Of primary importance

We need better primary health centres more than AIIMS-like institutions.

Written by N. Devadasan | Updated: June 11, 2014 8:00 am
It is not clear why the government is planning to establish more AIIMS-like hospitals. It is not clear why the government is planning to establish more AIIMS-like hospitals.

The ministry of health is reportedly planning to open 10 more AIIMS-like institutes as well as cancer centres in different states. Creating new cancer centres is desirable, given the burden of the disease and the inadequate number of treatment centres. Today, cancer is one of the main causes of premature mortality in our country, and the 25 regional cancer centres are not being able to cope with the high load of patients. Additional cancer centres would definitely be meeting a badly felt need.

However, it is not clear why the government is planning to establish more AIIMS-like hospitals. The health ministry may wrongly believe that India needs more such centres of excellence to train doctors as well as to provide high quality healthcare services to people.

However, such a move has serious implications for the rest of the health system. The government spends about 1.3 per cent of the GDP on healthcare —  among the lowest in the world. As per the ministry’s own report, the government spent less than Rs 1,000 per Indian in 2012-13. Of this, more than 10 per cent already goes towards medical education. If more scarce resources are diverted to tertiary care and medical colleges, the allocation for primary and secondary healthcare may be reduced. Primary healthcare is the centre of any health system —  be it in India or in the United Kingdom. Currently, in most states, primary health centres (PHCs) and referral hospitals are severely understaffed and under-equipped. One PHC with a single doctor is responsible for the health of 30,000 people. In Brazil, a comparable centre has four doctors for every 10,000 people. The government spends just about Rs 5 per person on medicines. This is so inadequate that most PHCs do not have medicines beyond the first few months of a year. Patients are asked to purchase medicine from private pharmacies, incur out-of-pocket expenses at a time of illness. This creates a significant financial barrier and prevents patients from accessing healthcare at the PHC. If the money that would be spent on these AIIMS-like centres were used to increase the budgetary allocation for PHCs, there could be more staff and medicines at these centres. Patients’ trust in government facilities would be enhanced and there would be a corresponding increase in their utilisation. It would be a step in the right direction if we were able to achieve universal health coverage in the near future.

Apart from the economics of building more AIIMS-like centres, such institutions have other effects. They will attract specialists from existing health centres, thereby further depleting the human resource pool for district and referral hospitals. Also, because of their iconic stature, patients may bypass the existing facilities to seek care directly at the AIIMS-like centres. This is evident in the original AIIMS, New Delhi, where patients come from neighbouring states and crowd the outpatient and inpatient services. This compromises the quality and effectiveness of the centre. On the other hand, if PHCs and referral hospitals are strengthened, patients can be provided good quality care closer to their residence. This is beneficial both for the patient and for the health services.

And finally, it has been hypothesised that these centres will create more doctors who can then work for the country. However, existing evidence proves otherwise. In 2009, AIIMS, New Delhi, was spending Rs 98 lakh on a single medical graduate. More than 50 per cent of these graduates went on to serve in rural areas in the US and UK. It is a fallacy to expect all graduates from these centres of excellence to work for our country. On the other hand, investment in the three-year BSc in rural health course would increase the probability of having clinical staff at the PHC level. Chhattisgarh has shown the way and we can definitely learn from it.

Today, for every 1,000 live births, more infants die in India than in countries like Nepal and Bangladesh. We need to catch up with these countries, and the main way to do this is to increase investment in preventive services like routine immunisation, good quality antenatal care, screening for cancers and promoting healthy lifestyles. Our country needs to provide quality outpatient services and round-the-clock emergency services at facilities that are close to the people, not only at district headquarters. If India is to ensure that all people have access to quality healthcare, we need to provide quality primary and secondary healthcare for all, rather than tertiary healthcare for a few.

The writer is director,  Institute of Public Health,  Bangalore. Views are personal

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First Published on: June 11, 2014 12:22 am
  1. A
    Jun 11, 2014 at 9:04 pm
    I really hope the government takes notice of this article. Evidence and experience has told us that in the face of limited resources, strengthening primary care is a much better investment. A good primary care system will also help in preventing serious diseases thereby reducing the need of tertiary care. Thanks.
    1. A
      Jun 26, 2014 at 9:12 am
      why only doctors? ban campus placements in IITs and force them to work for paltry 20,000 in government sectors for 3 to 5 years. would you live without electricity in villages like doctors have to ?. sir this is no solution. make rural postings attractive. pay good ries and provide at least basic necessities in villages before you expect doctors to do rural service.
      1. S
        Sriram Chadalavada
        Jun 12, 2014 at 6:43 pm
        Actually, the writer has addressed the suppy side. He talks about BSc in rural health course that will educate many who will work at PHCs. PHCs can always refer to the secondary or tertiary care, such as the AIIMs.
        1. G
          Jun 11, 2014 at 7:31 am
          simpler solution for brain drain of doctors would be mandating 3 to 5 years of rural service in India.that way, at least cost of educating them can be recovered.
          1. S
            Sandeep Nayak
            Jun 26, 2014 at 9:14 am
            According government data, gov spend 98laks for a single medical graduate...gov should increase budget for strengthening existing public health facilities rather than constructing new hospitals and at the same time, there should be increase health professionals (ANM, Health Eduactor, Aganwadi) those who can provide basic health services...
            1. S
              Sandeep Nayak
              Jun 26, 2014 at 9:05 am
              We don't need more AIIMS. Rather than we have to strengthen and improve basic health services and centres... Creating new AIIMS doesn't improve the existing health services!!!
              1. P
                Prasanna S
                Jun 11, 2014 at 7:41 pm
                The writer is ignoring the supply side of the medical care system. Who will work in those primary health centers? We need more skilled doctors, nurses and trained laboratory staff in the first place to work, which is hardly available in this country. So it is very apt decision by the government to create more AIIMS. The scope of these insutes should be enhanced to include training of nurses, laboratory staff too.
                1. R
                  Jun 12, 2014 at 5:01 pm
                  Sir can u plz explain in details about the words govt spends around 98 lakes for a single medical graduate , those are money to build hospitals which serve public and not exclusively for students like engineering
                  1. V
                    Jun 12, 2014 at 3:04 am
                    More hospitals? Maybe but it's better to first take up a drive to strengthen the current medical system. There are literally no doctors in the UP hospitals. Big buildings are showcased as the ground work of political establishments, but there's hardly any doctor, if any, is not properly trained. In India, there are many patients dying because of improper healthcare. I don't see such initiative being taken up ever at the centre. If questioned, they would definitely blame the state governments which may be correct, but who will take up the responsibility and improve the current sorry state? You bring AIIMS or cheat private health care, but bring quality.
                    1. S
                      Jun 11, 2014 at 8:27 am
                      More AIIMS are needed. It will only help the nation. This should not come in the way of strengthening primary health centers. Probably there is something wrong the way primary health centers are run, their business model. Unless what specifically needs to done is defined, we will end up having neither AIIMS nor primary health services.
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