Documente Academic
Documente Profesional
Documente Cultură
REVIEW OF LITERATURE
2.1: Introduction
2.2: Current Picture of the Primary Health Care System in Rural India
2.4: Funding
2.5: Disease Profile of Rural India
2.10: Conclusion
CHAPTER 2
REVIEW OF LITERATURE
2.1: INTRODUCTION
evaluate the existing primary health care systems by going through the
government and the central government and the articles published in the
20 000 people, the country currently has one PHC per 31 000
population. Even the existing public health facilities run with abysmally
41
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
services in India. However, the picture is still below the standards set up
India, highlighted that primary health centres are the solution to global
through their full participation and at a low cost. According to her the
(such as GDP per capita, total physicians per one thousand population,
42
ambulatory care visits, per capita income, alcohol and tobacco
consumption).
evident that the success of health systems exists in tapping the existing
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
43
the national health system. Indian primary health care system brings
treatment for illness and injury. She also pointed a number of positive
involvement.
in India, Neesha also critically analysed the present health status of the
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
medicines, patients usually not visiting PHCs in the early stages of their
44
diseases and healthcare providers are forced to focus only on seriously
45
2.2.2: In 1995, Dreze and Sen observed that “India has poor health
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
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%
less than 20% had a telephone. Less than a third of these centres stocked
very cheap but essential drug like iron and folic acid.
46
for delivery complications are unavailable outside cities, resulting in
maternal death rates in the northern states. He states that even this trend
India accounts for a fourth of all maternal deaths worldwide, and the
numbers are increasing. Uttar Pradesh has a huge population base and
According to Das, even the existing health care delivery system in Uttar
diseases.18 states that have weak public health indicators, including the
seven north eastern states, and 11 states in north and eastern India.
the facilities.
47
According to the study, 80% of general practitioners in PHCs
73% of the doctors consider cost to be the most important factor when
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
handle cases of diarrhoea, but only 29% knew the exact composition of
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
48
centres in Tamil Nadu. According to her study, an important factor that
decided the accessibility of health services was the location of the PHC.
PHCs in her study area along with the main objective of studying the
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
allocated for the drugs and the surgical equipments were under special
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.
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
49
constraint in vehicle. A few PHCs did not depend on the main PHCS
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.
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
50
equality have widened the gap between „urban and rural‟ and „haves and
class, and gender disparities still remain high. The authors had compared
(e.g. access to healthy and nutritious food, clean air and water, nutritious
2.3.1: The literature also point towards the reality that there exists rural–
51
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
centres.
have been always insufficient, and even the rural and urban investment
pattern has been uneven with the result of health of rural people
of the GDP; public health investment is only 0.9%, which is by far too
52
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
salaries.
set up medical practice in rural areas, and the rural population as a result
53
In the case of medical research, a similar trend is observed. While
of pregnant mothers.
ward, (d) two quarters, one each for auxiliary nurse mid-wife and lady
54
health worker, (e) a generator, (f) provision of supply of safe drinking
combined design i.e while carrying out the field survey on CHCs,
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
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
55
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
The evaluation study had come out with the following results
was found to be equipped with all the eight essential facilities; viz; well
quarters, generator, drinking water, ambulance and lady doctor that were
Among the requisite facilities, the post of lady doctor for attending on
sample PHCs had been posted with a lady doctor. Though, a few
56
were available in many of the sample PHCs, such facilities could not be
were in position in assisted PHCs, while 96 per cent of them were found
absenteeism among the doctors from their work places was very high-a
programme assisted PHC was 68386 people and it was 57705 people by
prescribed norm of 6 sub-centres per PHC. This indicated the fact that
57
delivery of health care services, but also accentuating the problem of
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
Safety Net Programme had not been able to achieve the objective of
auxiliary para-medical staff. It was also observed by the field teams that
since the PHCs were not equipped with diagnostic facilities, the patients
58
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
and proper attention not given (35.71%). The second important reason
in PHCs. About 66.67 per cent of the beneficiaries expressed this view.
PHCs had still expressed their preferences for PHCs for seeking health
59
care services over other alternative sources of treatment. It was revealed
to stay away from the public health care delivery system primarily
60
services if the quality of delivery improved. The beneficiaries were
affirmative.
