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Indian Journal of Community Medicine

Vol. 26, No. 2 (2001-04 - 2001-06)

Editorial

Functioning of Subcentres in the System of Primary Healthcare

India is largest democracy in the world, with the population of over 1027 million (2001). Over 74% of population lives in rural area. The first all round Community Development Programme was launched in the country in Oct. 1952. It was then proposed to establish one Primary Health Centre (PHC) for each community development block; covering population of 80,000 to 1,00,000. Every PHC had three subcentres (SC) having a trained midwife for providing Maternal & Child Health Services. Subsequently, over the last many years the health services organization and infrastructure have undergone extensive changes and expansion in stages following review by a number of expert committees. India became signatory to the Alma Ata declaration of 1978 and committed to attaining the goal of `Health for all' by the year 2000 AD through Primary Health Care. Subsequent to National Health Policy, which was adopted in 1983 the health infrastructure was reorganized to universalize Primary Health Care. While the progress of establishing three tier system of Primary Health Care in terms of establishing subcentres and primary health centres may be viewed as satisfactory but the establishment of community health centres leaves much to be desired. The gap is to be rectified in ninth plan period to ensure development of effective referral system1.

Normative approach was followed to distribute the available manpower of Auxiliary Nurse Midwives (ANMs) to subcentres, as it was impossible to cover the total population. At one stage it was resolved that a sub-centre would cover 10,000 population, an `intensive' area within a radius of 5 km from the subcentre containing some 4,000 people and a "twilight" area with approximately 6,000 people. In the intensive area it was envisaged that female health worker (FHW) would cover the entire `intensive area' in three months time in a cycle of regular home visits to provide MCH & FP services and in the twilight area she would be available on request. Subsequently, national norms for subcenters were evolved and population size for each subcentre was reduced to 5,000 and 3,000 for plain and difficult areas respectively. Similarly, norms for health guides; one per 1000 population and one traditional birth attendant for each village were arrived at. Anganwadi workers were also introduced in the rural and urban slum areas at the scale of one per 1000 population. As a commitment towards universal primary health care in rural areas to make it more accessible and affordable massive infrastructure of subcenters and primary health centre was built up. As on 30th June, 99 we had 1,37,271 functioning subcenters, thus arriving at an average figure of one subcentre for 4,579 population.

The subcentre is the most peripheral village based institution in the three tier system of primary health care. It is the first contact point between the community and Govt. health set-up, as such it has a pivotal role in providing primary health care to the population. Realizing the importance of subcentres, Govt. has given a high priority to them by including the establishment of subcentres under the revised minimum needs programme. It is manned by one Multipurpose Health Worker (Male) and one Multipurpose Health Worker (Female)/ANM as per national norms. These workers are auxiliaries and have basic skills in health and family welfare with background of one and a half year and one-year basic training followed by continuous education and on the job training during service. Majority of subcenters (97,757), out of total 1,37,271 are funded by the Department of Family Welfare and the rest are being funded under the State Minimum Needs Programme/Basic Minimum Services Programme2. The annual recurring cost of running a subcentre is around Rs. 50,000, but the states are being reimbursed far less than half of what they need to run and maintain subcenters3.

The shortfall of male health workers is to the extent of 50% or even more in some areas. This has been cited as one of the reasons for sub-optimal functioning of subcenters and health system1. There is large gap in construction of buildings of subcentres and consequently there are large number of subcenters and PHCs functioning without their own buildings. Cost of construction of these subcenters is enormous. Average cost of construction of one subcentre works out to be Rs. 1.5 lacs. Nearly 50% (65,852) of subcenters have Govt. buildings and the rest function in rented/rent free buildings4. The facility survey data and our own observations reveal that large number of subcenters continue to function in a discarded single room and everything is dumped in that single room. The accommodation of subcenters given by village Community/Panchayati Raj Institutions is seldom adequate and physical facilities tend to be poor or very shabby. Most of the times the shop has to be set up and lifted periodically on the whims of village panchayat. Most of these subcenters are devoid of facilities of water and electricity. Plight of those subcenters which were built by Govt. is not different either. These were built outside the village and are exposed to all kinds of vagaries of theft and vulnerable to floods as also isolated from village population. Maintenance work of these subcenters has been neglected to a great extent. Residential facility of Govt. built subcentre has been rarely used as most of the health workers female do not reside in these centres for reasons of safety. Though subcentre quarters are available but the location is unsafe. Nearly 95% of female health workers commute from nearby town and substantial time goes unproductive on travel alone5. Some of these subcenters are quite inaccessible to women and children. Reach of these subcenters is confined to subcenter village only and the rest of the population and hamlets are difficult to reach through the system of subcenters because of distances and poor transport facilities and bad road conditions.

