Health sub-centres crying for attention

In India, 75% of dispensaries, 60% of hospitals and 80% of doctors are in urban areas, serving just 28% of the population. Meanwhile, 72% of the population, who reside in rural areas, face a chronic lack of medical facilities.

To provide essential healthcare in rural areas, the government has been setting up Sub-Centres (SCs) as the most peripheral and first point of contact between the primary healthcare system and the rural community. Each SC is meant to serve a population of 5,000 in plain areas and 3,000 in hilly/desert/tribal areas. With a growing population, the number of SCs has also increased — from 84,376 in 1981-85 to 1,58,417 in March 2018.

In 2005, 44% of the total 1,46,026 SCs operated from their own buildings (that is, health department–owned buildings). Most other SCs were based out of leased buildings or rent-free panchayati properties.

To ensure SCs have a permanent location with adequate space, the government decided to allocate SCs their own buildings, funded by government grants. Consequently, many state governments constructed new buildings for SCs under the Sector Investment Programme (SIP). By 2018, 72.17% of the SCs were moved to such government-owned buildings.

While this initiative looks good on paper, the ground reality is a different story. Many SCs were allocated buildings on the outskirts of villages, making them harder to access. An important clause of the Indian Public Health Standards (IPHS) was violated — Sub-Centres must be located within the village for providing easy access to the people.

A primary cause for this inaccessibility is the government’s policy of relying on the village sarpanch to allocate free-of-cost land to the SCs. Such land is generally available in village communal areas, which are often located away from the main settlement. Approximately Rs 9 lakh is allocated for the construction of an SC building; if the government can spend an additional 10-15% for purchasing land, these SCs can be located well within the main settlements. Consequently, SCs would be able to provide accessible healthcare services.

The additional (location) cost is justifiable as it will be lower than the annual operating cost of SCs and will also be negligible in the long run, as these new SC buildings will last for at least two decades. This extra expenditure should also be considered justified because data shows poor health outcomes at unnecessary expense by the public if these SCs are not located within the village.

The SCs built on the fringes of villages are also prone to thefts and burglaries. They are often vandalised and misused; their maintenance is neglected, and they remain vulnerable to natural hazards such as flooding. While residential facilities exist, most health workers do not reside there because of safety concerns.

Location factor

The ‘Rural Health Statistics 2018’ report by the government shows that there was a shortage of 32,900 SCs (18% shortfall on the basis of the 2011 census) as on March 2018. Further, 44,084 SCs (27.83% of the existing 1,58,417 SCs) are running in rented premises or rent-free panchayati buildings, and these need to be moved to government buildings.

So, a total of 70,850 new SC buildings were yet to be constructed as on March 2018, to cover the shortfall in SCs and to house all the existing SCs in government buildings. All in all, about 44.72% of SC buildings are yet to be constructed, and if these SC buildings can be made accessible to the villagers, people will not be forced to seek expensive private healthcare. In fact, out-of-pocket expenses spent on healthcare are one of the prime factors that push families to poverty.

To make these newly constructed SC buildings accessible, effective and useful, they should be constructed on purchased land (in accessible locations) rather than free land on outskirts of villages. Moreover, effective and efficient delivery of healthcare is possible only if the Auxiliary Nurse Midwife (ANM) permanently stays at the SCs, for which SCs should be located in the heart of villages.

This location factor becomes even more important as the Union government has decided to convert 1.5 lakh Sub-Centres and Primary Health Centres (PHCs) into Health & Wellness Centres (HWC) by 2022 under the Ayushman Bharat Yojana to provide comprehensive primary healthcare services close to community.

(The writer is senior research analyst, Center for Study of Science, Technology and Policy (CSTEP))