Stop blaming doctors and paramedical personnel

Improve Infrastructure Immediately

Nearly 17.5% of the world’s population resides in India. But, the country is responsible for 20% of the global burden of diseases, 27% of all neonatal deaths and 21% of all child deaths (younger than five years), drawing reference from Lancet. India’s miserable healthcare infrastructure network attributes to this. Both Central and State Governments are responsible for not fulfilling their Constitutional obligations.

BJP’s sweeping victory in the Assembly polls in Uttar Pradesh and Uttarakhand cannot hide the fact that in states like Gujarat; Jharkhand and Chattishgarh, where the party is ruling for quite some time, majority of the Primary Health Centres (PHCs) do not have even a single doctor. The situation in Uttar Pradesh is also very much unhealthy. Out of a total number of 3,497 PHCs in Uttar Pradesh, 1,288 don't have a single doctor. The number of doctors for each PHC in Chhattisgarh (0.46 doctors per PHC); Gujarat (0.71); Madhya Pradesh (0.85); Odisha (0.77); and in West Bengal (0.79), which hit the bottom of the list. (See Table-1)

 

No. of PHCs vis-à-vis doctors

Table-1

State	No. of PHCs (2015)	Doctors for PHCs (2015)	Doctor per PHC
Gujarat	1247	889	0.71
Madhya Pradesh	1171	999	0.85
Odisha	1305	1008	0.77
West Bengal	909	723	0.79
Jharkhand	327	372	1.13
Rajasthan	2083	2412	1.15
Chhattisgarh	792	368	0.46
Kerala	827	1169	1.41
Tripura	91	158	1.73

Source: Rural Health Statistics, Ministry of Health and Family Welfare, Government of India

To take care of 1.3 billion Indian’s health, the country has only 938,861 registered doctors, which accounts for seven doctors per 10,000 people. According to the Central Bureau for Health Intelligence (CBHI) statistics, released in March 2015, states like Bihar and Maharashtra have the worst doctor to patient ratios; with one doctor treating 28,391 and 27,790 patients respectively. Chhattisgarh stands third with a doctor to patient ratio of 1 : 25,032.  This shortage of number of doctors is further compounded by unfair distribution across rural health centres. In community health centres in rural areas of many states, ranging from Gujarat to West Bengal, the shortfall of specialists exceeds 80%. This also holds true for other healthcare professionals. (See Table -2)

Table-2                                               (Source: Lancet)

	Desired Density	% Shortfall
	per 100,000 population
	(as per 12th five year plan)
Doctors	85	49.1
AYUSH Practitioners	49	11.3
Dentists	15	106.0
Pharmacists	70	72.3
Nurses	170	177.5
Auxiliary Nurse Midwives	85	185.0

 AYUSH = Ayurveda; Yoga and naturopathy; Siddha;

Unani; Homoeopathy practitioner            

According to the Rural Health Statistics (RHS), published by the Statistics Division of the Ministry of Helth and Family Welfare (2014-15), there are 153,655 Sub Centres, 25,308 Primary Health Centres (PHCs), 5,396 Community Health Centres (CHCs), 1,022 sub divisional hospitals, 763 district hospitals and 1,253 mobile medical units across the country. Does this infrastructure network suffice the need of 1.3 billion Indians? Using the prescribed norms on the basis of rural population from Census-2011, there are shortfall in health infrastructure by 20% in Sub Centres; 22% in case of PHCs and 32% for CHCs (all India shortfalls are derived by adding state-wise figures of shortfall).

As on 31 March, 2015, out of 153,566 functioning Sub Centres, 71,433 had no male and 8,138 had no female health workers. 5,053 Sub Centres did not have either male or female health workers. The Sub Centres across India had 18,226 vacancies for the posts of female health workers; 20,492 for Auxiliary Nurse Midwives (ANMs) and 37,888 for male health workers.

