The paper focuses on the importance of strengthening primary health care services in Bihar using evidence from the various countries experience namely Cuba, Thailand, Brazil and a south Indian state, Kerala, that have improved the health status of their residents by prioritizing the same. In the end, the paper made a few recommendations, which can be adopted by policymakers towards improving the primary healthcare services in Bihar, leading to improvement in access to quality healthcare services.
In India, health is a state subject which means the state governments are responsible for the delivery of health care services to its residents. Bihar is an East Indian states that have been placed, consecutively for two years, at the bottom in the health index prepared by National Institute of Transforming India (NITI) Aayog. The reason for the same is the pitiable status of access to quality healthcare that translates into poor health outcomes, e.g. neonatal mortality rate is at 27 per 1000 live births, and the maternal mortality rate is 208 per 100 000 live births in comparison to 23.5 and 145 at national level respectively.1,2 One may argue that the fund crisis is one of the main problem leading to this status. Still, sadly pieces of evidence suggest that Bihar failed to spend even a third of 88.5 crores (INR) allocated by the centre to upgrade its existing primary healthcare centres (PHCs)3. Thus there is no shortage of fund relatively poor planning, or lack of political will is the reason behind the existing situation. The PHCs providing primary healthcare (PHC) services filthily lacks the necessary facilities like toilet, medical equipment and drugs. Somehow if a few have these essential facilities, there is no workforce—there is a 78% shortfall in PHCs, and the doctor-patient ratio is only 1 for every 17,685 people.4 Besides, above one-third of the state’s rural population, lives below the poverty line, which further prevents them from accessing the well-equipped expensive secondary and tertiary hospitals, in the absence of quality primary healthcare services. All these unsurprisingly leads to the poor health status of the state.
Investing in PHCs has the potential to improve the current health status in Bihar because studies suggest that a well-functioning PHC system can tackle 80-90% of the health needs of any population5. They are exemplified by the Cuban health system whose cornerstone is PHCs and preventive approach. The country has achieved a life expectancy of 79.5 years and infant mortality rates of 4.3 per 1000 live births (2015).6 Moreover, in many instances, PHCs are the only source of qualified health professionals in rural/disadvantaged area where the majority of poor resides. But, unavailability of basic facilities and infrastructure discourages both doctors and patients from delivering and accessing quality services respectively.
Furthermore, Primary health care services are more cost-efficient; the cost of outpatient services delivered through PHCs is 5 to 8 times lower than when the same services are availed at higher levels of facilities.7,8 Evidence proves that PHC has been the foundation on which many countries have commenced on the journey towards Universal Health Coverage. For example, the Brazilian healthcare system under the Unified Health System has a strong foundation of PHC.5 In India, poor quality of primary health care services pushes about 11 per cent of the population towards impoverishment due to ‘catastrophic’ health expenditure.9 Hence, there is a need to prioritize these PHC services ahead of hospitals that will achieve lower healthcare costs by less demand for expensive secondary and tertiary care.
The Cuban health care system depends heavily on primary care providers, both physicians and nurses, and more than 80% of health visits take place with primary care providers.10 Other than ensuring the availability of medical staffs, the system ensures that physicians access social determinants of health, understand people in all dimensions like education, housing, sanitation and clean air, food and nutrition, and employment and tailor services to the specific needs of each community.11
Similarly, Thailand invested in healthcare infrastructure, incentivized rural/disadvantaged posting and provided the opportunity to disadvantaged students. The key difference between Bihar’s and Thai health centre is the availability of an entire range of primary healthcare needs including care for all infectious diseases, as well as regular medication and care for hypertension, diabetes, etc.12 To deal with Human Resource crisis, the country recruits high-school students from disadvantaged areas under the special track with the condition that they have to work in their home districts post completion of their medical education. In the past, this Programme has contributed to 20% of the total annual national medical student enrolment. Between 2000 and 2014, the special track programme added 5,927 medical graduates to the provision of rural services.
Brazil institutionalized and mainstreamed community participation for healthcare improvement. Monthly meetings are organized at the clinic and are attended by the community, including representatives from the church, NGOs, schools and the input from the community is passed to the concerned authority responsible for implementing measures. The same can be adopted by Bihar to get feedback from the community regularly, which can improve the quality of services.13
One may argue that the points made above are altogether from different countries, but how about Kerala. The South Indian state’s decentralized governance and community engagement helped it to perform remarkably well and maintain its top rank in healthy state progressive report presented by NITI Aayog. The health gains made in Kerala can be attributed to several factors, which are missing in Bihar healthcare system. Still, decentralized governance and financial planning along with community participation and a willingness to improve systems in response to identified gaps, played a crucial role. The new budgetary allocations gave the local government control of 35 to 40% of the state budget, and the PHCs were brought under the jurisdiction of villages.14 Communities were brought together to determine which health topics were important and needed attention, with selected topics ranging from strengthening PHC facilities to improving water and sanitation safety.14 This decentralization in Kerala resulted in physicians and community members working together and many facilities undergoing significant renovations to address community priorities15,16.
To strengthen primary health care services the following recommendations are made, which can be adopted by the state :
a. Investing in Infrastructure Development : Since there is no shortage of the fund in Bihar, the government need to prioritize the investment like focus on renovating primary health centres and making available essential things like medicines, equipment, diagnostic kits, beds etc. because without that, even the medical team cannot be efficient. For example, in the case of Thailand, access to primary health services increased remarkably between 1977 and 2006 from 29.4 per cent to 41.1 per cent, after the government invested in the infrastructure under expanding geographic access.
b. Introducing a unique track system to recruitment the disadvantaged students : Similar to Thailand, Bihar can deal with human resource crisis in the healthcare system by recruiting high-school students from underprivileged areas under the special track programme. With the condition that they will have to work in their home districts post completion of their medical/nursing education. Evidence shows that these students are more promising and altruist to serve in a disadvantaged situation.
c. Providing need-based tailored services : Similar to Cuban health system, Bihar can adopt systems that ensure visits to patients’ home and can offer the need-based tailored services to the community. This can improve the quality of health services, handle problems before they become major and simultaneously develop trust in the government and system and encourage the use of PHCs as the first point of care.
d. Decentralization and Community Ownership within PHC Services : Drawing from the experience of Kerala and Brazil, Bihar needs to bring PHCs under the jurisdiction of villages, involve the community in decision making and also invest in infrastructure development. This will increase community ownership, and the close proximity of the community with healthcare system will also help in monitoring the quality of services.
References :
Author – Beauty Kumari
GHP – London School of Economics and Political Sciences(LSE), MBA – XISS, Ranchi (Gold Medalist)
Picture – Hindustan Times
Labour room in Bochaha PHC
