ISSN (Print) - 0012-9976 | ISSN (Online) - 2349-8846
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The Fragmentation and Weakening of Institutions of Primary Healthcare

A Prescription for Their Revival

Mathew George ( teaches at the Centre for Public Health, School of Health Systems Studies, Tata Institute of Social Sciences, Mumbai.

Originally envisioned to offer preventive, promotive, curative and rehabilitative services as per the needs of people at affordable costs, the health services in India are currently grappling with varied forms of fragmentation, at the macro-level institutions as well as at the level of primary healthcare. To arrest this crisis, it is necessary to revive referral services needed for primary-level curative care, by focusing on strengthening community health centres and developing a strong public health workforce at the grassroots level. The only way forward is to strengthen institutions of primary healthcare by effectively balancing people’s public health with their curative care needs.

The author would like to acknowledge the comments given by the anonymous reviewer and the paper has benefited immensely by incorporating them. The views expressed in the paper are personal.

Health services in India are envisaged as those which offer preventive, promotive, curative and rehabilitative services as per the needs of the people, at an affordable cost. They are organised in a comprehensive manner through a three-tier institutional infrastructure, close to the places where people live, owing to the principles of the Bhore Committee of 1946 (Banerji 1985). The Alma-Ata Declaration of 1978 formulated the idea of comprehensive primary healthcare (CPHC), which later became an ideology to restructure every country’s health services according to the global context. India too was influenced partly by the idea, though the country has implemented a narrow framework of selective primary healthcare. Primary healthcare was defined as

essential health care based on practical, scientifically sound and socially acceptable methods and technology made universally accessible to individuals and families in the community through their full participation and at a cost that the community and country can afford to maintain … It forms an integral part of the country’s health system of which it is the central function and main focus, and of the social and economic development of the community. It is the first level of contact on individuals, the family and community … bringing health care as close as possible to where people live and work, and constitutes the first element of a continuing health care process. (Sanders and Schaay 2008: 4)

Despite having a broader framework, there have been several challenges in implementing CPHC in its true spirit. This includes the overemphasis on vertical disease control programmes, including immunisation programmes, followed by health sector reforms of the 1990s that further reduced the already constrained funding in health, supplemented with the crisis in developing grassroots-level health workers and the dominant influence of the newer global health initiatives that adopted a kind of “selective” approach (Qadeer 1995; Sanders and Schaay 2008).

In the current Indian situation, the remnants of the novel idea of primary healthcare have been reduced to a few institutions in the health services. Not only has the focus narrowed down to curative care-oriented institutions, but it is also fragmented significantly at the point of delivery. However, the institutions that provide primary healthcare services, namely sub-centres, primary health centres (PHCs) and community health centres (CHCs), failed to win the trust of people as “curative care providers” at the primary level—one of the important functions of primary healthcare. This has resulted in people seeking services from the private sector, even for minor illnesses. The “felt need” of the people for curative care services has always been more intense and powerful than preventive and promotive care needs. This calls for an “effective” response to strengthen the curative care services as a prerequisite to strengthen the preventive and promotive (public health) care services.

One of the crises Indian health services currently grapples with is the varied forms of fragmentation within its institutions both in degree and in intent, some of which have historical roots and some are very recent. Fragmentation in health services is defined as focusing and acting on the parts without acknowledging their relation to the evolving whole (Stange 2009). In the context of financing, fragmentation refers to the existence of a large number of separate funding mechanisms with a wide range of providers paid from different funding pools (McIntyre et al 2008). Unfortunately, Indian health services grapple with both. Adding to this is the distorted and ever-changing “image” of healthcare institutions that gets created among the policymakers and the people through reciprocal engagement, which further contributes to the process of fragmentation. The transformation of sub-centres into health and wellness centres (HWCs), and the failure to deliver adequate curative care services in the PHCs and CHCs have posed existential questions about these primary healthcare institutions.

Fragmentation in Indian Health Services

At the central level, the three organs responsible for health in our country were the Ministry of Health and Family Welfare (MoHFW), the Directorate General of Health Services (DGHS) and the Central Council of Health; the latter had the mandate to liaison between the centre and states on health issues. The DGHS has been the key organisation with technical expertise, competency and official mandate to implement all activities related to public health, medical education and healthcare by coordinating with the state-level directorates (MoHFW 2020).

