(This article first appeared in News 18 on 20th August, 2017.)

As the dust starts to settle in the aftermath of nearly 100 children dying at the Baba Raghav Das hospital in Gorakhpur, it’s laid bare that Uttar Pradesh’s tattered primary health care failed these children long before they reached the hospital.

Primary health care in India is supposed to be the first point of medical access for a person, through sub-centres and primary health centres (PHCs) and community health centres (CHCs).

Instead, most fever patients in the region, a hotbed for Acute Encephalitis Syndrome (AES), have made the BRD hospital, a super speciality tertiary care centre, their first port of call. This is because the whole system is “a mess”, K Sujatha Rao, former health secretary of India, tells News18.

There is a shortage of 1,346 doctors in PHCs in UP, according to the 2016 Rural Health Statistics report of the central health ministry, even though the number of government buildings of CHCs and PHCs have gone up significantly.

Though the shortage of female health workers and auxiliary nurse midwives (ANMs) is low (288 at PHCs), without the required number of doctors and lab technicians staffing PHCs, they’ve become referral centres to bigger hospitals.

Indian healthcare is also under-budgeted, said Dr Amit Sengupta of Jan Swasthya Abhiyan, with the “rhetoric” of increased finances unmet in practice. Doctors don’t go to rural areas because of no infrastructure, shortage of drugs and rickety facilities.

“Patients are not supposed to reach tertiary care centres without being properly looked at in primary ones,” said Dr Rajmohan Panda, a public health specialist at the Public Health Foundation of India (PHFI), calling India’s primary healthcare, and not just UP’s, a “dysfunctional, disorganised and malnourished system”.

India has an acute human resource shortage, with 12.8% shortfall of allopathic doctors and a 5.3% shortfall in ANMs or female health workers in PHCs.

“It’s the sub-centre’s function in rural areas to take care as close to home as possible,” said Dr K Srinath Reddy, president of PHFI. “With increased staff hopefully they’ll be able to do so.”

For now, this trend is mirrored across rural and urban areas in India, including Delhi where the All India Institute of Medical Sciences (AIIMS) sees a footfall of approximately 10,000 people a day from all over the capital and north Indian states.

However, Delhi has also been home to an experiment in urban primary healthcare since 2015 — mohalla clinics. More than 100 operate in Delhi and were originally modelled on the idea of taking healthcare inside bastis, slums or urban villages, instead of people having to trudge to government facilities.

Though, as Dr Sengupta said, they’re not strictly primary healthcare — they don’t operate 24 hours a day, they’re staffed by doctors on contracts instead of regularised jobs and they’re not networked enough with the existing health infrastructure — they have been taking the steam out the intense demands on Delhi’s healthcare for two years now.

Dr Satbir Kaur, a young doctor three years out of her MBBS and previously with an MCD hospital, looks after one such clinic in south Delhi’s Panchsheel Vihar, bordering the urban villages of Hauz Rani, Khirki gaon and swathes of Malviya Nagar.

In a day, she is the general physician for over a 100 patients, some from as far as the Delhi-Faridabad Badarpur border. When News18 met her, it was past 1pm, closing time for mohalla clinics, yet the crowd was going strong — with coughs, colds, joint pains, boils, stomach problems, etc.

“I just wish I had more space,” Kaur said, as yet another patient turned up for tests referred by the nearby Pt. Madan Mohan Malviya hospital, a Delhi government hospital, as she functioned with lightning speed with a tablet, creating digital records, or looking up case histories of regular patients.

Though wary of “political” press attention on the clinic’s work, she called it a good model to work in.

In the waiting room, Rameshwari, a diabetes patient, waited with a boil on her foot. “She’s a good doctor, this clinic stays open till 2:30 or 3,” she said.

“The Malviya Nagar hospital had sent me here when I was ill last year for tests, so I trust this clinic for my children now,” said Geeta, a first-time visitor.

Unlike the commonly seen anger and frustration with government hospitals, the patients here had developed trust in the mohalla clinic. This was noted by the premier medical journal The Lancet in December 2016, as it read, “The initiative is aimed at expanding the reach and range of health services in unserved and underserved areas such as slums.”

In January 2017, former United Nations Secretary-General Kofi Annan, commended Delhi CM Arvind Kejriwal as the clinics were “consistent with the Universal Health Coverage goal” of the World Health Organisation (WHO).

“Those with money go to private clinics,” said Maheshwari, “but a government hospital saved my life.”

The mohalla clinics, said Dr Sengupta, were fulfilling the role of the general physician of yore, who would be known to and available to everyone in a residential area before the system was supplanted by specialists in hospitals.

It also comes close to what Dr Panda of PHFI said was needed in rural primary centres — a generalist who could treat fever, diarrhea, snakebites etc.

Instead, both Sengupta and he said, PHCs were staffed with physicians woefully under-trained to look at the various complaints and emergency situation.

Comparing the system to the UK’s National Health Service (NHS), he said it was staffed more with trained nurses, while Sengupta drew similar comparisons with Thailand’s health workers.

As examples of advanced urban primary healthcare, Dr Reddy drew comparisons with models in Singapore and Hong Kong.

However, as The Lancet noted, the project of expanding the clinics to 1,000 in a year has been “caught up in a political dispute”. Infighting among Delhi’s various authorities has stalled the opening of more clinics.

Though most public health specialists ruled in favour of the mohalla clinic, even it came up short as a model to be replicate.

“We don’t know what the outcomes of the mohalla clinics are as they’ve not been evaluated regularly,” said Panda. “Human resource is finite, and mohalla clinics are drawing people away from dispensaries and MCD clinics.”

India needs a cadre of trained public health professionals, not just doctors, for an ideal model, said Panda, adding that rural postings need to be incentivised for doctors.

Panda said that instead of putting money in dialysis centres, spending on equipping PHCs for preventive treatment would reduce the number of patients with failing kidneys. All it takes is political will, he said.

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