P7: And if you go there, get the (case) paper issued...then wait in line...even then they don't treat properly, don't touch us, they just give the medicine and ask us to go. (Community discussion, Mixed gender group, Location: Far from district head-quarters (>60 km), primary health center in the same village as place of discussion, center more than 10 years old).
"Once there was a drunk man...came in demanding I give him IV at once since his hands and legs are paining. Was shouting here -standing right where you are...Gets angry because I gave the IV line to the other patients. I have only limited IV lines- and others are also patients...how can we attend to everyone in a fast way" (Nurse, 25 years, Female, experience-5 years)
Out-patient care gets low preference-within target-oriented structures
The primary health centers' biggest role is in national program...because of the national program and their targets, there is less focus on the OPD...there are a lot of targets...conduct deliveries...do vaccination...then all new programs have their own targets. (Medical Officer, Male, 39 years, experience-12 years).
Risk-averse behaviours and poor referral practices deter its function as a 'link' to higher tiers.
Our senior used to tell us 'if you want to take a risk, then you do it elsewhere ....if you want to play, then do it only if you have the guts...if you want to play, do it elsewhere or in your private practice....not in the primary health centre...nothing happens here and don't try to change things... Also, the issue is that if there is some issue...even a tiny issue, at least five journalists will turn up here...and we have to answer them...and they will dramatise the episode.' (Medical Officer, Male, 33 years, experience-9 years).
In short, most doctors are not happy at primary health centres; and said that they would prefer private sector jobs, that were regarded as more lucrative, or express a preference for working at higher tiers of the public health system:where the clinical work is perceived as more challenging. In the region, we collected empirical data from, many posts for second doctors at primary health centres are vacant:in a desperate attempt to fill these posts the government has enforced a compulsory 1-year stint at primary health centres for new medical graduates. The graduates we interviewed do not plan to stay on beyond completion of this stint.
The community views and evaluates primary health centres like any other curative health facility on the basis of OPD services (and some inpatient services). Community expectations are clearly centred around these centres being good, primary-level curative care facilities:dispensing a variety of free drugs and treatments:and most centres could not live up to these expectations. First, primary health centres, designed under the ethos of 'selective care', offer a very narrow range of curative health services:and have only a few generic drugs available. The community feels that these centres dispensed the 'same medicines for all diseases'; and even those medicines were not given at times due to stock-outs (see box 2). Second, these centres function mostly from a 'rational clinical care' perspective; and do not cater to demands for 'instant relief' by the community. Hence, the treatment offered by primary health centres is often in contrast to those offered by local private practitioners. These practitioners, not bound by the strict regulations that government doctors had to adhere to, cater to 'mass appeal':by administering strong drug combinations that provide instant relief, and intravenous rehydration therapies as per the patients' demand (even when these treatments were clinically irrational). These practices set a different set of expectations in the community about primary-level care:which primary health centres could not address. In addition, strained community-provider relationships (described in the next section) adversely affect people's opinions of these centres. All these factors together make the local private practitioner the first access point to primary-level curative care. Primary health centres today, are, at best, accessed for select services such as immunisation, family planning, for antidotes to animal bites and treatment of certain diseases like tuberculosis and malaria.
A common community complaint is the lack of 'attention' given to them at primary health centres. Attention appears to comprise (1) the doctor taking time to understand the issues, (2) doctor using the stethoscope and touching the patient during the interaction, (3) support staff who speak politely and follow doctors' instructions and (4) the prescription of strong medicines. All this, the community feels, does not happen in most primary health centres (see box 2).
Doctors' notions of attention are different from those of communities. For one, most doctors do not believe that the type of ailments people came with to primary health centres require more than a quick appraisal. This quick appraisal and the small window of contact with the doctor sometimes has adverse consequences. For instance, one patient we met:who reported throat pain:had not informed the doctor at the centre of her prior visits to a specialist who suspected throat cancer. When asked why she did not share this information, her answer was that the doctor never asked. She also suspected the doctor of pocketing throat-related medication from the centre. This case is also an example of suspicious attitudes of the community towards primary health centre staff. Indeed, the community, in general, has poor views about all public institutions as well as employees who work at these institutions (It must be noted that though people relied on local private practitioners for first access, the community had developed a sense of wariness about these practitioners; people believed that private practitioners were sometimes money-minded, had tie-ups with drug stores and prescribed unnecessary and costly medicines).
The wariness of the community towards the staff is not a one-sided phenomenon. Primary health centre doctors express frustration over patients who demanded drugs like cough syrups and intravenous rehydration:despite having no clinical need. Nurses and laboratory technicians report of people fighting with them over the non-arrival of laboratory reports or unwillingness to wait in the line for their turn (see box 2). In summary, mutual wariness between the community and staff at primary health centres deters a trust relationship, essential to the provision of good primary-level care.
The biggest contribution of primary health centres within the health system is perceived:by almost all health system staff:to be in operationalising vertical programme and schemes (see box 2). This perception stems from a complex interaction of factors:including strict targets set within the system for vertical programme; and targets which the staff feel compelled to complete because they are held accountable only for these within bureaucratic work environments. Staff express more concerns on how they 'report' the schemes:rather than how they carry out activities under various schemes. Also, activities whose targets (numbers) are checked less frequently by higher level managers get less attention. Within such target-oriented vertical structures, there is little support and encouragement for activities:like the OPD:from the authorities. While two OPDs are mandated in a day, it is an accepted practice to conduct only one. In short, basic curative care at primary health centres has been side lined; this fact, exacerbated by the lack of drugs and equipment, in an environment of mutual wariness between the community and health staff, has made poor quality OPDs a harsh reality at these centres.
Doctors perceive themselves as 'professionally isolated' at primary health centres and in practice-feel delinked from the referral tiers. They express concerns about having to deal with consequences of adverse events (such as a death or a mishap) with no peer support. This isolation, combined with drug-stock outs and lack of equipment/diagnostics, has led to 'risk-averse' behaviour among doctors, resulting in an increased number of referrals from primary health centres than necessary from a clinical angle (see box 2).
Health staff at primary health centres do not see the referral tiers as 'support' to their work: when cases were referred, they see this as passing on the legitimate clinical work of the higher tiers. This 'referral' is not perceived as making any difference to the goals of the centres:whose work is viewed as that of programme operation. Hence, staff do not think of it as their duty to follow up on referred cases (The exception to this was delivery. In Maharashtra, recent efforts have been made to strengthen ambulance linkages between the primary health centres and the higher tiers- to ensure that referral during delivery was timely. The primary health centre was held accountable for such referrals).
Consequently, instead of becoming an integral link in a referral system, primary health centres have become institutes for 'preventive' issues and 'programmes' that refer even primary-level cases. Hence, these are thought of as 'too basic' and places that 'can't really do much'. Disparaging attitudes towards primary health centres are encountered in conversations with almost all health staff, but most explicit among doctors and administrators.
A summary of the micro context is presented in table 2.