Silver Bullet Or Booster Dose? Healthcare In Three BJP-Ruled States Needs Both

Numbers, they say, only tell half the story. But some statistics are staggering by themselves. Consider this: Madhya Pradesh, Rajasthan and Chha­ttisgarh together account for nearly half the number of primary health centres running without doctors in the country. The big picture is this: the three poll-bound states have a medical emergency of a different kind. They need doctors to attend to the immediate healthcare needs of millions of people. While healthcare—or the lack of it—is not considered a major issue to influence voting trends, primary healthcare in these states offer a dismal picture even going by India’s stymied public healthcare facilities.

While the urban population in these states have the luxury of flocking to private clinics and chambers, people in rural areas have to rely on public healthcare. And the first point of contact is generally the primary health centre (PHC). Besides taking care of immediate medical needs, proper functioning of PHCs also have a bearing on some major indicators—infant mortality rate (IMR), wasting and stunting of children; anaemia, maternal morbidity ratio (MMR) and fertility rate in women. Compared to Kerala, considered one among the best performing states in the healthcare sector, Chhattisgarh, MP and Rajasthan have failed to achieve much in children’s health indicators over a ten-year period. (See graphic)

It isn’t that these states have a shortage of doctors. Between 2010 and 2017, the number of doctors in MP increased by 28.7 per cent, and in Rajasthan by 40.8 per cent, as per the National Health Profile 2018. The jump is, in fact, higher than the national average of 25.9 per cent. However, the two states have been unable to woo doctors to hospitals in the countryside. In Rajasthan, the number of PHCs without doctors has increased from 70 in 2010 to 167 in 2017. In MP, the figure increased from 211 in 2010 to 393 in 2017, while Chhattisgarh has 390 such PHCs operating without doctors. The shortage of specialist doctors in various healthcare centres in the three states is also high. There are new central government-run AIIMS at each of these states since 2012 but they operate with less than 50 per cent doctors, according to a response by the Union health ministry to a question in the Lok Sabha in February.

“Human resource such as medical officers, specialists and staff are crucial and we have been trying hard to woo them to various centres. We have even tried to emulate best practices from other states such as Uttar Pradesh and Karnataka but we have been unable to staff up the healthcare centres as of now,” says Dhanaraju S, director for the National Health Mission in Madhya Pradesh. He says even an incentive of 25 per cent extra salary for postings in remote areas inhabited mostly by tribal people has failed to attract doctors.

Health economist Amirullah Khan agrees that attracting doctors to rural areas is a major challenge. “It is difficult to recruit both doctors and other staff for these centres. Only a limited number of doctors graduate each year and the number is controlled by the regulator (Medical Council of India), which has an incentive to stifle competition. Doctors are also more attuned to settling down in urban centres which have better amenities and offer better living standards. The only way to offer doctors employment in rural areas is to give them better housing and more pay. The third issue is of the supply of medicines and healthcare equipment,” says Khan, who was earlier with the Bill & Melinda Gates Foundation.

Some numbers have gone up without actually leading to improvement in the healthcare scenario. By 2015-16, both Rajasthan and Chhattisgarh managed to raise their per capita health expenditure above the national average of Rs 1,112. Madhya Pradesh, however, is still lagging behind with Rs 716 in 2015-16. Despite the higher expenditure, Rajasthan ranks second from the bottom in composite healthcare score among 21 large states in India, the latest health index released by NITI Aayog show. MP is placed three ranks above Rajasthan. Chhattisgarh climbed one rung to the 12th spot though large swathes of the state, especially those with a tribal population, remain uncovered by the best-laid healthcare plans.

Between 2010 and 2017, the three state governments also appear to have built around 40 per cent of the 9,162 new sub-centres in the country. Rajasthan alone built 2,919 of these while MP has built the least (323) during this period. MP has also built the least number of PHCs at 16 while the government says that 24 of its community healthcare centres (CHCs) have been upgraded to ‘civil hospitals’ between 2010 and 2017. Building the CHCs may not be enough because very few of these centres in the three states have all four specialists—surgeons, obstetrician and gynaecologists, physicians and paediatricians.

“Most people require a general physician for basic healthcare and not a super-specialist. In Chhattisgarh, they may need a snake-bite venom or treatment for a rat bite for which you need a doctor with an MBBS degree and not a super-specialist. The AIIMS costs many times more than a district (or a civil) hospital to build and needs more specialised doctors, which are not easy to find,” says Khan.

Perhaps, the poor state of public healthcare facilities, both in terms of infrastructure and personnel, is the reason why the central government fell back on the private hospitals and clinics for its ambitious Ayushman Bharat Scheme, under which the government will subsidise insurance premiums for 500 million people. The beneficiaries can claim healthcare services at empanelled hospitals. Shifting to that model and phasing out existing models can be premature as the new scheme has a lot of loopholes (refer: Modicare Doesn’t Address Glaring Concerns Of Past Healthcare Plans, published in Outlook last month). As per news reports, Rajasthan was initially sceptical of signing up for the programme since the Vasundhara Raje government had launched its own health plan in 2014. It later fell in line.

When the three states, all with BJP governments, go to the polls, the ruling party will perhaps showcase Modicare—as the new insurance scheme is being dubbed—to hide their collective failure in delivering the most basic healthcare facilities to the people, especially the poor. How much will this influence voters in the politically important states is anybody’s guess.