Have India’s health centres really ‘collapsed’? Premium

Study examines health centres in North India, highlighting progress, challenges, and potential for improving public healthcare system.

Jean Drèze, Reetika Khera, Rishabh Malhotra, ‘The Changing State of Health Centres in North India’, Economic & Political Weekly (2024)

There is a well-documented infamy around public health centres. Some have likened it to a chasm, others to a systemic rot representing the “greatest failure of the Indian state”. There is proven dilapidation and disrepute — there are no doctors, no diagnostics, no drugs. There are no buildings either sometimes, and people walk for miles to get substandard treatment. These centres, as reflections of the vast network of public healthcare, stoke the fear that India’s health system has either collapsed or is disintegrating rapidly.

In this paper, the authors counter and complicate the prevailing narrative of ‘collapse’. They present a portrait of the healthcare centres in five north Indian States, documenting their strengths and struggles alike. Their survey shows a pattern of “improving quality and utilisation [of services] over time”, but the nature of progress is “largely cosmetic”, and “the pace of improvement” remains “far from adequate”. Still, there is scope and strength in redeeming health centres’ potential, they say. Against all odds, health centres “are mostly functional” and show “a demonstrated capacity to improve”.

Health centres are the lowest rung of India’s public health system, charged with offering accessible and affordable primary care. Almost two lakh in number, they are conceptualised as a three-tier system: sub-centres (later renamed as health and wellness centres), public health centres (PHCs) and community health centres (CHCs). 94% of these centres are located in rural areas, but reports show that less than 20% of them function effectively, pushing disadvantaged communities to rely on expensive, exploitative private health care. “Torn between the two, many patients end up risking their health or their wealth, if not both”. Last year’s Economic Survey showed that in the absence of proper insurance and affordable services, almost half of all health spending in India is still paid by patients themselves, pushing many households into poverty.

The answer to social and health inequity may lie in accelerating the expansion and improvement of health centres. Localised healthcare “is a much better way of dealing with most health problems than to let patients loose on larger public hospitals or the private sector”.

The researchers studied the performance of 241 health centres — 26 CHCs, 65 PHCs and 150 sub-centres, spread across Bihar (23), Chhattisgarh (36), Himachal Pradesh (45), Jharkhand (37) and Rajasthan (100). They referred to data from two studies from two different decades, one in 2002 and one in 2013, conducted in Udaipur and parts of Bihar, Jharkhand, and Himachal Pradesh. Centres from the 2013 survey were revisited in 2022, with Chhattisgarh added to the mix.

Himachal Pradesh was always a “trailblazer” with functional centres serving 83% of its population, but States like Chhattisgarh and Rajasthan have introduced “valuable initiatives”. “Health centres today have better facilities, dispense more medicines, serve more patients, and provide a wider range of services than they did 10 or 20 years ago”, the researchers found. This perception of progress was shared by health workers too, who found that “the work environment and the work culture seem to improve hand in hand”.