It was in 2005 when the nation implemented the National Rural Health Mission (NRHM). Originally conceptualised in a mission mode for a seven-year period, it created various provisions for new institutional structures, like the mission steering group at the highest level to the village health, nutrition and sanitation committee at the village level with several intermediary institutions. Of the five major components of NRHM, the most crucial component that contributes to the strengthening of health services was the innovation in human resource management, as there were several personnel added on to the system at various levels with contractual appointments and incentives as the key (GoI 2007).

Similar to other disease control programmes, all these approaches have contributed immensely to the achievement of the goals of the NRHM, but the indirect consequence has been that any short-term vertical programme, when it continues to become long-term without getting integrated effectively into its original institutional structure, can result in distorted growth that can threaten the very existence of the original organisation. This is a characteristic feature of any organisation, when one of its programmes or functions outgrows the overall structure, goal and purpose of the organisation, and the very existence of the original organisation can be threatened, as was in the case of the World Health Organization, when it was burdened by its extra-budgetary funds (Vaughan et al 1996). Historically, the family planning programme in the Indian health services is a well-known case in point in this regard.

The successful transformation of the NRHM into the National Health Mission (NHM) has not only resulted in fragmentation within the health services, but also led to a precedence in the Indian health services of implementing programmes in a flagship or a mission mode by creating temporary institutions and infrastructure as a “model” for successful implementation. This was obvious from the implementation of the national-level, publicly financed health insurance scheme, the Rashtriya Swasthya Bhima Yojana (RSBY) in 2008. Originally, the scheme was targeted at the below poverty line population and was under the Ministry of Labour and Employment, as its goal was to reduce the catastrophic health expenditure among labourers due to serious illnesses, accidents, etc, and later it was expanded to the disabled, informal sector labourers and other vulnerable communities (National Informatics Centre 2016).

Later, in 2015, this scheme was brought under the MoHFW and after several strides, it has now become the Pradhan Mantri Jan Aarogya Yojana, under a completely autonomous body named the National Health Authority (NHA). Following the lines of the NHM and the RSBY, now the NHA has also created an independent institutional structure with a contractual staff pattern followed from the top to the bottom level, where the real implementation takes place. A similar format is followed even at the state level with programmes like ambulance services provided by the Emergency Management and Research Institute, the Rashtriya Bal Suraksha Karyakram, and others.

Thus, currently, there are at least three parallel bodies at the central level with a similar structure, followed across the states and union territories, namely: (i) the erstwhile DGHS, which has permanent staff and follows the recruitment pattern in tune with the government recruitment rules of the country’s health services; (ii) the NHM and its institutions; and (iii) the NHA for Ayushman Bharat. Moreover, there were also changes in the Department of Ayurveda, Yoga, Unani, Sidda and Homoeopathy, which was earlier under the MoHFW and became an independent ministry in 2014. The budget allocation on health for the last few years is an indication of how even the financial allocation is fragmented across each flagship programme (Mann 2020). The danger is that when healthcare delivery systems are subjected to frequent changes in a shorter period of time and if these are not in tune with the felt need of the people, then we are tampering with the “image” of public sector healthcare among the people, which is an important determinant of their treatment-seeking behaviour.

At the Block Level

The above fragmentation of health services at the centre has similar implications at the state and district levels. The situation at the block level will be focused on here, as the institutions of primary healthcare operate at this level. The financing, administration and service delivery of health services at the taluka/block level is where the CHCs with their corresponding PHCs and sub-centres function. At all these three institutions, the staff salaries are paid through multiple sources. For instance, the salary of permanent staff at these facilities, which include the main medical officers, nurses, pharmacists and other support staff, are paid through the funds from the zilla parishad.

However, the salaries of most of the contractual staff in the above institutions, like the additional medical officer, additional auxiliary nurse midwife (ANM), accredited social health activist (ASHA) and others, are paid from NHM funds. Moreover, most of the key district-level positions like the district programme manager, district and state epidemiologist are on contractual basis and are paid from NHM funds (Sharma nd). Further, the incentives of ASHAs are paid from multiple sources within the NHM. The delivery-related incentive comes from the reproductive and child health (RCH) flexipool, for outreach for immunisation, it comes from the routine immunisation progamme, and disease-specific incentives for leprosy and non-communicable diseases are paid from the centrally sponsored programmes, which together contribute to the ASHA’s “earnings.” 1

This is not just a problem of fragmentation in financing alone, but it has serious implications for day-to-day administration, and the low morale and job satisfaction of the staff of health services from a human-resources perspective. Due to fragmentation, there is no clear accountability and long-term commitment towards the health services organisation among most of the contractual staff. Their affiliation being short-term, they mostly work towards completing targets that are necessary for their contract renewal. Further, there is differential treatment of permanent and contractual staff while they perform their duties in the same institutions, thus creating different layers of authority and forms of discrimination within the health services. For instance, a nurse or a pharmacist on a permanent roll in a PHC will have higher authority over a medical officer of a PHC, who is in a contractual position, to whom the nurse and pharmacist officially report.

