Author : Shrimee
Co Author : Apurva sharma , AMU
In the country in which hunger, poverty, environmental and health problem are too common we should demand from our government a good primary health care system. As India, being a democratic country provides us with the basic fundamental rights, especially the right to life enshrined in Article 21 which includes health, education, privacy etc. so it is the need of an hour to improve our primary health care system which would further help the people of the country to live healthy and enjoy their basic rights.
The primary health care system should be made universally accessible to individuals and families in the community through their full participation and at a cost that the community and the country can afford to maintain at every stage of their development in the spirit of self reliance and self determination. The Declaration of Alma-Ata was adopted at the International Conference on Primary Health Care (PHC), it expressed the need for urgent action by all governments, all health and development workers, and the world community to protect and promote the health of all people. It was the first international declaration underlining the importance of primary health care. The primary health care approach has since then been accepted by member countries of the World Health Organization (WHO) as the key to achieving the goal of “Health For All” but only in developing countries at first.1
PRESENT SCENARIO OF PRIMARY HEALTH CARE
In this modern world, with ongoing increasing population the health sector is an important sector to show a greater concern as it is well said that a good health is above wealth. So, to deal with the primary health care system in India there is various agencies and organization working to improve the health issues in rural and urban areas. There are mainly two sector i.e. Public health sector and private sectors. These are working for improvement of health in our country.2
The public health system in India comprises a set of state-owned health care facilities funded and controlled by the government of India. Some of these are controlled by agencies of the central government while some are controlled by the governments of the states of India. The governmental ministry which controls the central government interests in these institutions is the Ministry of Health & Family Welfare. Governmental spending on health care in India is exclusively this system, hence most of the treatments in these institutions are either fully or partially subsidized.3
So, if we look towards our public sector in health the government should come up with new policies and measures to ensure better health to the people in India as the government action has a great impact on the public at large. Therefore, the polices should also have some positive effect. However at present there is a lot of burden chronic non-communicable diseases, demographic transition (increasing elderly population) and environmental changes, the tobacco-attributable deaths range from 800,000 to 900,000/year, leading to huge social and economic losses. The rising toll of road deaths and injuries (2—5 million hospitalizations, over 100,000 deaths). Insufficient financial resources for the health sector and inefficient utilization result in inequalities in health. The inequalities in health is somewhere due to the social, economic stratification in society according to income, education, occupation, gender and race or ethnicity.4
The country’s healthcare system is characterized by inadequate infrastructure and limited resources. In fact, India’s healthcare infrastructure metrics is amongst the lowest in the world. According to the WHO World Health Statistics 2015, the public sector in India spent 1.16% on health as a percentage of the GDP, ranking 187th among 194 countries. The investment in healthcare is inadequate. Global evidence on health spending shows that unless a country spends at least 5-6% of its GDP on health, basic healthcare needs are seldom met.5
Furthermore if we look at private sector in health care system, according to National Family Health Survey-3, the private medical sector remains the primary source of health care for 70% of households in urban areas and 63% of households in rural areas. Reliance on public and private health care sector varies significantly between states. The main reason at the national level is poor quality of care in the public sector, with more than 57% of households pointing to this as the reason for a preference for private health care. Most of the public healthcare caters to the rural areas; and the poor quality arises from the reluctance of experienced health care providers to visit the rural areas. Consequently, the majority of the public healthcare system catering to the rural and remote areas relies on inexperienced and unmotivated interns who are mandated to spend time in public healthcare clinics as part of their curricular requirement. Other major reasons are distance of the public sector facility, long wait times, and inconvenient hours of operation. The study conducted by IMS Institute for Healthcare Informatics in 2013, across 12 states in over 14,000 households indicated a steady increase in the usage of private healthcare facilities over the last 25 years for both Out Patient and In Patient services, across rural and urban areas.6
TIERS OF PRIMARY HEALTH CARE SYSTEM:
(A)PUBLIC HEALTH CARE
PHC are established and maintained by govt.
Primary Health Centres
In developing countries the Primary Health Centre (PHC) is the basic structural and functional unit of the public health services. These is the parts of government funded public health system in India and are the most basic unit of this system.7
As per the given data, 1, 00,000 of population is covered under every primary health centre and it covers all over about 100 villages. According to WHO report, in the developing countries health system is not responding accordingly as per the needs of society. India adopted primary health care system even before the declaration of Alma-ata on the principle that inability to pay should not prevent people from accessing health services.8
The first contact point between the primary health care system and the community is Sub-Centre(SC). All the sub centres are provided with the basic drugs as to easily accessible of drugs for all men, women and children. Sub centres are made so that it covers a population of 3000 in hilly or tribunal areas (difficult areas to access) and 5000 in plain areas.9
Presently a sub centre is staffed by a male health worker and with one female health worker, prior one is known as Multipurpose worker and latter is known as Auxiliary nurse midwife. Sub centre must be at a place which could be easily accessible to general public as a whole, it should be in a central location.10
Community Health Centre
The Community Health Centre (CHC), the third tier of the network of rural health care institutions, was required to act primarily as a referral centre (for the neighboring PHCs, usually 4 in number) for the patients requiring specialized health care services.
