On May 5, the Union health ministry released the Rural Health Statistics (RHS) report for 2020–2021. The report quantifies crucial personnel availability issues to which patients’ experiences and media reports alike have alluded—for example, that community health centres have an 80% shortfall of specialist doctors.
Oddly, however, the report also says that 19 states and six Union territories have reported more doctors at primary health centres (PHCs) than are actually required. This is a triumph—or is it?
PHCs have one MBBS-level doctor each plus other support staff. Their mandate is to be the second point of care for care-seekers in rural areas (the first is health sub-centres, which don’t have fully trained doctors but help to screen patients and refer them to the appropriate facilities). Typically, each PHC serves around 30,000 people.
To have more doctors than there are PHCs is for a state government to be able to claim that the state’s rural population is well taken care of. But this conclusion is at odds with India’s long-standing, and widening, disparity of access to healthcare between rural and urban areas.
The 2019–2020 RHS had also found many of India’s states and Union territories reporting a similar situation—with the addition this year of Uttar Pradesh. In the previous RHS, this state had reported a shortfall of 121 doctors at PHCs against a requirement of 2,880 doctors, and this year has reported an excess of 170.
“It is very difficult to believe these numbers,” Sunita Singh, a training officer at a civil society group called Sahyog, which has worked in Uttar Pradesh, said.
Even if there is a doctors’ surplus on paper, she added, there is a ground-level issue that undermines the statistic: they are often absent.
“As a result,” Singh said, “the poor patients are forced to go to private healthcare facilities, which have now opened in good numbers in rural areas as well.”
Dr Shakeel, a doctor practising in Patna and running a civil society organisation named Charm, echoed her, and added, “It is not that the state government [of Bihar] is not aware” of doctors not being present.
Local media reports reflect his comment. Just last month, a report in a local edition of Hindustan, a Hindi daily, said a surprise inspection at a PHC in Bhagalpur, Bihar, couldn’t find the doctors on duty. Bihar is one of the states to have reported a surplus in the recent RHS.
States with a large number of PHCs functioning with just one doctor or without a doctor are indicative of relatively higher rural infant mortality rates and maternal mortality ratio.
There doesn’t exist much good recent research on the prevalence of doctor absenteeism in the country—but a paper published in 2011 indicated the extent of the problem at the time. Its authors, of the University of California (San Diego), Prince University, Harvard University and the World Bank, wrote:
“We find that national average absence rates are quite high: 39% for all health workers and an even higher, 43%, for doctors. There is substantial state-level variation in doctor absences, ranging from 30% in Madhya Pradesh to 67% in Bihar.”
“It is an open secret now that doctors hardly attend duties at PHCs or that they go there just to complete shifts,” Dr Shakeel said. “But this jugglery is not reflected in reports, such as the Rural Health Statistics.” He also said that it is common for PHCs to be staffed only by an AYUSH doctor. PHCs have separate positions for AYUSH doctors; the two roles aren’t interchangeable.
The 2018 Economic Survey was one of the last credible national government reports to throw light on absenteeism among healthcare workers. It read:
“States with a large number of PHCs functioning with just one doctor or without a doctor are indicative of relatively higher rural infant mortality rates and maternal mortality ratio. … What this data does not reveal is that even if the personnel are present, their level of participation in providing health services may not be at desirable levels due to lack of supplies, inadequate infrastructure facilities and poor monitoring of the staff.”
Doctors’ absenteeism is an old problem in India and that it has persisted for a variety of reasons.
There have been reports from Rajasthan corroborating this side of the problem—that doctors simply being present shouldn’t automatically count as a win. The state has reported a shortage of 129 doctors at PHCs in the latest RHS.
Dr Sanjana Brahmawar Mohan, who works for an organisation called Basic Health Services that provides healthcare services in rural Rajasthan, found this number strange. “The patients who come to our clinics clearly say that since they didn’t find a doctor in the PHC, they were forced to come to us,” Dr Mohan told The Wire Science.
“Remember, some of them come from really far away, where they already have a PHC situated in or near their village.”
According to her, patients often tell her that doctors visit their PHCs once or, at best, twice a week. She estimated based on the experiences of her organisation that no more than 20% of all doctors attended duties at their PHCs for five days a week.
Many experts to whom The Wire Science spoke said that doctors’ absenteeism is an old problem in India and that it has persisted for a variety of reasons. For T. Sundararaman, a public health expert and former global head of the People’s Health Movement, the biggest one is the temptation of private practice.
“When [many] state governments allow government doctors to do private practice and which earns them more money, why would a doctor posted at a rural PHC care to actually go there?” he asked.
He also said that many doctors are appointed to PHCs in an ad hoc manner, under the National Health Mission. These are temporary appointments: today they exist, tomorrow they may not. If their numbers have been added to the list of doctors posted at PHCs, Dr Shakeel added, the total numbers may look inflated – to the point of showing a surplus.
Both Drs Mohan in Rajasthan and Singh in Uttar Pradesh said they have found that there aren’t enough incentives for doctors to continue at PHCs. This includes proper accommodation facilities, meaning that doctors often prefer to stay at home.
The RHS report may capture the quantitative reality of doctors at India’s PHC, but the numbers alone don’t convey the full picture.
“There are many demons that these doctors have to fight in their heads, including peer pressure [from doctors who work in cities] to an almost complete lack of support from their seniors,” Dr Mohan said.
This said, while retaining doctors is a complicated problem, it needn’t be a wicked one. Sulakshana Nandi, the national joint convenor of Jan Swastha Abhiyan, pointed to Chhattisgarh’s success at holding on to doctors in its rural areas. According to the latest RHS, the state has 271 fewer doctors at PHCs—but Nandi coauthored a report for the WHO casting its model as worthy of emulation.
In Chhattisgarh, if an MBBS doctor upon her graduation devotes a certain number of her years at PHCs, she gets bonus points in the entrance examinations of postgraduate courses—as well as financial incentives over her regular salary, well-staffed PHCs, better state accommodation and better equipment.
As a result, according to the WHO report,
“There has been an increase in availability of MBBS doctors by 207% (from 28 to 86), specialists by 1,300% (from 3 to 42) and nurses by 1,240% (from 20 to 268) in the three district hospitals of Sukma, Dantewada and Bijapur [in Chhattisgarh] from 2009 to 2018.”
The RHS report may capture the quantitative reality of doctors at India’s PHC, but the numbers alone don’t convey the full picture. Specifically, even an excess of doctors, on paper, can’t necessarily improve the quality and accessibility of healthcare in the public sector. We must also ensure that they are available when required and attend to their duties in spirit.