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Rama Devi travels from Jawalapuri in Nangloi in west Delhi to Ram Manohar Lohia Hospital in central Delhi once a week for a minor stomach ache. She takes the early morning train from the local railway station and reaches RML hospital by 7 am to stand in queue.
There are times when she waits till 3 pm to see a doctor. She has been doing this for the last one month and got her basic blood and urine tests done, apart from consulting the general physician.
She goes through this ordeal despite the presence of four Delhi government dispensaries in Nangloi. There are also MCD dispensaries in the area.
“I visit RML hospital because I am always referred here even for minor ailments,” said Devi.
Such is the state of primary health care in Delhi.
The Delhi government came up with standards for the state’s primary health centres and dispensaries under the Delhi State Health Mission (DSHM) in 2006. The Cabinet then passed the standards for setting up Primary Urban Health Centres (PUHC) in 2010. Though funding is not a problem, governance and administrative issues mar delivery of health services.
Multiplicity of agencies
“There are multiple government agencies in the primary health care sector, with the Delhi government, MCD and NDMC being the major ones, apart from special services for railways staff and other government employees,” said a senior official of the directorate of health services.
“Firstly, the political alignment between the two major service providers, namely the Delhi government and the MCD, is missing. Secondly, both of them lack proper coordination,” said the official.
“The geographical division for both is different and thus, coordination becomes even more tough,” said another official.
The public health expenditure of the government has consistently remained above six per cent of the total plan budget for the last two decades, with a substantial chunk going into primary health care.
Delhi’s per capita expenditure on health is Rs 685 against the all-India expenditure of Rs 260 per annum.
“We have a large network of institutions in Delhi. Funding and resources are not a problem. But the political and administrative set-up is a hindrance” said Dr Rajib Dasgupta, associate professor, Centre for Social Medicine and Community Health, formerly with the MCD’s health department.
Another issue is the different mandate for dispensaries under different agencies. The MCD’s mother and child welfare centres provide preventive care only to women and children, and a male with cold and cough cannot be treated there, while MCD dispensaries provide only curative care wherein basic illness like cold and fever are treated. “Our centres promote institutional delivery during pre-natal and post-natal situations. We do not deal with high-risk cases,” said Dr V K Monga, chairperson of MCD’s health committee.
Non-uniformity in services
“The network of primary health care institutions is not uniform, especially in peripheral areas. Outreach services are also failing due to administrative problems,” said Dr Gupta.
The government has 247 dispensaries and the MCD runs 170 mother and child welfare centres and five PHUC. A total of 422 centres are nearly double than what is needed in the state, going by the ‘one PHUC for every 50,000 persons’ stated in the DSHM. But the distribution of these services is extremely skewed, say officials.
There are several undeserved areas while in some the facilities are overlapping.
In Madangir, the government’s and the MCD’s dispensaries are located across the road. But in Narela and Madanpur Khadar, there are no such facilities.
The government’s efforts are marred due to problems in acquiring land. No land was earmarked for healthcare units while the city was expanding. Of the 20 dispensaries that the government opened in 2011, only five were on government land.
No indoor patient depts
What is haunting residents who are willing to avail government services is the fact that the new standards of PHUCs do not have indoor patient departments (IPDs). The government says there is no need for IPDs in these centres as Delhi has a fairly good secondary care system, and it would become too resource intensive coupled with the need of a tremendous increase in manpower. Thus, the mandate for PUHC is only to have outpatient departments (OPDs), laboratories and efficient immunisation.
But it is not a secret that government hospitals accommodate two to three patients on one bed, while several sleep on the hospital floor. This affects secondary and tertiary care delivery, too.
“There is no proper referral system. If a person goes to a government dispensary and is referred for secondary treatment, the patient does not get any priority in hospitals. The patient has to start all over again,” said advocate Ashok Agarwal, advisor of Social Jurist, a civil rights group.
Health care under one umbrella
“Gujarat is an example where the government has implemented urban health projects despite its extensive private sector. The state has a relatively higher proportion of urban population, and its primary health sector programme is fully public financed and provided,” said Dr Gupta.
“The government has put many schemes in place, such as maternity benefit scheme. There is also an insurance policy through which people are entitled to Rs 30,000 for treatment at a nominal deposit. These schemes should be scrapped as they are full of corruption and the benefits never reach the needy. Instead, there has to be a comprehensive health care for all under universal health access,” said Agarwal. He recommended a Right to Health Act on the lines of the Right to Education Act.
“There is no right to health in India, and therefore, you cannot demand it as a right. Only Assam has an Act that has the provision of providing 24-hour health service,” said Agarwal.
A senior government official said different agencies must work together and reach out to new areas.
“Unless a unit provides all basic facilities, people won’t be convinced enough to go there. But since they have no choice, they continue to go as of now,” said the official. She also stressed on the need to define accountability, which is one of the major bottlenecks in healthy delivery of health services.