PHCs had a shortfall of 12,448 female and 15,513 male health assistants. Out of total 25,308 PHCs, 14,189 were managed by only one doctor and 2,041 PHCs had no doctor at all. 9,649 PHCs had no laboratory technicians and 5,553 had no pharmacists. Only 6,436 PHCs had lady doctors. Number of ANMs in PHCs was decreased from 213,400 in 2014 to 212,185 in 2015 and major contributory states were Tamil Nadu, Maharashtra, Jammu Kashmir, Rajasthan, Madhya Pradesh etc. Vacancies in sanctioned posts of medical specialists also increased from 2014 to 2015. (See Chart-1)

% of sanctioned posts of specialists remained vacant in PHCs

Chart-1

 

In CHCs, out of required 21,584 specialists, only 4,078 doctors were in position as on 31 March, 2015 leaving a shortfall of 17,525 doctors. The number of doctors, in position, in CHCs was declined from 4,091 in 2014. Major decrease came from Rajasthan and Punjab. The number of sanctioned posts for General Duty Medical Officers was 13,066 out of which 11,822 were in position leaving vacancies for 1,244 posts. The number of shortfall of doctors in CHCs can be seen across all specialties. (See Table-3)

Shortfall of number of doctors in CHCs

Table-3

Specialist	Required (2015)	In position (2015)
Surgeons	5,396	896
Obs & Gyna	5,396	1,296
Physicians	5,396	918
Paed	5,396	968
Total	21,584	4,078

According to the statistics provided by the Union Health Ministry as on 31 March 2015, there was a requirement of 29,337 PHCs across India but it had 6,556 PHCs less attributing a shortfall by 22%. Similarly, there was a deficit of 2,316 CHCs which amounts to a massive shortfall of 32%. The CBHI data suggests that there were 20,306 hospitals in India with 675,779 beds; the rural and urban allocations were 183,602 and 492,177 beds respectively. One government hospital bed serves 1.923 people on an average. The worst ratios are in Bihar (8,789) and Jharkhand (6,052). For every 10,000 people, India has the least numbers of physicians and hospital beds in compare to many countries. (See Chart-2)

Physician and Hospital Bed per 10,000 people

Chart-2

 

With minimal government funding and poor health infrastructure network, there is a large unregulated private sector in healthcare business. Despite high cost of treatment, people in general prefer to visit private hospitals more frequently. The National Sample Survey Office (NSSO) data shows a declining trend in the use of public hospitals over the past two decades (See Chart-3). As on March 2015, only 32% of urban Indians use public hospitals which were 43% in 1995-96. Ironically, a large section of these private practitioners may not be qualified or may be under-qualified as pointed out by Lancet. A study in rural Madhya Pradesh found that only 11% of the sampled healthcare providers had a medical degree, and only 53% had completed high school. 

% of population treated their ailment at different outfits

Chart-3

 

Another astonishing fact reveals that public healthcare system in India benefits higher income class more than the poorer section. The poorest income class is the least benefited from such facilities. According to World Health Organization statistics, the proportion of lower income classes in India with access to free healthcare is 17.33 in compare to the proportion of higher income class which remains as 22. This situation is undoubtedly alarming and exposes the fact that the policymakers at different levels are not so “pro-poor”. (See Chart-4)

Country wise % population in different income groups

 having access to free healthcare

Chart-4

 

This anarchic situation in healthcare system has pushed India far behind. India has the third highest child mortality rate among SAARC countries with 48 deaths reported per 1,000 live births. Nearly five women die every hour in India from complications developed during childbirth. Nearly 45,000 mothers in India die every year due to causes related to childbirth which accounts for 17 per cent of such deaths globally. According to World Health Organisation, the major cause of maternal deaths in India is post-partum haemorrhage which is often defined as the loss of more than 500-1,000 ml of blood within the first 24 hours following child birth. Majority of these deaths are among women in the 15-29 age groups. For every maternal death in India, 20 more women suffer from lifelong health impairments that result from complications during their pregnancies. Almost 90% of women in Maharashtra and Gujarat, the most prosperous states in India, are anemic due to inadequate nutrition. Only 23.1% of mothers, just one in five pregnant women, receive iron and folic acid during pregnancy. More than half the women in the child bearing age group (56.2 percent) are anemic. Only 4% of expectant mothers take a de-worming drug during pregnancy. Many women are unable to attend prenatal visits throughout pregnancy. 70% of patients who face an emergency situation do not have a means of transportation readily available. They had not planned for it earlier. 40% of deaths occur at home, mainly from severe infection (sepsis) and bleeding. Delays occur while trying to find money or while transporting the patient. Even if a mother gets to a hospital in time, there is no guarantee that her life is safe because the right medical facilities, trained professionals, medicines and other critical inputs like blood are not available.

To conclude: healthcare infrastructure of India needs immediate overhaul. Indian states also cannot overpass their responsibilities. People’s lives must be saved as priority. Only chanting slogans through media advertisement won’t help the hapless. Our policy-makers across the states and at the Centre must realize that.

@pradipsinterpretations