The Eighth Plan pointed out that it is not only the rural poor who
are deprived: in large cities, where about 40-50 per cent of urban
dwellers live in slums, their health status "is as bad, if not worse than in
rural areas". Further, "the infrastructure for primary health care in urban
urban primary health care system and factors that influence their health
problems.
centre in the middle of the city. Their results of their study revealed that
54% of the patients who attended the OPD came from the urban
but shifted because the treatment didn‟t work, or it became too costly.
61
They did not go to the urban health centre because there was just one
practitioner for less than 2,000 people in the municipal ward where the
hospital was located. The dispensary could hardly match the coverage of
the private sector or consider itself the main provider of first –level care.
2.3.5.2: Study by Aditi and others (1996) throw some insights in to the
the reason for why people travel to distant public health centre to seek
treatment for their illness. They found that financial reasons forced 30%
care. Fifteen per cent went outside for outpatient public care. Apparently
for this group, the cost and inconvenience of travel was less than the
private sector for outpatient care and slightly fewer for in patient care, a
patients of Dharavi rarely used the urban health centre due to lack of
62
private doctors for minor problems or the public tertiary hospital for
patients came to the tertiary hospital, they found 3.2% of the patients
were not provided with beds, 19.5% were not provided with linen, and
16.3% were not given hospital clothing and 21.1% of them did not have
linen and 27.6% of hospital clothes had never been changed. 68.1% of
the patients had to buy medicines from outside pharmacies. One out of
three had to get tests done outside. Only the poor come to public
hospitals.
2.4: FUNDING
health care system in India. Funding for the health care in India has
following part of the literature review will focus on the funding and the
impact of lack of funding has on the primary health care system in India.
63
by people made the Eighth Plan to support the philosophy of a
spending under the heads of family welfare, nutrition, water supply and
medical and public health declined. Also during the period from 1974-5
that after the introduction of economic reforms, the Central Plan outlay
Rs. 302 crores in 1992-3 to Rs.670 crores in the 1995-6 period. A large
and now AIDS (Rs. 421 crores) as well as salaries and maintenance
(GOI 1996).
64
A nation-wide survey conducted by the National Council for
health care funding and people‟s utilization of public and private health
care services. The survey, which was conducted across 6,354 rural and
facilities (Shariff 1995:17). While the private health markets served two
thirds and more of the sick in Uttar Pradesh, Kerala and Andhra
Pradesh. The survey found that the poorer households spent 7-8 per cent
cent spent by the richer households. The study also noted that per capita
expenses were much higher when individuals used private facilities: for
data from selected urban areas in a number of states was Rs. 2611 for a
public hospital and Rs. 1,115 for a private hospital, and Rs. 36 and
65
Rs.81 for non-hospital expenses in the public and private sectors
2.4.4: Though the number of Public Health Centres went up almost three
increase between 1971-81, field studies show that not only is there a
concentration in certain states, but also that the large majority of centres
are ill-stocked, inadequately staffed and too far from the target
population. Thus, there was already a crisis in the State-run health sector
country in 1996 noted that the system which "caters to the needs of 25-
66
Further, a good percentage of the Central budget on health goes on
decline from 1.3 percent in 1990 to 0.9 percent in 1999. The aggregate
expenditure in the Health sector is 5.2 percent of the GDP. Out of this,
allocation for health over this period, as a percentage of the total Central
Budget, has been stagnant at 1.3 percent, while that in the States has
Central resources to the public health funding has been limited to about
15 percent.
2.4.6: Further the 2002 Policy commended that for the outdoor medical
67
frequently negligible; the equipment in many public hospitals is often
that less than 20 percent of the population, which seek OPD services,
and less than 45 percent of that which seek indoor treatment, avail of
such services in public hospitals. This is despite the fact that most of
2.4.7: The findings of the National Health Accounts for 2001-02 also
came out with some alarming findings on the health care expenditure.
including not just expenses for treating illnesses, but also payment of
68
insurance premiums. State governments contributed 13%, the Central
to health-care providers went to the “for profit” private sector, 23% went
the level of public health spending was relatively higher in the states of
Himachal Pradesh, Jammu and Kashmir, Punjab and Kerala while lower
spending in Kerala was the highest while Assam was the lowest in the
country.