The main aim of having a CHC is in two fold, first one is to make modern health care which should be easily accessible to rural public and second is to ease the overcrowding in district areas. CCHCs were mainly designed to consist of four specialists in the field of medicine, surgery, paediatrics and gynaecology; 30 beds for indoor patients; operation theatre, labour room, X-ray machine, pathological laboratory, standby generator , etc., along with the complementary and Para medical staff. But dealing with present scenario only 30 percent of the total are working accordingly with their position and rest of the 70 percent are running with one specialist or even without any specialist. This shows the lack of facility system related to health care system in India.11
Health care system to be successful in rural areas is a big challenge for the health ministry of India to take care of, because most of the population about 70 percent of the total population is residing in rural areas where mortality rate due to diseases are on a high. Though there are several schemes run by government but there is lack of implementations as a cause which arises and results into non access of basic needs like availability of medicines. In rural India 8 percent of the centres do not have doctors or medical staff, 39 percent does not have lab technicians and 18 percent PHCs do not even have a pharmacist.12
According to a report by IMS institute for health care and informatics, the current situation is the urban residents have access to 66 per cent of the total hospital beds available in India. In rural areas, to seek OPD treatment 32 per cent of rural respondents had to travel over 5 kms, while 68 per cent travelled less than 5 kms for the same.13
Health Insurance Scheme
Health insurance scheme for Indian workers is a a self financing social security. This scheme is managed and headed by ESIC as Employees State Insurance Corporation in accordance with the rules and regulations stipulated by there in the ESI act 1948. It is an autonomous corporation by a statutory creation under ministry of labour and Employment government of India.14
Central Govt. Health Scheme
The Central Government Health Scheme (CGHS) was started under the Indian Ministry of Health and Family Welfare in 1954. It was aim to provide comprehensive medical care facilities to the Central Governmental Employees including the pensioners and their dependents residing in CGHS covered cities. This scheme took place for the first time in Delhi in 1954, subsequently it spreaded to the following 17 cities: Allahabad, Ahmadabad, Bangalore, Mumbai, Kolkata, Hyderabad, Jaipur, Jabalpur, Lucknow, Chennai, West Bengal, Nagpur, Patna, Pune, Kanpur, Thiruvananthapuram and Guwahati.15
(B) PRIVATE SECTOR
Private hospitals are not funded by Government, they are run by one for personal benefit and to avail the service through direct payments from patients and insurance providers, and do not receive public money. Collaboration with the private sector to provide health services to the poor has generated many challenges. In our country people are choosing private hospitals because of lack of facilities available in the public hospitals even though to afford the price of private hospital is almost next to impossible for most of the people.16
Indigenous system of medicine
This system includes Ayurveda, Siddi, Unani and Tibbi, Homeopathy. Most of the traditional systems of India including Ayurveda have their roots in folk medicine. Ayurveda is considered as most efficient system which originated in India about 3000-5000 years ago as an oldest health care system in the world. Similarly Siddi, Unani, Tibbi and Homeopathy are the various system for health care especially adopted by the Indians. India is a vast country with a variety of religions where people still belief in their cultural system rather scientific system.17
(C) NATIONAL HEALTH PROGRAMMES
Since India became independent, several measures have been taken by the Indian Government under national health programmers in India. Some of the recent initiatives are: Rashtriya Bal SwasthiyaKaryakaram (RBSL), Rashtriya Kishore SwasthyaKriyakaram (RKSK), Weekly Iron Folic Acid Supplementation Programme(WIFS). The main object of these programmes are-
- to control or eradication of communicable diseases
- improvement of environmental sanitation
- raising the standard of nutrition
- control of population
- improving rural health18
In India, communicable diseases, maternal, perinatal, and nutritional deficiencies continue to be important causes of deaths non communicable diseases like diabetes, cardiovascular diseases, respiratory disorders, cancers, and injuries are showing the rising trends. Delivering of qualitative health care services is considering a basic need irrespective of age, gender, and culture. The key growth inhibitors are: 19
Neglect of rural population: In major urban areas, healthcare is of adequate quality, approaching and occasionally meeting Western standards. However, access to quality medical care is limited or unavailable in most rural areas. This has led to a deterioration of health in rural areas, which is also affecting the agricultural sector, with increased rate of malnutrition found in the backward areas of the state, high infant and maternal mortality rate, and increased risk of spread of diseases in rural areas and the nearby urban areas.20