ASHAs prioritise their work differently depending on the source of funding and it is well documented (Bhatia 2014). Multiple forms of authority and a diverse chain of command within a single institution create chaos and fragmented objectives and goals for most of the staff within the Indian health services. This interferes with their routine activities and can cause further divisions in the tasks performed in each institution. The latest institution are the HWCs under Ayushman Bharat, directly controlled by the centre with only cosmetic changes to the existing sub-centres. This can be viewed as a piecemeal approach to capitalise on the goodwill and support gained by the NHM while strengthening the then existing grassroot-level institutions.

Policy Prescriptions for HWCs

HWCs—the less-talked-about component of Ayushman Bharat—were originally conceptualised to transform the existing sub-centres by appointing a mid-level health provider, and thereby equipping the centre to provide 12 comprehensive services.2 However, there seems to be a failure in acknowledging the three institutions (sub-centres, PHCs and CHCs) at the grassroot level, their diverse capacities and their interconnectedness towards rendering CPHC services, when the HWC is projected as an entirely “new” institution in rural areas. Further, there is an ambiguity in organising its preventive and curative functions, when the community health provider is expected to gain the capacity to practise medicine by completing a “bridge” course (GoI 2019).

There is a differential capacity and skill set required for professionals to do public health work as compared to that of a doctor, as the former is focused on the population within a societal context, whereas the latter deals with individual healing (Upshur 2002; Lang and Rayner 2012). Doctoring always gained its value and acceptance in any society through the act of diagnosis, prognosis and treatment and the recent proposal to equip the “community health provider” to practise medicine “minimally” envisions the new professional as a “dignified chemist.” People value a doctor’s capacity to diagnose their illness, and if a doctor fails at that, the institution they belong to will not be able to win the trust of the people as a curative care centre.

Subsequent to the initial directive to roll out sub-centres as HWCs, there was another directive issued from the NHM directorate to strengthen the existing PHCs and urban PHCs also as HWCs.3 Several states followed this directive by renaming their existing PHCs, urban PHCs and even CHCs as “HWCs,” partly to “effectively” use the funds under Ayushman Bharat, especially in situations where sub-centres were non-existent in several villages. Additionally, for the financing of the HWC, it was mentioned that the PHC would be a hub and the medical officer of the PHC would be the locus of funding to the community health provider of the HWC in situations where sub-centres were non-existent or when they were collocated in the PHCs (MoHFW nd).

It is a truism in the country that there is a shortfall of around 20% sub-centres and several sub-centres still function as collocated centres within the PHC premises (GoI 2015). By adding new structures, people’s access to curative care can be improved, and this was the rationale behind the establishment of HWCs. The recent move to transform all the existing institutions of primary healthcare into HWCs fails to acknowledge the interconnectedness and diverse functions entrusted to each of these institutions. This has not only contributed to further fragmentation, but also raises questions about the very “identity” of these grassroot institutions among the people, as from now on HWCs can represent sub-centres, PHCs and CHCs simultaneously. One of the obvious consequences will be the weakening of the institution of the PHC, the last powerful institution that has survived and stood the test of time. This will become obvious when we examine the historical evolution of each of these institutions that render diverse components of the primary healthcare services.

Institutions Rendering Primary Healthcare

PHCs: They render primary healthcare services and were originally established as part of the community development programme of 1952, for ensuring a first point of contact for people in the rural areas and their healthcare needs (Banerji 1985). Though these centres were expected to deliver curative, preventive and promotive services, it is a fact that most of the PHCs, in the process of focusing on disease control programmes and their implementation, had compromised their strength for rendering curative care at the primary level. Historically, the vertical disease control programmes implemented during the 1970s have weakened the curative care rendered in the grassroots institutions, thereby creating fragmented priorities between the centre and the states, despite health being a state subject.

This was obvious with several district-level officers appointed specifically for the control of malaria, tuberculosis, leprosy and family planning services along with the district health officers, with the latter having the administrative authority and responsibility to respond during public health emergencies at the district level. CPHC, actualised through the Alma-Ata Declaration of 1978, was an opportunity to correct this fragmentation, though it was overpowered by a selective approach to targeted health problems like RCH (Banerji 1985; Qadeer 2000). For people, the PHCs were the ones that implemented disease control programmes during the 1970s, and later their image was transformed as a provider of RCH care, especially family planning services and maternal and child health (MCH) care, along with some drugs provisioned for treating minor illnesses.