2.4.8: The latest GDP figures available for a complete financial year are
69
The number of medical practitioners in 1991 was 4.7 per 10,000
populations (as against 1.7 in 1951); however, almost 50 per cent of sub-
centres, PHCs or CHCs did not have buildings of their own. Indian
at the Primary Health Centre level in 1991 observed that only 22.6 per
supply was safe in only 71 per cent of the PHCs evaluated (ICMR 1991:
17, 19). A state wise look at infant mortality and poverty figures taking
Assam, Gujarat, Rajasthan and Bihar had above average Infant Mortality
Pradesh had a larger population living below the poverty line. In other
words, poverty, lack of facilities and high infant mortality rates are
vitally linked. This led the Government of India to admit that "the lack
70
a government document in 1994 points out that "biases in, favour of
2.5.1: While Park (2000), speaking on the disease profile of rural India,
stated that the majority of rural deaths, which are preventable, are due to
diseases in the world, an Indian. Annually, 1.5 million deaths and loss of
areas, as follows:
71
Diseases that are carried in the air through coughing, sneezing or
1.2 million cases are added every year and37 000 cases of measles are
About 2.3 million episodes and over 1000 malarial deaths occur every
million of which are active cases and 500 million people are at risk of
developing filaria.
Nearly, 1.2 million cases of leprosy, with 500 000 cases being added to
do not get two meals a day. More than 85% of rural children are
72
2.5.5: A survey by the Rural Medical College, Loni(2002), in the
3. All women invariably do hard physical work until late into their
pregnancy.
16 weeks of pregnancy.
diseases are all quite common in rural areas, for example: mechanical
73
psychological problems of the female, geriatric and adolescent
bronchitis among the aged. Though not common, there were cases of
skin disease, insects‟ bites and wild animal attacks and dog bites.
drugs is inadequate in all of the PHC, SC and hospitals that have been
74
2.7: PEOPLE’S HEALTH AND DECENTRALISED HEALTH
there has not been much people‟s participation in India in planning for
professionals. Further, WHO reiterated that the present system has not
left any scope for the involvement of the community, nor for grassroots
selected person from the village, and providing them with essential
training so that the community can cope more effectively with its health
„vertical programs‟.
75
2.8: PRIMARY HEALTH CARE SYSTEM IN KERALA
developed countries. The hall mark of Kerala model is low cost of health
state such as high female literacy rate (87.72%). The widely accepted
health indication viz death rate, Infant Mortality Rate (IMR) and
expectation of life at birth too are far advanced than the rest of the states
in India and are even comparable with developed countries. Such that in
Kerala, the expectation of life has increased, infant mortality rate is very
low and there is decline in death rate. Also the health awareness among
71.8% are PHCs (including sub centres), 8.2% are CHCs and 11% are
continuous to be 5074 for the last 12 years and there is a sub-centre for
76
every 6.16 sq.km and a primary health centres for every 33.3 sq.km
medical and para medical personnel and there is one medical officer for
both from urban and rural Kerala is high in Kerala compared to other
Indian states. Thus the paradox is that on the one side Kerala stands as
the state with all indicators of better health care development in terms of
IMR,MMR, birth rate, death rate etc. on the other it outstrips all other
dengue fever etc is the major diseases dominating the health profile of
77
higher suicide rates, health problems and death due to road traffic
Sedentary life styles, lack of physical activities and obesity increases the
getting alienated from the common man due to lack of medicines and
public health centres are being utilised mostly for maternal and child
led to the impetus growth of the private medical care set up in the state
and the dependence on private health care is quite high even among the
lower expenditure classes and rural areas. In the changing scenario, the
78
in the state. Thus the state's health scenario is slowly drifting towards
2005).
was conducted in three stages. The first stage included all 990 village
panchayats (their respective PHCs and sub-centres), one each from the
top five and the bottom five, were chosen for the third stage.