Although, there are large no. of PHC’s and rural hospitals yet the urban bias is visible. According to health information 31.5% of hospitals and 16% hospital beds are situated in rural areas where 75% of total population resides. Moreover the doctors are unwilling to serve in rural areas.21
Emphasis On Culture Method:
The health care system of our country depend upon the western model, and there is no use for culture method for health care but in actual practice mainly in rural areas we can say due to shortage of money or inconvenience they use their own traditional method to cure the disease known as desi dawai, ayurvedic medicines etc. even more in early days delivery of a woman were done at homes in villages by mid wives.22
Inadequate Outlay for Health:
According to the National Health Policy 2002, the Govt. contribution to health sector constitutes only 0.9 percent of the GDP. This is quite insufficient. In India, public expenditure on health is 17.3% of the total health expenditure while in China, the same is 24.9% and in Sri Lanka and USA, the same is 45.4 and 44.1 respectively. This is the main cause of low health standards in the country. Due to insufficient doctors, the rural people have to suffer a lot in getting proper medical treatment. As per Hindustan Times India is Short of 5 lakhs doctors, India has just 1 for 1,674 people.23
According to the National Family Health Survey-III (2005-06) clearly highlight the caste differentials in relation to health status. The survey documents low levels of contraceptive use among the Scheduled Castes and the Scheduled Tribes compared to forward castes. Stunting, wasting, underweight and anemia in children and anemia in adults are higher among the lower castes. Similarly, neonatal, postnatal, infant, child and under-five statistics clearly show a higher mortality among the SCs and the STs. Problems in accessing health care were higher among the lower castes.24
Expensive Health Service:A new government survey shows that in 2014 more than 70% of illnesses were treated in the private sector including clinics, hospitals and charitable institutions, a four percentage point increase over a 10-year period. Private Doctors were the most important single source of treatment in both rural and urban sectors,” said the National Sample Survey Office (NSSO) survey of over 3.3 lakhs households across India released this week. The survey also said the number of people visiting private institutions for healthcare was higher in urban areas at 79% than just 72% in rural India. Many people are turning to private health providers that have mushroomed across the country because of poor infrastructure at often overcrowded government-run hospitals. The NSSO data showed that people opted for private sector even though it cost almost four times as much as treatment in government institutions. The numbers are telling: In 2014, the average cost of hospital care by a public utility was Rs 6,120 while a private institution cost more than four times as much at Rs 25,850. A decade earlier, the difference between the two was less than three times. For higher cost treatments like cancer, the average cost in a government hospital was Rs 24,526 compared to Rs 78,050 in the private sector. The cost of treatment for skin infections, respiratory and accidents is between four to 10 time higher in private clinics, the survey showed.25
Behind all this glitter there are some ominous signs of the ills that pervade the health care system. A coherent and sustainable plan that addresses the healthcare needs of the masses is strikingly absent. There are no national standards by which physicians, nurses, pharmacists and hospitals are trained. According to public health foundation of India, Mr. Reddy has given few recommendation:
Increase health-care spending to 2.5% of GDP: At the moment, the Indian government spends about 1% of its gross domestic product on health care, according the Organization for Economic Cooperation and Development. But it is recommended to spend 2.5% of GDP by 2017.While public spending is high as a portion of GDP, low priority is accorded to health.” The report puts Indian public spending at 33% of the GDP, of which only 4% is spent on health care.
Spend more on primary care: Additional funds shouldn’t go only to maintaining the present health system, with its skewed spending choices. Much as in education, Indian health spending has often favored treatment at hospitals in large cities over more widely available basic and preventive care. Over time, 70% of public spending should be on primary care. Pre-natal check-ups and regular deliveries would be primary care, for example, while a cesarean-section delivery would be secondary care.
Develop an all-India public health service:
The committee suggested the country needs an all-India service of public health workers along the lines of the system that Tamil Nadu has, which some observers say is the best in India.
In general, to make a national health system that works, the report says that more medical and nursing schools will need to be set up and millions more basic health workers will be required, particularly in villages. We need doctors, we need nurses, we need community health workers. “We need a multilayered health work force.”
