Alibaug, a two-hour ride away.
In Neral Arogya Mandir, community health officer Dr Pradma Tavhare, said it is difficult to diagnose non-communicable diseases such as oral, breast or cervical cancer and heart problems. “If a suspected case comes to us, we refer it to a higher centre,” she told Scroll. “We can only detect hypertension and diabetes here.”
According to the RTI response Scroll received from the Union health ministry, currently 42,517 Arogya Mandirs do not provide eye care and 39,905 centres do not provide oral care services across India. The ministry claimed that with the exception of these two, all centres provide the listed services.
In Bihar, however, activist Shohini said no villager has accessed mental or palliative care services in Ramghat and Bishanpur center of Araria district and in Barari centre of Katihar district. “There is a huge gap between what is on paper and what is on the ground,” she said.
A 2021 government study on the status of health and wellness centres in 18 states had also flagged inadequacies in the programme. It showed that none of the health and wellness centres in Bihar, Uttar Pradesh, Jharkhand had the full staff of medical officer, nurse, lab technician and pharmacist, while less than 50% in seven states had the required staff.
The study also found that not all health and wellness centres were screening for all 12 parameters. Sub-centres that had been converted into Argoya Mandirs fared worse than the primary health centres.
Of 118 sub-centres surveyed, only 21% provided dental care, 22% did ENT screening, and less than 32% provided mental health, eye and palliative care. Yoga was undertaken in only 17% of centres.
Dr Bawaskar, who oversees health and wellness centres in Maharashtra, said doctors have not yet been trained to handle mental health and palliative care support. “But the community health officers are screening for cancers and heart ailments,” he claimed.
A district health officer in Maharashtra, however, said in most cases the community health officers in Arogya Mandirs are forced to refer patients to higher centres. “They show they have screened a patient for oral or cervical cancer, but they only do a visual examination which is not enough,” the officer said.
Scroll asked the health ministry to provide data of patients who visited these centres and were referred to other health centres. Till March 2024, 257 crore patients have visited these centres, the ministry said. It, however, did not provide a count of those referred to higher centres.
Medicine shortage
In rural areas, a sub-centre that has been converted into an Arogya Mandir is supposed to keep 105 essential drugs and offer 14 diagnostic facilities. A primary health centre turned into an Arogya Mandir ought to stock 171 drugs and offer 63 tests respectively.
The most common demand in these centres is for diabetes and blood pressure medication, apart from basic antibiotics. But in many centres across Karjat, patients complained there were no medicines for these two lifestyle ailments.
Dr Mala, from Ambivali centre, said her centre usually stocks 30-40% of required diabetes medicines. “When there is no steady supply, patients also stop asking us for medicines,” she said.
Shirsathe, from NGO Disha, said the idea of an Arogya Mandir was to provide medicines and basic treatment close to home for the rural population. “That objective is defeated when there is no medicine,” he said. Most patients, he said, are referred to the sub-district hospital for medicines.
In Vaijnath, on the shelf of the medical room, Scroll found several expired medicines and injections, including those needed to handle adverse reactions to vaccines. Of a list of 105 essential medicines the centre should stock, there were less than 50, a staffer told Scroll.
In Karnataka, too, local residents have complained of medicine shortages. In Belgaum’s Bidi village, Suvarna Kothale said there is usually no medicine for hypertension and diabetes at the local Arogya Mandir. “We get fever medication, but for anything else, there is usually a stock out,” she said.
All photographs by Tabassum Barnagarwala.
This reporting was supported by a grant from the Thakur Family Foundation. Thakur Family Foundation has not exercised any editorial control over the contents of this article.