The Kartar Singh Committee report recommended the need to have one sub-centre for every 3,000–3,500 population and proposed 16 sub-centres under every PHC that covered a population of 50,000 then (GoI 1973). The committee also recommended a cadre of multipurpose workers (both male and female), as an attempt to integrate the then existing disease-specific focus among these workers. The major activities were to make regular community engagement and respond to the preventive and promotive needs of the community under the supervision of the health supervisor of the PHCs. Two important characteristics of public health practice were obvious in this historic report on human resource planning for sub-centres.

First was the need to have a population coverage that was feasible for the staff of the sub-centre through community outreach. Second, the term “multipurpose” was used to integrate the then fragmented focus of multiple disease-control staff, specifically for malaria, family planning, leprosy and others, into a single worker with multiple skills necessary for controlling multiple diseases from the same centre through regular community engagement. Here, there is an acknowledgement of the multifactorial dimensions of health and the need for multifaceted skills in a public health worker, along with the necessary capacity required to engage with populations. In other words, the idea of setting up a sub-centre as an outreach centre with supervisory staff at the PHCs to monitor and consolidate the functions of the sub-centre explicitly acknowledges the interconnectedness between the two and their diverse roles envisaged.

CHCs: These were the first referral unit catering to 80,000 to 1.2 lakh population and were established across the country against the backdrop of the recommendation of the National Health Policy (NHP) of 1983, primarily to strengthen the referral functions of curative care services provided by PHCs at the primary level. They were conceptualised as referral centres with at least four specialisations, namely medicine, paediatrics, surgery, and gynaecology, which would then become the first full-fledged modern hospital accessible to the rural people for their curative care needs. Ensuring that the CHC is a fully functional centre, along with being a referral centre, would also prevent overcrowding at district hospitals for curative needs (Program Evaluation Organisation 1999).

Despite this, some states have failed to implement this in its entirety even now. For instance, in Bihar, a PHC caters to a population of 1 lakh, and “additional PHCs” cater to a population of 30,000. In other states, these institutions are a CHC and a PHC, respectively (IIDM 2010). Further, there are evidences that demonstrate the spatial inequality in the distribution of these centres in Bihar (Singh 2017), which is true for other states as well. Additionally, shortage of infrastructure, specialists and other essential services are reported across states like Uttar Pradesh, Madhya Pradesh and Rajasthan, along with Bihar (Iyengar and Dholakia 2015). CHCs were conceptualised and developed predominantly to deliver curative care to the people at the block level, even though most of them deliver services like upgraded PHCs in terms of curative care, mostly due to the shortage of infrastructure and the mismatch between the specialists and facilities due to resource constraints (IIDM 2010; Iyengar and Dholakia 2015).

Decline of Primary Healthcare Institutions

There are various factors other than the macro-level policy factors that contributed to the weakening of the institutions of CHCs and sub-centres and their lost linkages with PHCs, resulting in an overall decline of primary healthcare services (Qadeer 2000). These three institutional structures have been the backbone of India’s health services system, even though they have also been the invisible “face” of India’s health sector for the generalists in the field of healthcare. Historically, states like Bihar, Jharkhand and Uttar Pradesh failed to establish CHCs and sub-centres according to the population norm on the recommendations of NHP, 1983.

Added to this was the differential terminology used to denote CHCs across countries, and in the majority of the states, they were developed by upgrading the well-performing PHCs, without replacing those with newer PHCs. In states like Tamil Nadu, the terms used were “upgraded PHCs” to denote CHCs and in states like Maharashtra, they were always called rural hospitals. RCH services like essential antenatal, natal and postnatal care—including immunisation services—were the dominant services provided in these institutions, and they failed to adequately develop curative care. CHCs were the worst affected against the mandate of becoming referral centres for PHCs by ensuring four specialist services, and instead, they became referral centres exclusively for RCH services.

Sub-centres were expected to develop a cadre of health workers, with strong community engagement on a regular basis, covering 3,000–5,000 population, thereby strengthening preventive and promotive care at the community level on a regular basis. They are generally located in the interior areas and were weakened mostly by infrastructure inadequacy—the lack of buildings, electricity, water supply, and so on, due to poor overall development of the region. The excessive focus on RCH care resulted in the diminished role of the multipurpose worker (MPW, male), with the ANM (MPW, female) emerging as the “face” of sub-centres, who has been offering delivery services, immunisation and other services of MCH care (Lisam et al 2013).

