(This article was first published in 2022. It has been republished from The Quint's archives in light of the Rajasthan Assembly passing the Right to Health Bill on 21 March.)
Delivering on a political promise made in 2013, the Ashok Gehlot-led Rajasthan Assembly passed the Right to Health Bill on Tuesday, 21 March, a radical health policy measure – in a move towards universal healthcare.
Targeting a population of 7.8 crore, these measures guarantee free treatment for all. Given that health expenditure continues to be a major burden for households, this is a step, if not a stride, towards access to equitable healthcare.
The National Health Service (NHS), the United Kingdom’s flagship universal healthcare programme, was introduced in 1948 after a bitter winter and years of economic austerity. Facilities had to be prepared, and tens of thousands of health workers were to be trained. But there was another interesting effect. The unmet healthcare needs of thousands of people could suddenly be met.
In 1947, a year before the NHS's implementation, doctors issued 70 lakh prescriptions per month. This number nearly tripled to 1.9 crore in 1951. Over the decades, ensuring quality care has become a central tenet of the NHS.
Rajasthan faces a similar challenge only 74 years later.
The article draws its insights from interviews with health workers and patients in rural areas of district Udaipur and its blocks Girwa, Gogunda, and Badgaon, which make up more than half the district’s population.
It becomes quickly evident that the government must shift focus. With tests and treatments now free, the change in health aspirations of people will soon demand more than just free treatment – quality care – which will become the rubric of its success.
Improvements in Medicine Supply, but Missing Staff
Positive things first. Comparing the findings from the Health Facilities Survey 2013, tests and medicine supply continue to remain available at a village level. In fact, the range and availability of medicine supply and testing equipment have seen a marked, positive change.
At the village health sub-centre (SC) level, the first point of contact, essential tests like blood haemoglobin, sugar, and even malaria tests are largely available. Medicines for common ailments like analgesics or essential supplements such as iron and folic acid (IFA) tablets are commonly found, crucial for the health of pregnant women.
A malaria test slide waiting to be sent to a Community Health Centre for diagnosis from a Health and Wellness Centre.
(Photo Courtesy: Saksham Singh)
However, all is not fixed. Challenges remain with respect to infrastructure. Both human and physical. Health facilities, especially at the village SC level, face crippling seepage that is made worse by rains, lack of electricity, and sometimes even vandalism from drunks. The nature of challenges for staffing and personnel management has evolved.
Vacant posts and a lack of specialists can lead to the denial of services.
The need for a specialist is strongly felt in Chirwa block, a community health centre (CHC) which sees 80-90 deliveries a month.
“We need specialists like gynaecologists with so many deliveries… sometimes even a doctor is not present, and deliveries can be complicated… we deliver most of the babies”, as per a nurse at the CHC. Quality of health outcomes, such as a safe birth, can be crucially impeded in such circumstances.
The problem of insufficient personnel, from doctors to cleaning staff, universally persists across small and big facilities. Under new health policies, several SCs are being converted into Health and Wellness Centers (HWC). While traditionally, SCs have only had a nurse, the new HWCs will add the post of Community Heath Officer – an entirely new cadre. This will allow the facility to remain open for patients, even if one of the frontline health workers must be in the field.
A Community Health Officer in front of a Health and Wellness Centre.
The Changing Nature of Demand for Healthcare
Almost all health workers, right from SCs level to CHCs, have reported a marked increase in patient numbers in a post COVID-19 world. Patients now visit to report simple cough or fever, which was not the case earlier. It implies that there is an expectation that they will get better. This can potentially be explained by a combination of two factors.
One is the state’s new health policy, and two is the demand-inducing effect of COVID-19. Post COVID-19, patients appear to be more concerned about their health, fearing ailment. Health infrastructure upgrades might also be a signal of change.
Patients already display a preference for facilities which have better infrastructure – physical or human resources – a signal of quality. If a village SC lies in the catchment area of a larger hospital, patients prefer travelling to the larger facility – even if it costs more – given the higher odds of receiving better treatment.
When the SC becomes an HWC, there is not only a notable change in the physical infrastructure but also in human infrastructure, ie, the CHO. To any patient, at first instance, it indicates that the quality of health services may have now improved. Supplementarily, at bigger government facilities, there are instances where despite free treatment, patients trust doctors who provide a better service over others.
