Jean Drèze, Reetika Khera, Rishabh Malhotra, ‘The Changing State of Health Centres in North India’, Economic & Political Weekly (2024)
There is a well-documented infamy around public health centres. Some have likened it to a chasm, others to a systemic rot representing the “greatest failure of the Indian state”. There is proven dilapidation and disrepute — there are no doctors, no diagnostics, no drugs. There are no buildings either sometimes, and people walk for miles to get substandard treatment. These centres, as reflections of the vast network of public healthcare, stoke the fear that India’s health system has either collapsed or is disintegrating rapidly.
In this paper, the authors counter and complicate the prevailing narrative of ‘collapse’. They present a portrait of the healthcare centres in five north Indian States, documenting their strengths and struggles alike. Their survey shows a pattern of “improving quality and utilisation [of services] over time”, but the nature of progress is “largely cosmetic”, and “the pace of improvement” remains “far from adequate”. Still, there is scope and strength in redeeming health centres’ potential, they say. Against all odds, health centres “are mostly functional” and show “a demonstrated capacity to improve”.
Why do health centres matter?
Health centres are the lowest rung of India’s public health system, charged with offering accessible and affordable primary care. Almost two lakh in number, they are conceptualised as a three-tier system: sub-centres (later renamed as health and wellness centres), public health centres (PHCs) and community health centres (CHCs). 94% of these centres are located in rural areas, but reports show that less than 20% of them function effectively, pushing disadvantaged communities to rely on expensive, exploitative private health care. “Torn between the two, many patients end up risking their health or their wealth, if not both”. Last year’s Economic Survey showed that in the absence of proper insurance and affordable services, almost half of all health spending in India is still paid by patients themselves, pushing many households into poverty.
The answer to social and health inequity may lie in accelerating the expansion and improvement of health centres. Localised healthcare “is a much better way of dealing with most health problems than to let patients loose on larger public hospitals or the private sector”.
‘Unsurprising’ improvements
The researchers studied the performance of 241 health centres — 26 CHCs, 65 PHCs and 150 sub-centres, spread across Bihar (23), Chhattisgarh (36), Himachal Pradesh (45), Jharkhand (37) and Rajasthan (100). They referred to data from two studies from two different decades, one in 2002 and one in 2013, conducted in Udaipur and parts of Bihar, Jharkhand, and Himachal Pradesh. Centres from the 2013 survey were revisited in 2022, with Chhattisgarh added to the mix.
Himachal Pradesh was always a “trailblazer” with functional centres serving 83% of its population, but States like Chhattisgarh and Rajasthan have introduced “valuable initiatives”. “Health centres today have better facilities, dispense more medicines, serve more patients, and provide a wider range of services than they did 10 or 20 years ago”, the researchers found. This perception of progress was shared by health workers too, who found that “the work environment and the work culture seem to improve hand in hand”.
Two case studies stand out. Chhattisgarh was a pleasant surprise: by 2022, it illustrated a “radical expansion in public provision of healthcare”. Local health workers reported running water, functional toilets, better facilities (for cold storage, vaccines, contraceptives, etc.), more medicines, a supportive role of ASHAs and open centres with staff present most of the time. There also has been a surge in public healthcare utilisation. On the other hand, the “twin States” of Bihar and Jharkhand presented a contrasting narrative, with Bihar the apparent laggard. The quality of health centres was “dismal”, some local sub-centres were dormant and others were non-existent.
On average, contrary to popular belief, there is “evidence of functionality” across PHCs: “The centres are generally open during working hours, patients are being treated, basic facilities (not more) are in place, and healthcare is more or less free except in Bihar.”
What changed between 2002 and 2022? The share of health expenditure in the Union Budget increased drastically, coupled with the introduction of the National Rural Health Mission. India’s flagship Ayushmann Bharat programme, launched with the vision of achieving universal health coverage, in 2018 introduced a health insurance component (PMJAY) and a public provision component through health and wellness centres (HWCs). State-specific schemes launched by Rajasthan and Chhattisgarh boosted their performance. The survey noted that COVID-19 contributed to a “sustained increase in patient utilisation”, with people placing greater trust in public health facilities.
The flip side
Progress is rarely ever linear or logical. The study contextualises these signs of life as “modest improvements” only. The centres are still “grossly underutilised”: there is high staff absenteeism, the number of patients per day is low, services are limited and “quite likely, of poor quality”. Bihar’s sub-centres “are still trapped in the old pattern where Auxiliary Nurse Midwife (ANMs) focus mainly on family planning targets and ‘motivating’ people—mainly women—for sterilisation”.
The health workers interviewed listed challenges that remain neglected: lack of staff ; irregular flow of funds; lack of toilet facilities; no transport or residential facilities; no drugs or functional testing equipment; and the growing burden of both online and on-field work. The study also documented social discrimination in health centres: some upper-caste doctors had “disparaging attitudes towards marginalised communities”, and upper-caste families routinely disrespected Dalit ANMs. Care isn’t offered in a vacuum devoid of social realities; identity markers like caste, class, gender, and religion have historically shaped Indians’ access to health services.
Researchers also made a rare mention of the critical role women play in rural health settings. The study found female nurses and staff members ran district hospitals and did “the bulk of the effort”, while men in senior positions tended “to take advantage of their seniority”. ANMs and ASHAs worked in grim environments with centres lacking running water and toilets. Still, they “tend to perform much better than the system in which they work”. The researchers echoed demands made by frontline health workers: to enhance investment in this “veritable army of valuable health workers” so that women can reap the recognition or rewards of their work.
The pursuit of development
Investment in healthcare increased, but the “improvements are patchy” and allocations prioritise material development in tertiary healthcare. Take the composition of the healthcare budget: the allocation in 2022–23 (1.9%) was almost the same as a decade ago in 2013–14 (1.7%). The National Health Mission share shrank from 69% to 44%. In comparison, the government spent 10 times as much money on PMJAY and new regional AIIMS hospitals than on public welfare arms like the HWCs. The researchers poked holes in the claim that lakhs of HCWs were ‘created’ — these were “minor upgrade[s]” of existing centres. The HWCs “have a relatively attractive look” but were only “marginally better” than sub-centres, with improvements only “cosmetic” in nature.
The study sketches India’s health centres as sites of hope, debunking cynicism surrounding its failures and dissects claims of progress. These struggles “cannot be regarded as successful, but nor is it hopeless”, because “hope lies in the experiences of States that have shown how decent standards of healthcare can be achieved in the public sector”. The researchers conclude by noting that “beyond the current tokenism of Ayushmann Bharat”, “major support from the centre...would make it much easier for the poorer states to emulate these initiatives”.