The health sector reforms during the 1990s further weakened public-sector curative care in general with reduced public expenditure, which in turn triggered rampant privatisation of healthcare at the higher level, in the name of efficiency (Qadeer 2000). The weakening of CHCs with a strong curative focus and sub-centres with a preventive and promotive focus have burdened the PHCs as all primary healthcare services are expected to be delivered through them, without them having the capacity or resources to do justice to either. It is not a coincidence to find that those PHCs that are performing well in their implementation of national health programmes and community outreach are those which are not doing well in their primary-level curative care and vice versa.

The efforts of the NRHM to strengthen the rural health infrastructure has continued the earlier trend of converting several of the then existing PHCs into CHCs, wherein the location of the centres was still in the interior regions, failing to geographically represent the block or its catchment area. Moreover, the space and the building available were originally meant for PHCs, some of them were originally even sub-centres. This was obvious from the report of Rural Health Statistics, which indicated that the total number of PHCs and CHCs added during 2005–15 were 2,072 and 2,050, respectively. This implies that the proportional increase in the actual number of PHCs and CHCs during this period was 8.2% and 38%, respectively (GoI 2015). Another development under the NRHM is the creation of taluka/block health officer in some states, whose office has become an administrative unit that consolidates, monitors and “cleans” all the information related to national health programmes and is responsible for the day-to-day administration of all the three centres.

On the curative front, in the process of strengthening CHCs as a referral centre for PHCs, several CHCs were equipped to provide emergency obstetric care services for managing high-risk pregnancies and developed a special newborn care unit for newborn care and nutrition rehabilitative centres for treating undernourished children. The overemphasis on RCH services in the Indian health services has resulted in them taking centre stage, and the institutions built around them have thus been misconstrued as the “face” of Indian public health. The additional focus towards RCH was also influenced by the global development goals (Millenium Development Goals and Sustainable Development Goals), which have always been dominated by MCH indicators. In the process, grassroots centres largely concentrated exclusively on RCH services, and all other forms of curative care gradually shifted to higher level facilities at the district-level and above, if not the private sector.

An unintended consequence of this was the blurring of boundaries between “public health” and “medical care” services, wherein grassroot-level institutions were “misconstrued” as providing “public health” services, thus narrowing down the scope of public health itself with the idea of providing curative care by these institutions as “minimal.” Thus, several CHCs have transformed themselves and been upgraded into facilities capable of providing minimal curative care (mostly primary level), but due to the inaccessible location and failure to recognise them as full-fledged hospitals, their “image” among people was of “upgraded health centres,” locally known as dawa khaana,4 thus undervaluing their capacity as hospitals.

The Way Forward: Transforming CHCs

It is high time the existing CHCs shed their image of “upgraded health centres,” especially at a time when there are serious lacunae in addressing the curative care needs of the masses in rural areas. Considering the mandate of CHCs, efforts need to be taken to develop them as full-fledged referral hospitals for every 80,000–1,20,000 population, with at least four specialisations: medicine, gynaecology, paediatrics and surgery. It is not just the shortage of specialists that prevented the strengthening of these centres, but a mismatch and poor infrastructure facilities that resulted in specialists not preferring to work in these settings (Program Evaluation Organisation 1999; Iyengar and Dholakia 2015).

To start with, the government can aim at having a 10-bedded facility, with the target of attaining 30-bedded hospitals in three phases. These rural/block hospitals then can become the face of public hospitals (sarkari aspathal) by ensuring referral services for PHCs, along with offering quality secondary care for the people of rural areas. The institution can be developed with residential staff quarters, with a greater effort towards planning like any other full-fledged 30-bedded hospital. Similarly, for urban areas too, one of the ways to strengthen the existing curative care delivery within the public sector is to emulate the peripheral hospitals, also known as area hospitals, which can provide quality secondary-level care for the urban population.