To enhance the access of subcenter system to difficult areas, where the road communication is poor and areas are remote and population is scattered in hamlets, flexible population norms be adopted for establishing subcenters. Though the Reproductive and Child Health Programme (RCH) has adopted a differential approach for 265 category `C' districts where additional ANMs have been provided to subcenters to ensure better coverage. Additional equipment kits, IUD insertion and ANM kits have also been provided under RCH programme6. The results of this approach are keenly awaited. Data of one year achievement as observed in one district does not reflect enhancement of coverage of services. These additional ANMs have been employed on contract basis and draw fixed salary of Rs. 3847 per month. Essential supplies of medicine and equipments in most of subcenters was found to be adequate as these are being supported by central govt.; however, these are not being put to use. Thus the coverage, spectrum of services as also the quality of services and performance tends to be low or sub-optimal in most situations. Antenatal check-up, abdominal examination, pelvic assessment and copper-T insertion are seldom performed by the health workers female; mostly because of apathy and also due to inadequate skills and lack of space and privacy to perform these functions. Though district training teams have made massive efforts to build the clinical skills of Multipurpose Health Workers (female) but this has not made much impact on the improvement of coverage and quality of services at the level of subcentre. Rapid household surveys for assessment of coverage, quality and client satisfaction undertaken in districts of the country during 1999 revealed that only 11.5% of respondents were visited by ANM during one month prior to survey and the remaining 88.5% were not visited by ANM. With this speed of coverage the ANM would be able to cover only one third of eligible couples in her area in three months time against the requirement of total coverage of eligible couples; through home visits. NFHS-2 also reported distressingly low level (14%) of household visits by health workers in the past one year7. Contacts between the ANM and the women in reproductive age group are thus insufficient and infrequent, hence not enough to establish a relationship of trust and confidence. Adequate information, education and communication becomes the casualty in this process. No wonder then the higher levels (25.34%) of unmet needs of contraception in the community and the lower level of demand generation for contraceptives. Over 80% of deliveries in rural areas in northern states occur in homes and only 5.4% of deliveries are being conducted by ANMs5, though the NFHS-2 reports that close to 42% of deliveries are being attended by health professionals. Similarly, coverage and quality of postnatal care in rural areas and newborn care is quite low. This is due to the fact that MPHW(F) are non-resident and not available for the function of delivery and neonatal care. Traditional birth attendants, bear the burnt of home deliveries and neonatal care. A vast increase in number of trained birth attendants at least two per village as envisaged by National Population Policy is a step in right direction8. Setting up a maternity hut in each village appears to be a wishful thinking at least in northern states where home deliveries are preferred on cultural and socio-economic grounds.

