Eight Charts to Explain the State of Rural Healthcare in India

The recently released Rural Health Statistics show that healthcare centres have functioned in 2021-22 with staff strength that is less than even the preceding year, 2020-21. 

New Delhi: India fought the worst wave of COVID-19 pandemic in 2021-22 with a significant shortfall of human resources in the rural areas of the country. The Rural Health Statistics 2021-22 released recently show that health sub centres (SCs), primary health centres (PHCs) and community health centres (CHCs) functioned with a staff strength that was less than even the preceding year, 2020-21. 

According to the RHS 2021-22, the number of auxiliary nurse midwives (ANMs) at SCs in the country in March 2022 was 2,07.587. This number was 2,14,820 in March 2021. They are the first point of contact at SCs. 

Similarly, the number of doctors working at PHCs decreased to 30,640 in 2021-22 as against 31,716 in the previous year. This is important because in 2021-22, India had already battled the first wave of COVID-19 and it was common knowledge that because the worst had not happened yet, preparations were a must. The shortfall in rural health resources was going to have an impact and was also, therefore, not difficult to gauge. 

SCs are the most peripheral point of health care in rural areas. They are supposed to have two health care workers – an ANM and a male healthcare worker. There is supposed to be one SC for every 5,000 people.

Next in the hierarchy come PHCs. They are supposed to have four to six beds, a medical officer in-charge and subordinate staff. For every 30,000 people, there has to be one PHC.

At the top of this tiered system are CHCs. They are mandated to have 30 beds with labour rooms and operation theatres, along with other specialised services. Every 1,20,000 people have to be covered by a CHC, according to the norms prescribed by the Union government.

The number of lab technicians at CHCs and PHCs, according to RHS, saw a minor increase of 50 in 2022 with a little over 22,000 of them working at CHCs and PHCs. So was the case of nursing staff, which rose from 79,044 to 79,933. The number of radiographers, who usually operate X-ray equipment, saw a marginal increase from 2,418 to 2,448 at CHCs and PHCs.

However, while this gives a broader picture of the country, the following five charts explain state-wide variations in India. 

Many states in India have been reporting zero shortfall of ANMs, in fact, many are reporting a surplus now. However, some continue to report a shortage in terms of the number of posts required vis-a-vis the number of ANMs actually posted. In this chart, we look at the shortfall of ANMs at SCs and PHCs in those states which reported such a shortfall in 2022 and have compared it with that of previous year. While some states have closed the gap, in others it widened in one year. 

In case of nurses too, who are deployed at CHCs and PHCs, we find that while some states report surplus numbers, those which reported a shortage in 2021, continued to do so in 2022 as well – with some states reducing their shortages, while in others, the gap increased, in 2022.

Nursing staff are the backbone of healthcare at PHCs and CHCs. Their presence is especially important to make some of the PHCs and CHCs functional all day, everyday. In the following chart, we report only those states which showed scarcity in 2021-22 and compare it to that of the previous year.

CHCs, the facilities which lie at the top of hierarchy of rural healthcare are supposed to each have one obstetrician/gynaecologist, paediatrician, surgeon and anaesthetist, each, besides a general physician.

In some states, some CHCs do not even have a single sanctioned post of doctors with these specialities. On top of that, there is a lack of personnel against what is sanctioned. 

The very purpose of these upgraded health centres is for them to be a place where patients can be referred to for these specialist services. However, CHCs, across many states, continue to report a shortage of all these specialists. At least two of these four speciality service providers – obstetrician/gynaecologist and paediatricians – have a direct impact on infant mortality and maternal mortality rates. Absence of these two and the remaining leads to a situation where an attendant is forced to rush with a patient to a far off district hospital or a medical college. Not only does this mean stress on patients’ resources but also loss of crucial time when emergency care might be needed. 

Lab technicians (who conduct various diagnostic tests) and radiographers (who do X-ray) at peripheral health centres play an important role. But almost every state is reporting a lack of these experts as per the 2022 RHS. Their shortage would mean the treating physician will either have to ask the patient to go to a private lab; or rush to a far off public health facility, which in turn, would lead to delay in diagnosis and treatment.

Every CHC is supposed to have at least one to four lab technicians (depending on type of CHC) and one radiographer each, according to Indian Public Health Standards (IPHS) for CHCs, prescribed under the National Health Mission programme of the Union government.

According to IPHS norms for PHCs, it is “essential” for all such facilities which function round the clock to have one minor operation theatre (OT) where minor procedures/surgeries are performed. “This caters to patients needing minor surgeries/procedures. It should be well equipped with all the emergency drugs and instruments,” the norms say. However, the RHS shows that in many states, such PHCs which do work 24×7 do not have the facility. 

It should be noted here that the IPHS norms mandating a minor operation theatre is currently for 24×7 PHCs only and not all of them. For example, Odisha has 1,288 functional PHCs. Out of them, as per RHS, 316 give services for 24 hours, and hence, at least these many rural PHCs should have a minor OT. But, only 29 out of 326 have them. On the other hand, there are outliers like Karnataka where out of 2,138 PHCs, 904 work round the clock but a minor OT is present in more than 1,000 PHCs – thus indicating that other PHCs too have such a facility. 

While the above eight charts show the status of human resources and infrastructure in the health facilities that cater to the rural population, the RHS 2021-22 also reveal that there are many states where number of people served by one SC, PHC or CHC are way above than the prescribed norms.

Laggard states continue to be in the red. For instance, as per norms an SC should be present for every 5,000 people. But in Uttar Pradesh, Bihar and Jharkhand, more than 7,000 people depend on one SC. In 10 states, 5,000-7,000 people depend on one such centre. Similarly, for every 30,000 people there should be one PHC but in Uttar Pradesh, Bihar, Jharkhand and West Bengal, more than 50,000 people depend on one PHC. In another five states, 30-50,000 people get services from one PHC. 

The higher level of health facility, a CHC, is needed for every one lakh people. But in Karnataka, Andhra Pradesh, Telangana, Maharashtra, Madhya Pradesh, Bihar and Uttar Pradesh, 2-5 lakh people depend on one CHC.

However, what these statistics don’t reveal are some ground realities. While a certain number of health personnel are shown posted at a health facility, it does not take into account absenteeism – which was officially reported in the Economic Survey 2018-19. 

“Moreover, what this data [number of personnel present at health centres] do not reveal is that even if the personnel are present, their level of participation in providing health services, may not be at desirable levels due to lack of supplies, inadequate infrastructure facilities, poor monitoring of the staff, and so on,” the Economic Survey 2018-19 said