The date collection was done using the published and unpublished
records, and facility checklist. Additionally, the key informant and client
exit interviews were also used for data collection. The study took also in
79
infrastructure and machinery, cost-effectiveness, services offered and
quality of care.
load, home visits by the PHC staff, facility hours, patient records,
health per se. Meanwhile actual PHC receipts were taken into account in
order to assess the impact of panchayat support.In the second stage data
80
exit interviews. Structured and pre-tested schedules (separate for
indicated by:
2. Presence of doctor for longer time and extended out patient hours
81
prescriptions to buy medicines from outside should be viewed as
indicative of inefficiency.
Equipment, instruments and furniture items were first listed and expert
opinion was sought to find out the value and expected life of each item
the amount of resources they allocate to them. The result indicated that
all the panchayat and PHC informants felt that panchayat intervention
would strengthen PHCs and listed five possible roles for panchayats in
1. Providing medicines
3. Constructing buildings
82
The overall results indicated that:
(12.7%).
more users.
few places, but wherever it was present, the result was positive. The
authors had also suggested an action plan for the improvement of the
channel panchayats towards health before health loses its battle for
resources.
83
2.8.3: Mala Ramanathan (2003) studied the Structure, facilities and
indicated that there are 944 PHCs and 5,094 sub-centres in Kerala, PHC
serves 30,732 people and covers a radial distance of 3.4 km, utilisation
centre, 20 patients per day, and 100 health centre. According to the
study, in RH – 1, One PHC did not have a doctor for several months
(MTP) was available at one Block PHC and the Taluk hospitals and two
women was available at one Block PHC and both Taluk Hospitals.
Vasectomy for men was possible only at one Taluk Hospital, Available
and condoms were available, 4 PHCs, BPHCs & taluk hospitals had
examining rooms in all the facilities were clean and had adequate
lighting, Two PHCs and the block PHCs and the Taluk Hospitals had
seating arrangements for the patients where as four of the PHCs did not
84
have adequate seating arrangements, Only three PHCs (3/10) lacked
equipment of some kind, except for one block PHC and one PHC all
others had disposable syringes available for use , all the units in the
study had blood pressure gauge available , Nine of the 10 facilities had
ILRs available.
With regard to the Equipments and records, 3 PHCs had height &
(furnished & equipped) but was never used, All PHCs maintained
concluded that PHCs less equipped for many reproductive health needs,
Women doctors were available , Quality service and heavy patient load,
85
were selected as better as and worse than average in family welfare
features, but PHC I had twice the population, proportionally more staff,
rehydration therapy, and maternal and child care. PHC I kept records
concern for quality of care and incentives for family planning acceptors,
scores on the job satisfaction scale were 50.7 for PHC I and 50.5 for
PHC II. 25% of staff from both centers combined were not satisfied
job satisfaction, proper facilities explained 15%, but salary was not
significant.
86
2.9: BENEFICIARIES’ OPINION ON THE PHC
2.9.1: The primary health care system in India has been dysfunctional
and not geared suitably to serve the health needs of the people due to
many reasons as has been established above with the help of available
literature. There have been many studies which looked in the popularity
degrees.
87
3. The reported illness and frank symptoms in the PHC fell in to 12
leprosy.
doctor as the first resort to deal with these illnesses. As for the
services, anti natal and post natal services, taken treatment for
reason for non utilization of the services was associated with non
remaining felt that PHC was a show piece of the government that
88
did not serve the real needs of the people. Sixty two percent of
the people felt that the health activities in the centre would bring
benefits to the people in the future. 56% evaluated the PHC staff
were the main of the reasons for the popularity of the PHC.
89
availability of medicines in PHCs. About 66.67 per cent of the
beneficiaries expressed this view. Similar results were obtained for non-
preferences for PHCs for seeking health care services over other
2.10: CONCLUSION
far over all indicates that the primary health care system in India is
very low quality health services, so much so that the private sector has
primary health care facilities, though extensive, is far less than the
what the facility has to offer in terms of medical care and whether it is
90
worth their while to use it are equally important in terms of their
care is that of it being of low quality, and therefore, even the available
their caste, religion, gender and language. Even setting aside socio-
facility close at hand, the delivery of quality health care services is not
of even basic drugs and equipment. This is especially true for rural
infant and child morbidity and mortality rates are intolerably high in
India. Not only social justice but economic efficiency ie to protect the
91