It is estimated elsewhere that there has to be at least one peripheral hospital with 150–200 beds in urban areas for every three lakh population, under which there can be six urban PHCs covering a population of 50,000 each (George 2016). Here too, the consideration is that the peripheral hospitals need to be treated as full-fledged hospitals competent to deliver secondary-level curative care. This can then become the popular face of “government hospitals” at the secondary level, which can build the trust of the public towards government healthcare, by providing effective curative care with a strong inpatient facility, including emergency facilities, and it can perform the role of an ideal referral centre. The non-availability of specialists at this level can be resolved by bringing in regulation in the private sector payment system for specialists followed currently (George 2020), and it can be implemented with the help of the existing Clinical Establishments (Registration and Regulation) Act, 2010. This can be a game changer for reviving the already crumbling public sector curative care at the secondary level, in both rural and urban areas, and it can also act as a strong regulator for commercial medical care. This can also reduce the overcrowding in tertiary care hospitals.

In order to deliver public health (preventive and promotive) services through the existing institutions of primary healthcare, it is important to acknowledge the distinction in the nature of “public health” and medical care services, both in terms of its epistemological basis and, hence, the differential skill set needed for the human resources (Weed 1999; George 2019). Medical care services target individuals who are ill and are in desperate need for curative care, whereas public health targets a population that is healthy by offering preventive and promotive services and it is primarily aimed at prevention of illness (Upshur 2002). The “felt need” and the intensity with which people seek medical care and public health services also varies, and the former is often more desperately required and, hence, prioritised over the latter by people.

Comprehensive Public Health Services

From the providers’ perspective, public health services can only be provided effectively when you have frontline public health workers regular engaging with the target population. In the current context, the frontline workers are ASHAs, ANMs, anganwadi workers and MPWs. Together, they form the cadre of grassroot-level public health workers, which is relied upon by the health services for community engagement, public health information and implementation of its interventions. Here, it is important to develop “comprehensive public health” services at the lowest level, with a coordinated effort of the grassroot-level workers and specific roles and responsibilities earmarked for each. PHCs are in an advantageous position to coordinate the activities of all six sub-centres, whereas the sub-centres in their new avatar (HWCs) can be a satellite centre to organise the field-level outreach activities at the community level.

The existing sub-centres can continue to have an ANM to manage the facility-based activities like immunisations, deliveries and referral to PHCs, with at least four public health workers (two males and two females) doing regular outreach activities; the female workers covering MCH and nutrition-related activities and male members covering environmental determinants including water and sanitation, along with lifestyle modifications for chronic disease control. The male members can be from the existing MPWs, and they can be redesignated as public health inspectors with necessary training and two female workers can be redesignated from the ASHA cadre.

ASHA facilitators who have completed their education level of Class 12 and above and can be upgraded to the position of junior public health nurse by introducing specific avenues for promotion and regularisation. These four public health workers together become the core outreach staff for public health activities at the grassroot-level, with greater accountability. All the above staff have to be on permanent appointment, with adequate potential for ensuring accountability through supportive supervision.

Necessary infrastructure needs to be developed for this under the sub-centres to coordinate all the outreach activities within their catchment area of 5,000 population. At the PHC level, one single nodal officer needs to be designated as a public health officer (PHO) who will oversee and monitor all public health activities within the catchment area of 30,000 population on a regular basis, and can coordinate with the higher level during public health emergencies/problems. The PHO can report to the block-level health officer on a routine basis, who is currently responsible for administrative and public health activities of all these centres. During epidemics and other public health emergencies, these grassroot-level staff can carry out the task of public health surveillance in the community, and these can be coordinated by the public health officer, who can integrate with the district epidemiology unit of the Integrated Disease Surveillance Programme.

This will free the medical officer of PHCs to focus exclusively on the primary-level curative care function at the PHCs, thereby strengthening it by having evening outpatient departments and basic laboratory support. Several studies have shown that one of the reasons why medical officers in PHCs fail to focus on primary-level curative care is their diverted focus on disease control programmes and day-to-day administration of the PHC staff (George 2009), which in the current context can be left to the newly appointed PHO. Southern states like Kerala, Karnataka and Tamil Nadu are known for this strong network of trained and permanent grassroot-level public health workforce, which is active during epidemic situations.

When we look at global evidence, it is important to emulate the role of epidemiologic health stations, which were established and have been functional in China since 1953. They are responsible for all the public health activities within a catchment area of three lakh population, with more than 50 staff members, including public health workers and barefoot doctors (Lee et al 2009). Though the first NHP of India in 1983 recommended similar sanitation cum epidemiological stations for the nation, now there is an opportunity to actualise the recommendation through the transformation of the existing PHCs into similar ones with a strong outreach provided by the new HWCs (sub-centres).