Buy more drugs in bulk:
Out-of-pocket spending on medicine has gone up in India, and now accounts for almost three-fourths of all private health-care spending, the Indian government could take a cue from Tamil Nadu, which purchases drugs in bulk and provides many medicines for free to patients. That would involve significantly increasing public spending on drugs from around $1 billion now.26
The present system (and its escalating costs) is not sustainable due to its inefficiency and a lack of aligned incentives for improving performance. It will not be easy and it will not be inexpensive. But it has been done in other parts of the world before and it can be done here too. The potential to create the best healthcare system in the world exists. It is time to commence the debate, develop a plan and execute it.27
As now we are in globalization era in which we have to develop ourselves with a very high pace in order to compete with the other developed countries. India’s progress towards achieving the Millennium Development Goal is slow and it is well known that primary health care is important for achieving the goals. The only thing which can be done is that government should take effective step in order to resolve the health related issues and problem.
Moreover in rural areas, it should be ensured that doctors prove themselves to be more resourceful then paramedical personnel, as in rural areas people mostly believe in the latter case. As our health care system is dealing with main two sector i.e. public sector and private sector. In both these sector although far reaching results are achieved but still for our country population is not enough we have to still improve working of both the sectors but primarily we should improve our public sector so that a larger no. of public is benefited specially the rural areas at affordable prices and with easy accessibility. And then secondly, we should improve private sector by providing them subsides though government which will help the people to get high technologies and advanced medicine at cheap rates and disease can be cured in every nook and corner of the country.
- Introduction available from Article- Pandve HT, Pandve TK. Primary Health Care System In India: evolution and challenges. Int j Health Syst Disaster Manage 2013;1:125-8 URL- http://www.ijhsdm.org/text.asp?2013/1/3/125/129126.
- Present scenario available from http://www.srmuniv.ac.in/sites/default/files/files/1.pdf.
- Present scenario available from https://en.wikipedia.org/wiki/Public_health_system_in_India.
- Present scenario available from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3114612/.
- Present scenario available from http://thewire.in/80401/increased-healthcare-spending-key-to-economic-growth-in-india/.
- Present scenario available from Ramya Kannan (30 July 2013).”More people opting for private healthcare”. Chennai, India: The Hindu. Retrieved 31 July 2013.
- Tiers of primary health care available from https://en.wikipedia.org/wiki/Primary_Health_Centre_(India)
- Tiers of primary health care available from https://www.ncbi.nlm.nih.gpmc/articles/PMC2940196/
- Tiers of primary health care available from https://data.gov.in/catalog/number-sub-centres-primary-health-centres-and-community-health-centres-established-during
- Tiers of primary health care available from https://www.scribd.com/doc/81536686/SUB-CENTRE-FUNCTIONS-STAFFING-PATTERNS
- Tiers of primary healthcare available from http://planningcommission.gov.in/reports/peoreport/peo/peo_chc.pf)
- Tiers of primary health care available from gramvni.org/?p=1629aa
- Tiers of primary health care available from http://www.thehindu.com/sci-tech/health/study-reveals-rural-india-gets-only-13rd-of-hospital-beds/article4931844.
- Tiers of primary health care available from https://en.wikipedia.org/wiki/Employees’_State_Insurance.
- Tiers of primary health care available from https://en.wikipedia.org/wiki/Central_Government_Health_Scheme.
- Tiers of primary health care available from http://www.pppinharyana.gov.in/ppp/sector/health/report-healthcare.pdf.
- Tiers of primary health care available from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2816487/.
- Tiers of primary health care available from http://www.srmuniv.ac.in/sites/default/files/files/1.pdf.
- Problem of primary health care available from http://www.economicsdiscussion.net/articles/7-major-problems-of-health-services-in-india/2305.
- Problem of primary health care available from http://www.insightsonindia.com/2015/02/23/3-critically-comment-on-indias-attitude-towards-health-care-in-rural-areas-since-independence-and-its-consequences/.
- Problem of primary health care available from http://www.economicsdiscussion.net/articles/7-major-problems-of-health-services-in-india/2305.
- Problem of primary health care available from http://www.nacd.in/ijda/volume-01-issue-01/8-cultural-factors-in-health-and-oral-health.
- Problem of primary health care available from https://www.quora.com/What-is-your-opinion-about-medical-health-system-in-India.
- Problem of primary health care available from http://www.thehindu.com/opinion/lead/caste-and-inequalities-in-health/article7075.ece.
- Problem of primary health care available from http://www.hindustantimes.com/india/most-indians-prefer-private-healthcare-services-over-govt-hospitals/story-KSgqT0rqLIebKzq34wRbJJ.html.
- Suggestion available from http://blogs.wsj.com/indiarealtime/2011/12/19/five-ways-to-improve-indian-health-care/.
- Suggestion available from http://www.rediff.com/money/2007/jul/23health1.htm.