Economic, political and social transition in India has far reaching impact. Devolution of powers to Panchayati Raj Institutions appears to be an important evolution and the process of decentralization of powers has been initiated by many states. Management of subcenters could be entrusted to village Panchayats. Women members of village panchayat have the potential to take the lead. This would offer an opportunity to recruit locally resident ANMs. These ANMs could be chosen from amongst practising birth attendants, anganwadi workers or already trained ANMs or staff nurses. This may solve the long standing problem of MPHW(F) who would belong to the same village and having her own residence and would be fully secured working in her own village. This would save the unit cost of subcentre as residence component of subcentre would no longer be required with this arrangement. Village panchayat should construct subcenters or hire the buildings for the function of subcenters. The cost of construction should be borne by the govt. or else adequate administrative and financial powers including powers of resource mobilization should be given to Panchayats. This task is stupendous but not an impossible one. Experiences of states, which have done so can be utilized to avoid the pitfalls and save time. Village Panchayats can accept public contribution in cash or kind to improve health facilities and services at the level of subcentre. To strengthen the subcenters and to improve the contacts with clients as also coverage of health and family welfare services, these should be linked with Integrated Child Development Services. Joint touring with AWW and helper can enhance the contacts and coverage through effective home visit programme. Similarly, some regular contingency or imprest money (Rs. 100 per month) should be made available to health worker female for minor repairs and purchase of utility material/articles. This money could be generated out of user charges or PRI should bear the cost of such an arrangement.

ANMs don't follow fixed work schedule except for outreach session of immunization. ANMs or subcenters seldom prepare work plan for the area and continue to work on adhoc basis. Spectrum of services and her availability at subcentre is not known to community. Work schedule of subcentre ANM needs to be revised to make it more efficient and relevant to the needs of community. More emphasis should be placed on services for priority clients and young eligible couples between 20-29 years age bracket. Most vulnerable and poor segment of population should have preference over others. Hence visit schedule should focus on priority clients. ANMs should learn the art of organizing and mobilization of community resources and use of existing women groups such as Mahila Mandals, Adolescent girls, Mahila Swasthya Sanghs, Mahila Panch and also other self help groups to enhance the information base and identification of priority clients, antenatals and registration of vital events. Her basic training and on the job training should give her enough opportunity and support to acquire skills of community organization and resource mobilization. ANMs should be chosen out of village workers such as AWW and traditional birth attendants. Adequate promotional avenues and upward mobility for career promotion opportunity be framed in the system to sustain motivation for work and job. Support system such as guidance and supportive supervision and on the job training for community need assessment and her training needs assessment should be the prime focus and work of the designated supervisors. Supervisors should enhance the skills and help guide ANMs in their work plans and segmentation of priority clients. Similarly, monitoring of subcentre facilities to ensure timely repairs of equipment as also replenishment of material/supplies should be the prime concern of supervisors. Referral support system has not been fully developed. Strengthening of referral network between district hospital, the community health centres, the primary health centres and the subcenters needs to be developed to enhance the confidence and raise the status of subcentre team in the community.

ANM's linkages with integrated child development services and anganwadi workers and practising TBAs can streamline her work schedule and enhance her efficiency. Innovations like joint touring, joint training and continuing education, sharing of records and information and a setting up of anganwadi at subcentre under one roof can enhance the work efficiency and each one draws mutual support from each other. ICDS model of team training and team building at village level should be promoted and this innovation has helped us using resources most effectively and efficiently as it avoids duplication and fragmentation of efforts.

The Multipurpose Health Workers (male) have played marginal role in health care delivery system at the level of subcentre. Most of the workload falls on MPHW(F). Distinctive and exclusive jobs performed by male workers consist of active surveillance for malaria, chlorination of wells, contacting and motivating men for contraception and covering floating and migratory population for health problem9,10. Performance level of health worker male tends to be dismally low. The practice of preparing stencils for systematic active surveillance has disappeared, the quality and coverage of surveillance has deteriorated over the years. Preparation of sputum smears in the field situation by MPHW(M) appears to be negligible, hence the rate of detection of tuberculosis quite low.

