Rajasthan government’s decision to ‘target’ free medicines and diagnostics is contrary to the recommended role of government in healthcare.
In 2002-03, Abhijit Banerjee, Angus Deaton and Esther Duflo studied health facilities in rural Udaipur, Rajasthan. They found that facilities were poor and absenteeism was rampant. In 2013, we decided to revisit the same public health facilities. The motivation was to study two bold initiatives of the then Ashok Gehlot government: the “free medicines” scheme launched on October 2, 2011 and “free diagnostics” for 25 essential tests (including blood, pregnancy, x-rays, ECG) introduced in April 2013.
The good news is that both services were visible everywhere we went, even though tests had been introduced only eight months earlier. Moreover, these two services recorded a big jump between the two surveys (in 2003 and 2013) at primary health centres (PHCs). There was massive improvement in physical infrastructure (buildings, toilets, medical equipment such as x-ray machines and incubators) at PHCs. Together these factors had an impact on health-seeking behaviour among local residents, visible in the steady trickle of patients at PHCs. According to official data, out-patients increased from 2.5 to 6.6 crore between 2010-11 and 2013-14.
But there is bad news, too. Though access to health facilities had improved and patients had started seeking them, there was no guarantee that they would meet a trained medical person (for example, a nurse, health worker, or AYUSH doctor). Appointments remain woefully inadequate and attendance rates have not improved much. Absenteeism emerged as the main problem at the PHCs. The message was clear: the commitment needs to go beyond medicines and diagnostics.
Here, the experiences of Himachal Pradesh and Tamil Nadu are pertinent. Both provide universal and free access to basic health services (such as medicines and diagnostics), which appears to have contributed to better health outcomes in these states. The achievements of Tamil Nadu’s public health system are well documented by Monica Das Gupta, among others.
In June 2014, we also surveyed public health facilities in two blocks of Himachal Pradesh. Sub-centres (at the gram panchayat level) in Himachal are reasonably well equipped, and have two trained “health workers” (male and female). The appointment of two health workers allows them to combine field duties with work at the centre. Since they are trained, they can screen and refer serious cases to the PHC, where doctors and good diagnostic facilities are available. At unannounced visits to sub-centres, one invariably found patients seeking medical attention. This suggests that they were accustomed to finding the sub-centre open. Why would people trek long distances if they did not expect to find it open?
There are three important insights from Himachal and Tamil Nadu, especially to deal with the continued…