Infrastructure woes

To fix India’s flailing public health system, health sub-centres need to be improved first

Health sub-centres are the first points of contact between people and the public health system. But many sub-centres need to do much better.

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.

We welcome your comments at letters@scroll.in.
Sponsored Content BY 

Relying on the power of habits to solve India’s mammoth sanitation problem

Adopting three simple habits can help maximise the benefits of existing sanitation infrastructure.

India’s sanitation problem is well documented – the country was recently declared as having the highest number of people living without basic sanitation facilities. Sanitation encompasses all conditions relating to public health - especially sewage disposal and access to clean drinking water. Due to associated losses in productivity caused by sickness, increased healthcare costs and increased mortality, India recorded a loss of 5.2% of its GDP to poor sanitation in 2015. As tremendous as the economic losses are, the on-ground, human consequences of poor sanitation are grim - about one in 10 deaths, according to the World Bank.

Poor sanitation contributes to about 10% of the world’s disease burden and is linked to even those diseases that may not present any correlation at first. For example, while lack of nutrition is a direct cause of anaemia, poor sanitation can contribute to the problem by causing intestinal diseases which prevent people from absorbing nutrition from their food. In fact, a study found a correlation between improved sanitation and reduced prevalence of anaemia in 14 Indian states. Diarrhoeal diseases, the most well-known consequence of poor sanitation, are the third largest cause of child mortality in India. They are also linked to undernutrition and stunting in children - 38% of Indian children exhibit stunted growth. Improved sanitation can also help reduce prevalence of neglected tropical diseases (NTDs). Though not a cause of high mortality rate, NTDs impair physical and cognitive development, contribute to mother and child illness and death and affect overall productivity. NTDs caused by parasitic worms - such as hookworms, whipworms etc. - infect millions every year and spread through open defecation. Improving toilet access and access to clean drinking water can significantly boost disease control programmes for diarrhoea, NTDs and other correlated conditions.

Unfortunately, with about 732 million people who have no access to toilets, India currently accounts for more than half of the world population that defecates in the open. India also accounts for the largest rural population living without access to clean water. Only 16% of India’s rural population is currently served by piped water.

However, there is cause for optimism. In the three years of Swachh Bharat Abhiyan, the country’s sanitation coverage has risen from 39% to 65% and eight states and Union Territories have been declared open defecation free. But lasting change cannot be ensured by the proliferation of sanitation infrastructure alone. Ensuring the usage of toilets is as important as building them, more so due to the cultural preference for open defecation in rural India.

According to the World Bank, hygiene promotion is essential to realise the potential of infrastructure investments in sanitation. Behavioural intervention is most successful when it targets few behaviours with the most potential for impact. An area of public health where behavioural training has made an impact is WASH - water, sanitation and hygiene - a key issue of UN Sustainable Development Goal 6. Compliance to WASH practices has the potential to reduce illness and death, poverty and improve overall socio-economic development. The UN has even marked observance days for each - World Water Day for water (22 March), World Toilet Day for sanitation (19 November) and Global Handwashing Day for hygiene (15 October).

At its simplest, the benefits of WASH can be availed through three simple habits that safeguard against disease - washing hands before eating, drinking clean water and using a clean toilet. Handwashing and use of toilets are some of the most important behavioural interventions that keep diarrhoeal diseases from spreading, while clean drinking water is essential to prevent water-borne diseases and adverse health effects of toxic contaminants. In India, Hindustan Unilever Limited launched the Swachh Aadat Swachh Bharat initiative, a WASH behaviour change programme, to complement the Swachh Bharat Abhiyan. Through its on-ground behaviour change model, SASB seeks to promote the three basic WASH habits to create long-lasting personal hygiene compliance among the populations it serves.

This touching film made as a part of SASB’s awareness campaign shows how lack of knowledge of basic hygiene practices means children miss out on developmental milestones due to preventable diseases.

Play

SASB created the Swachhata curriculum, a textbook to encourage adoption of personal hygiene among school going children. It makes use of conceptual learning to teach primary school students about cleanliness, germs and clean habits in an engaging manner. Swachh Basti is an extensive urban outreach programme for sensitising urban slum residents about WASH habits through demos, skits and etc. in partnership with key local stakeholders such as doctors, anganwadi workers and support groups. In Ghatkopar, Mumbai, HUL built the first-of-its-kind Suvidha Centre - an urban water, hygiene and sanitation community centre. It provides toilets, handwashing and shower facilities, safe drinking water and state-of-the-art laundry operations at an affordable cost to about 1,500 residents of the area.

HUL’s factory workers also act as Swachhata Doots, or messengers of change who teach the three habits of WASH in their own villages. This mobile-led rural behaviour change communication model also provides a volunteering opportunity to those who are busy but wish to make a difference. A toolkit especially designed for this purpose helps volunteers approach, explain and teach people in their immediate vicinity - their drivers, cooks, domestic helps etc. - about the three simple habits for better hygiene. This helps cast the net of awareness wider as regular interaction is conducive to habit formation. To learn more about their volunteering programme, click here. To learn more about the Swachh Aadat Swachh Bharat initiative, click here.

This article was produced by the Scroll marketing team on behalf of Hindustan Unilever and not by the Scroll editorial team.