It is important to note that any effective public health practice is possible only when there is a dedicated grassroot-level public health workforce, which can engage with the community on a regular basis. In the current context, PHCs are well-positioned to take on this task effectively for a population of 30,000. Further, the staff below the PHCs—those at the sub-centres and ASHAs—can be effectively integrated into the system of public health workforce (males and females), with designated tasks for regular monitoring of the determinants of ill health in their area, wherein the new HWCs can focus on the current tasks of health education, immunisation and so on in a comprehensive manner that is contextually relevant, thereby rendering public health functions for every PHC population.


Fragmentation in Indian health services has been an unintended consequence of the trajectory through which they have evolved over the years. The extent and spread of fragmentation within the system is diverse and deep, whose form and manifestation will be unravelled more in the future. The present paper is an attempt to examine the nature of fragmentation as it operates in the institutions of primary healthcare, to the extent that it threatens the very existence of the original institutions. An attempt is made to examine the possible factors that contributed to the fragmentation, with a view to integrate these institutions using an incremental approach, taking cognisance of the already existing health infrastructure with a view to accomplish the task of ensuring CPHC. It is argued that there is a dire need to acknowledge the diverse characteristics of “medical care” and “public health services” at multiple levels, acknowledging their epistemological distinctness and therefore the diverse expertise and capacities needed for the human resource professionals rendering diverse forms of care in the health services.

Further, the services need to be differently organised for rendering medical care services as compared to public health services, taking into cognisance the individual beneficiary and institutional basis required for the former, as compared to the population and community orientation for the latter. Lastly but more importantly, it is the felt need of people towards both these services, which is diverse in terms of urgency and intensity. Any policy prescription to transform existing institutions rendering primary healthcare should take into consideration the above distinctions, in order to deliver effective preventive, promotive and curative services according to the needs of the people. Any country’s healthcare system needs to consider comprehensiveness as a basic lifeline for itself to remain relevant, and it is possible only by ensuring that its institutions are comprehensive and sustainable.

This calls for measures to substitute short-term “flagship” programmes with those which contribute to institutional building that are often long term. There is a need to value basic tenets of institution building in the health sector that need proper authority and responsibility across levels, and sound human resource planning, together with inter-sectoral coordination necessary for ensuring public health. To recover from this crisis of fragmentation, Indian health services need to have a holistic approach for organic growth, by adopting specific measures to build trust among people, the most important characteristic for health services to sustain in any nation.


1 This is based on the financial data accessed from the district health office of Maharashtra. The data gives the funding source from the NHM and various subcategories, and the details of staff salary under the NHM and those under the Directorate of Health Services.

2 This is based on the government directive along with indicative costing for sub-centres released by the NHM directorate for state directorates to follow: D O No Z-15015/11/2017-NHM-I dated 18 May 2017.

3 Another government directive along with indicative costing for PHCs and urban PHCs was released by the NHM directorate for state directorates to follow: D O No Z-15015/11/2017-NHM-I dated 30 May 2018.

Dawa khaana is a term originally used for the dispensaries of the government, where the most “valued” service was the medicines one gets for free from the centres. People are in need of aspathal (hospital) at the block level and it is valued as a place where diagnostics, inpatient facility with observation and minor medical procedures can be carried out free of cost. The challenge is to transform the image of CHCs from that of a sarkari (government-run) dawa khaana to that of a sarkari aspathal.


Banerji, D (1985): Health and Family Planning Services in India: An Epidemiological, Socio-cultural and Political Analysis and a Perspective, New Delhi: Lok Paksh.

Bhatia, K (2014): “Performance-based Incentives of the ASHA Scheme: Stakeholders’ Perspectives,” Economic & Political Weekly, Vol 49, No 22,
pp 145–51.

George, A (2009): “‘By Papers and Pens, You Can Only Do So Much’: Views about Accountability and Human Resource Management from Indian Government Health Administrators and Workers,” The International Journal of Health Planning and Management, Vol 24, No 3, pp 205–24.

George, M (2016): “Healthcare Norms under Universal Healthcare (UHC) for Maharashtra: Relieving Illness and Ensuring Public Health,” Journal of Health Management, Vol 18, No 4, pp 569–83.

— (2019): “Public Health-oriented Healthcare Systems: Need for a Modified Typology,” The National Medical Journal of India, Vol 32, No 3, p 171.

— (2020): “The ‘Specialist–Entrepreneur’ and the Business of Medical Care,” Wire, 22 January,

GoI (1946): “Health Survey and Development Committee (Bhore Committee Report),” Vol 2, Government of India, New Delhi.

