Clipped wings: My (short) experience with village healthcare
If you are living in India, you must have heard this time and again— “India has a shortage of doctors”, “We need more doctors”, “Doctors just don’t have time!”, etc. Besides, you must have seen wild statistics narrating the same story. The World Health Organization (WHO) prescribes that there should be a minimum of 1 doctor per 1000 people in a country. A recent estimate suggests that the ratio is 1 doctor per 1456 people in India. Languidly speaking, this doesn’t seem so bad- doctors can work extra hours, right?
On the other hand, the ‘perceived’ shortage of doctors might not exist at all! An article published in 2018 suggests that if we add AYUSH practitioners to the list, we have 1 doctor for 746 people in India which is well past the WHO target. What’s more- AYUSH practitioners are trusted and respected by most Indians, especially in rural areas. Basically, that’s an Indian ‘Bazinga’ to the WHO.
Last month, I visited a few Primary Health Centres (PHCs) in Haryana as a part of my Community Medicine postings. I would describe my experience with a PHC located in Mohna, a medium-sized village with a population of about ten thousand people. Mohna is located deep within the Faridabad district of Haryana, some 50 kilometers from the heart of Delhi. As we traversed the roads in a small chartered bus, the village looked relatively prosperous. Most houses had a modern construction, adorned with beautiful metal gates and huge glass windows. SUVs and bikes were parked along the road in front of many houses. Albeit the striking paucity of consumer utilities, there was nothing to suggest that this was a traditional rural area.
The PHC was a small building of 2 floors surrounded by a sprawling green campus. We were told that this was one of the better-maintained PHCs under the Haryana government. The students of my batch got distributed and started exploring the PHC.
There were 4 MBBS doctors employed in this PHC, though none was available that day. A lady Dentist told us that there was some competitive exam and all the doctors were gone for attempting it. As the government guidelines require the employment of a minimum of 1 doctor per PHC, this one was relatively well-staffed. The AYUSH (Ayurvedic) side of the PHC looked more vibrant. Patients were entering the building with OPD cards and exiting with big bottles of ayurvedic concoctions and packets of bhasms. I was amazed to see how satisfied the patients from the Ayurvedic side looked — no wonder, the government invests heavily in the Ministry of AYUSH. It’s just politically profitable to the ruling party.
Many Indians are staunch supporters of Ayurveda and Homeopathy, to the extent that I found it difficult to convince my own family that Homeopathy is a gigantic hoax. Further, building educational infrastructure for Ayurvedic and Homeopathic training is far less expensive than modern medicine and these ‘doctors’ are more inclined to work in rural settings. Moreover, drug manufacturing for alternative medicine is cheap, unlike modern drugs which need extensive purification and monitoring. To ice it all, alternative medicine practitioners don’t perform surgeries or order expensive diagnostic tests. This is essentially a shortcut used by the government to satisfy people’s healthcare appetite — can’t say if it really satisfies the health needs as well.
From what I observed, I believe that MBBS doctors working in PHCs have their wings clipped. The Indian healthcare system is supposed to be a tier-based system. Doctors in the PHCs are expected to treat very simple illnesses and refer the morbid ones to the Community Health Centres (CHCs). CHC is the second tier of healthcare with one CHC for every 5–6 PHCs. CHCs are supposed to be emergency stabilization and infection treatment centers. For conditions like cancers, cardiac ailments, most surgical cases, and the like, CHCs refer patients to District Hospitals. Sadly, even district hospitals are not well equipped with super-specialty services and patients end up showing to private practitioners or going to tertiary care hospitals like AIIMS, Lok Nayak, GTB, etc.
As a faculty member told me, the PHC to CHC referral doesn’t really work out well- why would I drive to a CHC 15km away when the district hospital is located 17km away. At a PHC, the available diagnostic tests are altogether too limited for reasonably practicing modern medicine. For example, in PHC Mohna, you can’t even order basic diagnostic tests like blood count, liver function tests, kidney function tests, or even ESR. If you do order the available investigations like blood group, hemoglobin, or clotting time, the results would take 2–3 days to come. A lot of drugs adversely affect Liver function, still, these have to be prescribed without monitoring of LFTs. If a person presents with fever, you don’t even have a CBC to tell if it’s bacterial or viral. You just prescribe Augmentin — an antibiotic. Talk about drug resistance? Even if you manage to guess the diagnosis, you are supposed to treat with available drugs in the PHC, which are limited as well. Essentially, the bulk of your practice would be prescribing paracetamol and drugs for diabetes- you have to refer the patients for everything else.
The referral system is weak as well, mostly consisting of scribbling “Referred” on a sheet of paper. Once referred, it’s not the duty of a PHC doctor to ensure that the patient is looked after in higher centers. I went to Bihar to observe an NGO-based Epilepsy treatment camp. There, I noticed that so many people were living with epilepsy without receiving any treatment- just because they were referred by the PHC doctor and they didn’t understand where exactly to go. They went to the CHC, there was no neurologist. They went to the District hospital, there was no neurologist. No one explained the nature of their disease to them. They believed it was pure witchcraft and didn’t go to a higher center. Someone told them that a certain quack treats epilepsy, they went to him. This quack tricked them into paying hefty sums of money and dispensed dangerous drugs in loose form. A simple regimen of carbamazepine was enough to treat most of them, something a PHC doctor could have learned to prescribe with minimal training.
But PHC doctors have become referral machines. Barring chronic diseases, most diseases treated by PHC doctors would have resolved on their own. Even AYUSH doctors claim to treat these self-resolving illnesses. No wonder people equate AYUSH doctors with MBBS ones- they are treating essentially the same illnesses at a primary level and referring the rest, albeit MBBS doctors are cockier.
India urgently needs diagnostic and pharmaceutical infrastructure, more than it needs doctors. India needs lab technicians and assistants, more than it needs doctors. When they are already working with clipped wings, India’s health sector can not fly, even if you add more doctors with clipped wings.
“Referred” is an answer, not a solution.
Disclaimer: My experience is limited and my views might be biased.