Male workers at places help bringing supplies for immunization for outreach sessions but they seldom participate in practice of immunization. Similarly, chlorination of well water is not a routine/regular activity with male workers, it is resorted to during outbreak or on pressure from community leaders. Work on environmental sanitation and school health has been a missed opportunity. Physical environments in villages are deteriorating and so is the case with the school system. This is an area where male workers should have played some effective role jointly with other sectors but this continues to be neglected area, getting attention only in the event of some outbreak of disease or high incidence of mortality. The achievements of male health workers in the area of contraception is generally quite low, this is because of poor contacts and inadequate information, education, and communication to priority male clients. Inadequate male participation in family planning is an area of concern for action, as the usage rate of condoms in rural settings is only 1.6%. At most places only half of the required strength of MPHW(M) is available, funds available under additional central assistance for basic minimum services can be used to fill this gap. Disillusioned with their performance and inadequate resources the states are not very enthusiastic to recruit/fill up the positions of MPHW(M). Thus there is precarious situation about the performance of MPHW(M). The situation needs a serious evaluation of work performance and workload of male health worker. Could there be any alternative to this situation?

At subcentre level the health workers are required to maintain large number of registers (thirteen registers) to collect various kinds of information; on villages, households population, eligible couples, service registers for mothers and children, births and deaths, stock and supplies, diseases treated and cases referred etc.11 Considerable time and energy goes into this activity alone to generate monthly performance reports on prescribed formats. It has been observed that the coverage and quality of these records and reports is poor besides being incomplete and inaccurate on many accounts. However, these routine records and reports provide wealth of information at low cost; but the tragedy is that till date any information generated out of this effort is seldom used by the workers for local planning and evaluation of their own performance as also to improve performance. The information on vital events, prevalent diseases and disabilities is seldom shared with community and clients whose life it affects. There is no regular feedback by the managers to the health workers or community and higher formations also are not much enthusiastic to use the available information for district level planning. These records and reports are used to satisfy the requirement of the system. Regular monitoring of facilities, services and improvement of works and workers and their performance should become essential task at all the levels.

Built in system of sector level monitoring of work performance has been used at places for effective planning of work schedule and improve the work performance as also continuing education of subcentre teams. This system has lot many strengths hence should be promoted and supported. Curriculum of basic training of ANMs was evolved way back in seventies (1977) by Nursing Council of India and since then many changes have occurred in the health care delivery system. Imperative need arose to incorporate the suitable changes in the curriculum to make it more relevant and purposeful. Indian Nursing Council revised the course of basic studies of ANMs, however, after reviewing the draft course one gets a feeling that it is quite a heavy dose. Training is primarily hospital based and subject centered12,13. There is imperative need to shift it to community and make it community biased and community based. Content of training should be relevant to health needs and emphasis should shift to learning by doing. Training of trainers is essential for overall management of training and to improve its quality. Trainer should be oriented well to the health conditions in rural settings. Similarly, the job description of multipurpose health worker needs to be revised as these exercises were done way back in 1977-78. The Govt. of India (GOI) publication the Paradigm Shift 1996, formally states the shift in policy, inter alia, this publication states that National Family Welfare Programme moves from target based activity to a Target Free Approach (community needs assessment approach); wherein the emphasis is laid on decentralization (delegating responsibilities) and devolution (delegating authority and funds) to local bodies (Panchayati Raj Institutions and Nagar Palikas). Reproductive and Child Health Programme (RCH) envisages client centered, demand driven quality services programme14. Community needs assessment approach and subcenters action plans have been initiated, but these are much less understood by the health workers, these plans are persued in isolation, without any involvement of people or community leaders or clients. The workbook on decentralized participatory planning in Family Welfare Programme under target free approach is too cumbersome to be followed by workers to assess the service requirement, felt needs and expected service levels for the next year15,16. This needs to be made more practical and realistic. The kind of survey envisaged to assess the needs is beyond the capabilities of ANMs and it has seldom been used. In reality these exercises were being done as part of requirement rather than a blue print for local action and self-introspection and self-assessment. Every year the ritual of household surveys are observed and updated list of eligible couples is prepared just to give one more report or return rather than to act upon it in a planned manner. Community need assessment approach has not yet taken off the ground in many situations. Focus remains on immunization and female sterilization and full range of maternal and child health services and quality aspect of services has not developed at the level of subcentre. Attitude to listen, assess needs, inform and advise clients, are in transition at the most. Accountability of ANMs and the system as a whole continues to the bureaucracy and not to the community and clients, as the pace of devolution has been very slow. Operational research studies need to be mounted in the areas of assessment of the workload of health workers male and female, on the job training mechanism, training needs assessment, continuing education system, supportive supervision, team building and intersectional co-ordination, convergence of service delivery at village level, basic training programme curriculum and quality of training, community needs assessment approach and local planning, meaningful health information system, control of subcentre with PRI, community organization and resource generation for sustainability, improvement of quality and coverage of services, building plans of subcenters, recruitment and deployment of locally resident workers and so on. As the subcentres are the first contact point of community with Primary Health Care delivery system it is imperative to augment the infrastructural facilities in order to improve the coverage and quality of services and utilization of reproductive and child health services. Much more investment is needed in these institutions in order to achieve the desired goals. Panchayati Raj Institution should take more responsibilities and ownership to upgrade these subcentres. System of Primary Health Centers and Community Health Centers should extend adequate support to these institutions to realize their full potentials. Given right kind of support and leadership these centers can accomplish much more to revitalize the base of Primary Health Care in rural areas.