— (1973): “Committee on Multipurpose workers under health and family planning programme, (Kartar Singh Committee Report),” Ministry of Health and Family Planning, Government of India, New Delhi.

— (2007): “National Rural Health Mission Meeting People’s Health Needs in Rural Areas, Framework of Implementation (2005–12),” Ministry of Health and Family Welfare, Government of India, New Delhi.

— (2015): “Rural Health Statistics, 2014–15,” Statistics Division, Ministry of Health and Family Welfare, Government of India, New Delhi.

— (2019): “National Medical Commission Bill, 2019,” Government of India,

IIDM (2010): “Determinants of Workforce Availability and Performance of Specialists and General Duty Medical Officers in Bihar,” Indian Institute of Development Management, Bhopal.

Iyengar, S and R H Dholakia (2015): “Specialist Services in the Indian Rural Public Health System for Maternal and Child Healthcare—A Study of Four States,” Working Paper Series 2015-07-04, Ahmedabad: Indian Institute of Management.

Lang, T and G Rayner (2012): “Ecological Public Health: The 21st Century’s Big Idea?”

Lee, L, V Lin, R Wang and H Zhao (2009): “Public Health in China: History and Contemporary Challenges,” Global Public Health: A New Era, R Beaglehole (ed), New York: Oxford University Press, pp 156–71.

Lisam, S, D S Mairembam, A Hazarika, P Goel, R Srivastava and T Sundararaman (2013): “Fixed Human Resource Norms in Indian Sub Centers—Does the Changing Times Necessitate Innovations?” Bonfring International Journal of Industrial Engineering and Management Science, Vol 3, No 2, pp 81–87.

Mann, Gayatri (2020): “Demand for Grants 2020–21 Analysis Health and Family Welfare,” PRS Legislative Research, Institute of Policy Research Studies, New Delhi.

McIntyre, D, B Garshong, G Mtei, F Meheus, M Thiede, J Akazili, Mariam Ally, Moses Aikins, Jo-Ann Mulligan and J Goudge (2008): “Beyond Fragmentation and towards Universal Coverage: Insights from Ghana, South Africa and the United Republic of Tanzania,” Bulletin of the World health Organization, Vol 86, No 11, pp 871–76.

MoHFW (2020): “Directorate General of Health Services,”

— (nd): “Institutionalizing Performance Linked Payments (PLP) for Community Health Officers (CHO) and Frontline Workers (FLW): A Guidance Note on Performance Linked Payment,” Ministry of Health and Family Welfare, Government of India,

National Informatics Centre (2016): “Rashtriya Swasthya Bima Yojana: Health Insurance for the Poor,”

Program Evaluation Organisation (1999): “Functioning of Community Health Centres (CHC),” Evaluation Studies, New Delhi: Program Evaluation Organisation.

Qadeer, I (1995): “Primary Health Care—A Paradise Lost,” Indian Association of Social Science Institutions Quarterly, Vol 14, No 1, pp 1–20.

— (2000): “Health Care Systems in Transition III India, Part I The Indian Experience,” Journal of Public Health, Vol 22, No 1, pp 25–32.

Rao, M H (2019): “Primary Healthcare in India: Challenges and Way Forward,” International Journal of Research and Analytical Review, Vol 6, No 1, pp 517–21.

Sanders, D and N Schaay (2008): “International Perspective on Primary Health Care over the Past 30 Years: Primary Health Care: In Context,” South African Health Review, Vol 2008, No 1, pp 3–16.

Sharma, N (nd): “Maharashtra Public Health Work Force Study, Issues and Challenges,” Report submitted to the National Health Systems
Resource Centre, New Delhi.

Singh, B K (2017): “Spatial Distribution of Health Care Facilities in Bihar, India,” Demography India, Vol 46, No 2, pp 68–80.

Stange, K C (2009): “The Problem of Fragmentation and the Need for Integrative Solutions,” Annals of Family Medicine, Vol 7, No 2, pp 100–103.

Upshur, R E (2002): “Principles for the Justification of Public Health Intervention,” Canadian Journal of Public Health, Vol 1, pp 101–03.

Vaughan, J P, S Mogedal, G Walt, S E Kruse, K Lee and K D Wilde (1996): “WHO and the Effects of Extrabudgetary Funds: Is the Organization
Donor Driven?” Health Policy and Planning, Vol 11, No 3, pp 253–64.

Weed, D L (1999): “Towards a Philosophy of Public Health,” Journal of Epidemiology and Community Health, Vol 53, No 2, p 99.


Updated On : 20th Oct, 2020


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