In Dongargaon Khurd, a remote village in Bicchua block of Chhindwara, Madhya Pradesh, the newly constructed building of the sub-centre is open only twice a month. Once for the monthly immunisation day and then for completing paperwork. About 90 kilometres away, the sub-centre in Ghoghri village of Amarwara block has not been open for over a year. The building has been illegally occupied by a retired staff nurse who refuses to let anyone in. And in Panara village in Jamai block, which has an opencast coal mine, no one knows when, and if, the sub-centre opens.

These micro findings from a survey done by local students in a district in Madhya Pradesh, as part of an assessment of the state of public health facilities, necessitate a macro look at the way India’s sub-centres are functioning. Sub-centres play a crucial role in rural healthcare delivery. Being the first tier of the primary healthcare structure, they serve as the initial point of contact between people and health services. Each sub-centre is designed to cover a population of 5,000 in rural plains and 3,000 in hilly or desert or tribal areas through a staff of at least one female health worker or Auxillary Nurse Midwife and one male health worker. Sub-centres perform vital tasks that include providing health services related to immunisation, maternal and child health, and disease control, along with health education and motivation. In many ways, they form the foundation on which the goals of India’s public health are built.

But is this foundation as strong as it should be?

Problems at the bottom

The Rural Health Statistics of 2015-’16, brought out by the Ministry of Health and Family Welfare, reports that out of total 1,55,069 sub-centres in India, 86% do not meet the Indian Public Health Standards set up by the government. As on March 2016, 28% of sub-centres did not have regular water supply and one-fourth did not have electricity supply.

Although all sub-centres in Andhra Pradesh and Telangana, Tamil Nadu and Goa had regular water supply and electricity, much fewer sub-centres in Arunachal Pradesh, Manipur, Jharkhand, Jammu and Kashmir and Bihar had this essential infrastructure.

Along with functional infrastructure, primary healthcare requires adequate and skilled health personnel. Government data reveals an alarming shortage of male health workers, which may seriously affect the implementation of many important national health programmes like the National Vector Borne Disease Programme. More than 90% of sub-centres in Uttaranchal and Rajasthan, 88% in Jharkhand, 87% in Bihar and 84% Uttar Pradesh did not have a male health worker. Nationally, the shortfall of male health workers is as much as 65%. The only state with a surplus is Mizoram. The situation is far better in terms of female health workers or ANMs, with national shortage being only 3% percent of the requirement, and most states having a surplus.

As found by the survey in Chhindwara, the challenge for India’s health workforce is not only of shortage but also of high absenteeism. A nationally representative study in 2011 found that absence rates of medical workers were as high as 39%. Another study of 100 public health facilities (with 68 sub-centres) of four northern states reported that, on average, only 3.6 out of 10.5 appointed staff were found to be present at the time of a surprise visit. The authors argue that high absenteeism contributes to underutilisation of public health facilities.

Why sub-centres matter

If overall underutilisation of public health facilities is to be tackled, more attention needs to be given to sub-centres, where people first interact with the health services system. A badly functioning sub-centre reinforces public opinion of inefficient government health services. This contributes to the popularity of private practitioners, most of them untrained. It also exposes people to unsafe practices of medicine, and increases out of pocket expenditure on health, while undermining the public provisioning of healthcare.

Underperforming sub-centres are also partly responsible for the unmanageable patient load at the higher tiers of healthcare, which themselves are understaffed and deficient in infrastructure. Instead of going through a referral system where a patient first goes to primary levels and if needed is referred to secondary and tertiary levels, most patients go directly to higher levels without any referral. A 2008 study of three referral hospitals in Lucknow found that only one-tenth of all patients had been referred from the lower levels while all others were self-referred. This puts immense burden on secondary and tertiary care facilities, whereas primary levels of healthcare remain poorly utilised.

Fixing the foundation

For all the levels of healthcare to function well, it is necessary to strengthen the foundation. Recently, the government announced in its financial budget a plan to transform 1.25 lakh sub-centres into health and wellness centres in a phased manner. But a parliamentary panel on budget allocation noted that there was no solid roadmap to ensure the financial resources for such an initiative.

Any kind of roadmap for making sub-centres functional and effective needs to go beyond changing the nomenclature or financial allocation alone. It will have to tackle the overarching issues of infrastructure and human resources, especially the acute shortage of male health workers. Much can be learnt from the improvements in states like Tamil Nadu and Himachal Pradesh. There is also a need to check absenteeism and work ethics of medical workers. For this, action oriented methods like community based monitoring, social audits, and jan sunwayis or public hearings should be supported and strengthened. Finally, such a roadmap must be grounded in the ideals of public health and the primary health care approach, so that the health of those at the peripheries does not become peripheral.

The writer is pursuing her MPhil at the Centre of Social Medicine and Community Health, Jawaharlal Nehru University.