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 - 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