Samarin Bai, a 50-year-old Baiga tribal woman from Mahamai village lives in the dense Achanakmar forests of Bilaspur district, Chhattisgarh. A few days back, she decided to see a doctor for the big lump that had developed at the base of her neck and various other problems. Although there is a government sub-centre 6kmsix kilometers away, she knew that there was only one auxiliary nurse cum midwife (ANM) who wouldn't be able to help. So she trudged through 14km of rain-soaked forest to a health centre in Bamhani village set up by a local NGO, Jan Swasthya Sahyog (JSS). A doctor visits this centre every week and he diagnosed a dangerous thyroid enlargement which needed quick surgery. Samarin Bai waded across a monsoon swollen river and was transported by the JSS van to their hospital at Ganiyari, some 70km away. She is recovering there now.
Yogesh Jain of JSS narrates this story as an example of what is routine in the area. Healthcare delivery is so patchy and deficient that people travel dozens of kilometers to get treatment. "In the 10 years since the NRHM was launched, some improvement is there, buildings are there, some more equipment is there, upkeep is better. but doctors and key healthcare personnel are still deficient," he told TOI.
Recently released government data on the rural health infrastructure and personnel confirms that Samarin Bai's problem of not finding doctors nearby is not a rare example from some inaccessible forest. At the country level, there is a staggering shortfall of 81% of specialist doctors, 12% of percent general physicians, 21% nurses and 5% of auxiliary nurse cum midwives. Among technical support staff, shortfalls range from 29% percent for pharmacists to 45% percent for laboratory technicians and 63% percent for radiographers. But what is more shocking is that since a decade ago, many of these shortfalls have increased except for nurses and ANMs.
A bizarre aspect of this data put out annually by the ministry of health is that in many categories of health personnel, some states have surplus appointments while others have shortfalls. For example, at the country level, 25,308 doctors are required going by the Indian Public Health Standards (IPHS), which says that one doctor is needed for every primary health centre (PHC). But actually, there are 34,750 doctors sanctioned. 25 states have surplus doctors in position compared to required, the total surplus working out to 5,115. On the other hand, the remaining states have a combined shortfall of 3,002 doctors.
T Sundararaman, professor at the Tata Institute for Social Sciences and former executive director of the government's National Health Systems Resource Centre says,has an explanation. "IPHS recommended two doctors and one ayush doctor per PHC. In 2011, the doctors per PHC was revised downwards. But doctors are - unlike ANMs - paid only by the states. So many states, like Tamil Nadu, have two doctors per PHC as sanctioned. The 'required' number is the statistics department's interpretation of IPHS to mean that only one doctor is required per PHC. They have no basis to do this, and one doctor per PHC is not viable. The short falls are genuine - the over appointments are not," he told TOI.
This puts the whole data in a new light. The surpluses shown in healthcare personnel in many states are not real - they arise because goal posts are shifted by lowering requirements. In reality the shortages are all round. This would apply to ANMs too which are 'surplus' in 25 states/UTs amounting to a whopping 42,548 for India. This is because the earlier standard of two ANMs per sub-centre has been diluted to one. Despite this several states don't even have that sole ANM in many sub-centres.
In fact, the norm of having a sub-centre for every 5000 persons (or 3000 persons in tribal and hilly areas) is crumbling fast. Currently, the national average is over 5400, with some states like UP having an above 7000 average. Similarly, the national average of population per PHC is nearly 33,000 against the norm of 30,000 and the average for community health centres (CHC) is running at 1.5 lakh compared to the prescribed norm of one lakh per CHC.