“We have to buy medicines from private pharmacies, PHCs don’t give us most of them,” says Chunni Lal, a Jabrapur resident who had travelled to the Naveen Primary Health Centre in Fatehganj, Banda. He visited the PHC to get a treatment for the marks that had started to spread from his back and arms to his face, but had to leave only with a prescription and a request asking him to buy the necessary medication from the market.
Devised by the National Health Mission to be the first point of contact for medical care in rural India, Primary Health Centres, or PHCs, are supposed to be well-equipped to deal with in-and out-patient care, with an ambulance service, a functional operational theatre and a labour room. The Indian Public Health Standards for PHCs clearly state that all the drugs required for national health programmes, as well as emergency management, should be available in adequate quantities, as to ensure completion of treatment for all patients. The under-stocked PHC in Fatehganj is only one of the many centres in the country failing to meet this most basic requirement.
Uttar Pradesh, the most populous state in the country, has only 3621 functioning PHCs — a shortfall of 30%, as there is a requirement of 5194 PHCs in the state. These existing PHCs, as few as they are, are also providing only inadequate services. A Planning Commission report found that 66.67% of all beneficiaries expressed non-availability of medicines as one of their primary reasons for dissatisfaction with the functioning of PHCs.
“Apart from a handful of medications, we currently have everything stocked in our pharmacy — cetzine, paracetamol, antibiotics,” informs Premchand, pharmacist at Fatehganj PHC. But Anarkali, who had visited the same centre with complaints of fever, cold and cough — fairly minor illnesses, often treated with the same medicine compounds Premchand had listed — was asked to buy medicines from outside the centre.
Arpita, from the village of Jarkadha, flagged a similar problem, “I bought a syrup for Rs 200 from the pharmacy outside the hospital.” Rs 200, for one round of one medication, is not a small expense for people of a state where 30% population is living below the poverty line. “They are not providing us with required medicines, which are generally provided in every other hospital,” says another Jarkadha resident, Bhagwati, her frustration palpable.
Research has shown that 4.49% of the total consumption expenditure by households was made on out-of-pocket (OOP) medicines — significantly on the uptick in the last few decades — making it the largest component of total OOP payments. “Since PHCs don’t provide proper services, we are forced to visit private hospitals for a decent check-up,” explains Bhagwati. OOP medical expenditure, including paying for private hospitals, pushed 50.6 million people into poverty between 2004 and 2014 — of which 27% lived in Uttar Pradesh. In 2011-2012 alone, 38 million Indians were pushed below poverty line because of OOP medical expenditure.
According to an Indiaspend study, India spent the least on public health among all the BRICS nations in 2014. It also ranked 147 among 184 countries in this regard, only 31.3% of the total healthcare expenditure being done by the government that year. Meanwhile, the budget allocation for National Health Mission has seen a 2.1% decline from Rs 31,292 crores in 2017-18 (revised estimates) to Rs 30,634 crores in 2018-2019 (budget estimates).
The widely-publicised Prime Minister’s Ayushman Bharat Yojana, launched in September 2018, is supposed to be the solution to all rural healthcare woes, its flashiest promise — health protection cover of Rs 5 lakh per poor family per year. But research has shown that insurance-based government initiatives have been largely unsuccessful in easing the burden on citizens. In fact, households in districts where central and state governments target insurance policies are more likely to fall below the poverty line. How can an insurance scheme help if the service provisions themselves are sorely lacking? Our own reporting on this policy is a proof of this systemic flaw in the plan.
“Medicines for allergies and many other illnesses are still not available,” says Premchand, after some persistent nudging from our reporter. “But we are assuring our patients that all of these medicines would be made available by the end of December,” he adds. And as for the protocol of prescribing and giving medicines, he says, “If the medicines aren’t available, we ask the patients to come back again in fifteen days. And if they’re unavailable then as well, we ask them to either go to the district hospital or to buy it from outside.”
But healthcare isn't a leisurely activity; it is often a matter of urgency. When asked what they do if medicines are required immediately, Premchand has no answer.
Our reporter asks Bhagwati if she has ever complained about the services, or the lack thereof, in Naveen PHC, she replies with a sense of resignation, “Who listens to poor people?”
Khabar Lahariya is a women-only network of rural reporters from Bundelkhand.
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Updated Date: Jan 07, 2019 16:12 PM