References:

  1. Govt. of India. Ninth Five Year Plan. Thematic issues and sectoral programmes. New Delhi: Planning Commission. 1997-2000; Vol.II: 138-253.
  2. Govt. of India. Bulletin on Rural Health Statistics in India. New Delhi: Rural Health Division, Directorate General of Health Services, 2000.
  3. Measham AR, Heaver RA. Directions in Development, Supplement to India's Family Welfare Programme, Moving to a Reproductive and Child Health Approach. Washington DC: The World Bank; 1996.
  4. Govt. of India. Sixth Conference of Central Council of Health & Family Welfare. New Delhi: Ministry of Health & Family Welfare; 1999.
  5. Lal S, Kapoor S, Vashisht BMS, Punia MS. Coverage and Quality of Maternal and Child Health Services at Subcentre Level. Indian Journal of Community Medicine 2000; 26(1): 16-20.
  6. Govt. of India. Reproductive and Child Health Programme: Schemes for implementation, New Delhi: Ministry of Health & Family Welfare; 1997.
  7. International Institute of Population Sciences. India, National Family Health Survey (NFHS-2) Key Findings. 1999.
  8. Govt. of India. National Population Policy 2000. New Delhi: Ministry of Health & Family Welfare; 2000.
  9. Govt. of India. Manual for Health Worker Male. 1st Edi. Vol 1, New Delhi: Ministry of Health & Family Welfare; 1978.
  10. Govt. of India. Manual for Health Worker Female. 1st Edi. Vol 1, New Delhi: Ministry of Health & Family Welfare; 1978.
  11. Govt. of India. Health Management Information System (version 2.0) Subcentre Registers and Reporting Formats. New Delhi: Ministry of Health & Family Welfare: 1992.
  12. Indian Nursing Council. Syllabi and Regulations for the Courses of studies for Auxiliary Nurse Midwife. New Delhi: Indian Nursing Council; 1977.
  13. Indian Nursing Council. Syllabi and Regulations for the courses of studies for Auxiliary Nurse Midwife. (Revised) New Delhi: Indian Nursing Council; 2000.
  14. Govt. of India. Manual of Decentralized Participatory Planning in Family Welfare Programme. New Delhi: Ministry of Health & Family Welfare; 1996.
  15. Govt. of India. Manual on Community Needs Assessment Approach (Target Free Approach). New Delhi; Ministry of Health & Family Welfare; 1998.
  16. Govt. of India. Decentralized Participatory Planning in Family Welfare Programme under Target Free Approach, Workbook for Subcentre Action Plan. New Delhi: Deptt. of Family Welfare; 1997.

Sunder Lal
Prof. & Head Deptt. of SPM Pt. BDS PGIMS, Rohtak

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