More than two-thirds of Indians live in villages, but the healthcare facilities in these areas are yet to show the progress seen in urban areas. The chances of you going to a rural health facility without a doctor or a health professional is still very high in the country. The analysis of the data available with the Ministry of Health and Family Welfare tells us that things are way worse than they used to be 17 years ago, in 2005.

Picture this. In 2005 17.49 per cent of the primary health centres (PHCs) and Sub Centres (SC) functioned without doctors, but the proportion of such centres will be as high as 21.83 per cent in 2021, according to rural health statistics. While less than half the Community Health Centres (CHCs) had no specialist doctors in 2005, the vacancy was a whopping 67.96 per cent in 2021.

A Sub Centre is the first contact point between the people and the health care system, while a Primary Health Centre acts as a referral unit for six Sub Centres and is to be manned by a medical officer supported by paramedical staff. A Community Health Centre is a referral centre for 4 PHCs and must be manned by at least four medical specialists.

When it comes to female health workers or Auxiliary Nursing Midwives (ANMs), the number of primary health centres and Sub Centres devoid of them has jumped from 4.75 per cent in 2005 to 27.16 per cent in 2021, when the pandemic was ongoing. It is also shocking to note that all the community health centres in Sikkim and 95 per cent in Madhya Pradesh are devoid of a specialist. 43.2 per cent of the primary health centres in Chhattisgarh and 37.7 per cent in West Bengal also do not have a doctor. And in Bihar, 72.12 per cent of Sub Centres has no female health worker who is supposed to manage them.

Tales of empty hospitals

Why are so many health facilities in the country functioning without enough workforce? Virologist Dr Gagandeep Kang, a professor at Christian Medical College, Vellore, thinks that the lack of incentives may be prompting doctors to not work in rural health facilities. "Someone with an MBBS degree may not necessarily want to work in the Primary Health Ccentres until they are sure of their post-graduate seat," she says,

She also says that doctors prefer to prepare for their post-graduate entrance exams. “Doctors are all busy studying for the PG exams. They are perfectly willing to resign their job. Until they have all their degrees under their belt, they barely learn to work," she adds.

Weighing in on this, Anjela Taneja, Lead Campaigner at Oxfam says, “A lot of it is deliberate neglect. India’s healthcare system is chronically under-resourced. This poor spending is reflected in inadequate health resources and infrastructure, be it the presence of human resources, the establishment of centres or up-gradation of facilities," adding, "Delayed allocation of funds, staff shortages (and delay in payment of staff) are some of the key issues highlighted by the recent independent evaluation of Ayushman Bharat HWCs by the health ministry.”

Coming down strongly on the shortage of medical staff, Dr K R Antony, Former Director, State Health Resource Centre, Chhattisgarh, says, “Don’t construct rural hospitals for the sake of it. The point is that there should be the availability of staff with anaesthetic and reduce stress on district hospitals. 

Water water nowhere 

While on one end, we have positions for health staff lying vacant, on the other end of the spectrum, many health facilities are functioning without water or electricity supply. In Bihar, 31 per cent of the primary health centres have neither water nor electricity supply. Twenty per cent of these in Uttarakhand and 16 per cent in Kerala have no regular water supply. 

And this state of affairs unsurprisingly comes with a set of repercussions. “Neonatal mortality is three times in the poorest wealth quintile, highlighting inequalities experienced even by the young child. The lives of India’s poorest households are on average 7.6 years shorter than that of its richest 20 per cent households,” Taneja says. 

Also emphasising that more than half of the health expenditure is out of people’s pockets, Kang says, “The PHCs were not intended necessarily for major surgeries or hospitalisation. It’s meant for everyday services. It’s closer to where people live and they’re supposed to get those services there. Now, if that was the case and if the PHCs were functional why would our out-of-pocket expenditures be so high and stay that high?” 

The way forward 

Looking at what the government could do differently, Kang says, “The government should create a framework for the right staffing, duration and think about the incentives and career paths of doctors and all levels of staff to work in a rural health centre. They could say that if you give 5 years of service in a rural area, we will give you a guaranteed PG seat in any state that you want.”