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.
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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 main problem (absence of trained medical personnel) identified in the 2013 Rajasthan survey. One, studying Himachal’s and Tamil Nadu’s functional public health systems, one realises that Gehlot’s initiatives were important to create a decent work environment. Creating decent work conditions is the first step towards functionality. It is not reasonable to expect doctors to serve in remote areas without basic services (for example, electricity) and medical supplies (medicines and equipment). Two, to retain doctors, decent work conditions at PHCs need to be combined with incentives. In Himachal and Tamil Nadu, the state supports specialisation studies for doctors who complete three years in government service. Three, a “critical mass” is required to improve attendance rates: for example, if only one staff is appointed at sub-centres, she cannot keep it open and perform field duties. Doctors, lab technicians, nurses are more likely to stay in remote areas if there are several of them at each centre.
Universal primary level care is accepted, worldwide, as the government’s top priority in the health sector. Essentially, that means one must focus on “nipping it in the bud”: basic primary-level health services for minor ailments before they become major, and costly, ailments.
In light of this, Rajasthan Chief Minister Vasundhara Raje’s decision to “target” free basic primary level healthcare is baffling. The proposal is ill-advised on at least four grounds. One, it moves towards the discredited approach of “targeting” benefits, with its divisive effects and inevitable exclusion errors. Two, appointments and absenteeism were the weak link in the 2013 Rajasthan survey. Curtailing primary level healthcare will not resolve that issue. Three, while political posturing is to be expected (for example, in the election campaign in Rajasthan, Raje reportedly said that the free medicines were “poisonous”), her proposal reeks of pettiness; it will end up punishing people by reducing their access to essential health services. Four, the supply of free medicines is very much on her party’s agenda. Gujarat, which already provides free medicines and diagnostics, was studying Rajasthan’s system. The Centre also plans to adapt it. Most importantly, the National Health Policy 2002 (formulated in Atal Bihari Vajpayee’s time) noted that public health facilities functioned better in the southern states “because some quantum of drugs is distributed through the primary health system”, and “patients have a stake in approaching public health facilities.”
The writer is an associate professor, Economics, at the Indian Institute of Technology, Delhi