“Dr Parmesh (name changed) at the Tidi CHC is a great doctor… patients trust him because he hears them out and counsels them well… during his OPD, there are a lot of patients”, shared a care-seeker from Tidi village.
Often, doctors spend less than a minute seeing a patient. Most of the time, it is at best, a symptomatic check. If a patient says they have a fever, the doctor, if present, would not use a thermometer to validate but straightaway prescribes antibiotics. In some instances, even the intern, or lab cleaners, can be found to be doling medication. However, like Dr Parmesh, there are several other popular health workers. This is true even at the village level. In Majhawad, a small village in block Gogunda, patients start pouring in within a few minutes of the village nurse’s (called the ‘Auxiliary Nurse Midwife’ or ANM) arrival from Udaipur.
The demand for quality healthcare can be exemplified using another unfortunate incident outside a primary health centre. A father, a labour worker, of a 3-year-old girl child suffering from a Urinary Tract Infection was deeply distressed after a check-up.
“The nurse barely even saw her for a minute. She didn’t look or do any check-ups, and gave us this ointment and no other information. We will now take her to another private doctor.”
When checked with the facility staff, such claims were dismissed with the adage that patients have become more demanding since such services have been made free.
This is unfortunate as despite free healthcare, people might still be forced to go to private practitioners – adding to their expenditures.
Frontline Health Workers Deliver Despite Challenges
Delivery of quality healthcare is entirely dependent on the shoulders of individual health workers. The village nurses and Accredited Social Health Activist (ASHAs) serve as the lynchpin of the health system. Village-level health workers who are entrepreneurial and work proactively with the village community, like the panchayat and block-level officials, can create a lot of community impact. As per Vidisha (name changed), one of the four ASHA workers associated with the Majhawad HWC, “The ANM has been here for the last 12 years and has converted the SC from a defunct building to an oasis.”
Unfortunately, these ‘pins’ are overburdened and are buckling under pressure.
Where technology is supposed to make life simpler, ANMs must maintain online and offline registers – a double effort. The health system fails its workers on two additional accounts.
First, given the general lack of public transport, health workers struggle to access transportation to commute not only to the station but also during fieldwork – which becomes a real challenge in difficult terrains.
Secondly, there is a lack of complementary public services, such as the availability of schools and childcare facilities for the children of health workers. Many ANMs were found to bring their young children to their places of work.
Administrative bottlenecks don’t make their lives easier. In blocks like Gogunda or Girwa, there has been irregularity of payments to ASHA workers, who haven’t been paid for months. Compounding this uncertainty is the recent order of ASHAs being included under the health department has only added to this frustration. The system can do better for those on whom it relies the most.
Such challenges directly and negatively impact the ability of health workers to do their jobs well.
A village Sub-Centre notice board written by the ANM informing that the sub-centre is closed as she is in the field for ‘Shakti Divas’. In this village, the SC was on a hilltop and in a no-network zone.
(Photo Courtesy: Saksham Singh)
Accounting the Change in Health Aspirations, Institutionally
Rajasthan’s new health schemes for providing free healthcare are a move in the right direction. However, as is evident, the nature of demand for health and the patient's care aspirations have changed. And health care workers are the key to delivering any promise. To address these dynamics, along with health promotion activities such as TB or immunization awareness camps, the state must make quality care its cornerstone.
Doctors would need to focus on counselling patients, and frontline health workers would need to drive more measures to build trust within the community – especially when providing healthcare for the marginalised, who are more likely to visit the public health systems. Luckily, health workers can also be motivated by non-pecuniary rewards, such as recognition for their efforts or even quality training, which helps them do their work better. However, this is no excuse for delays in payments of the thousands of health workers.
Even as Rajasthan introduces a new ‘Right to Health’ bill, its success will depend on an institutionally embedded bottom-up, patient focussed, and community-based approach. This will build not only trust but a resilient and empathetic system of care.
(The article covers observations of the author from the Public Health Facilities Survey 2022, coordinated by Jean Dreze, Reetika Khera, and Rishabh Malhotra. The team for the blocks mentioned also included Monika, Vanshika, and Lalit. Saksham is a doctoral student at the University of Wisconsin-Madison. You can tweet to him at sakshamO_o.)
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