ABSTRACT
The Tamil Nadu model of public health is renowned for its success in providing quality health services at an affordable cost, especially to the rural people. This study attempts to throw light on the significance of strengthening the primary healthcare system, reducing barriers to accessing primary care, and, thereby, reducing the financial burden on those (especially the poor) who seek care from public primary healthcare facilities, namely, through health sub-centres. This chapter discusses a pilot initiative by the Tamil Nadu government to strengthen the health sub-centres at the lowest level of health service delivery, as a step towards providing comprehensive primary healthcare (CPHC) and achieving universal healthcare (UHC). Started in 2016–2017 in three blocks in the state, this initiative preceded the launch of the health and wellness centres (HWCs) by the government of India in 2018. This chapter is mainly based on three primary surveys carried out in the three pilot blocks. First was a baseline survey before introduction of the strengthening of the health sub-centres; the second primary survey was carried out as a month-by-month follow-up of the footfall in 67 health sub-centres spread across these three pilot blocks. An analysis of the utilisation of these sub-centres and the health-seeking behaviour of those who utilised these sub-centres was supplemented by another primary household survey of residents from 25 habitations (villages) administratively under these health sub-centres. The household surveys also collected information on out-of-pocket expenses for various health services availed from private and public facilities. This chapter also incorporates results of another (third) primary survey of health sub-centres and households in the districts of Cuddalore and Virudhunagar, carried out to evaluate the impact of the strengthening of sub-centres in the blocks where the HWC scheme was implemented (UHC blocks) and compare the results with non-UHC blocks during the year 2022.
Outcome: The outcome of the strengthening of the sub-centres in the pilot blocks, studied and documented by rigorous field visits, showed that there was a significant improvement in access to primary care at sub-centre level, reducing the overall dependence on private providers and a substantial fall in out-of-pocket expenditure (OOPE) for the users. This HWC model developed by the state underwent many design changes due to changing political priorities and the directives of the central government. Moreover, the provision of primary healthcare in the field was significantly affected by the COVID-19 pandemic of 2020–2022. When the effectiveness of the HWCs in delivering services to the people and their contribution to improving access and reducing OOPE were studied in two districts in 2022, the results showed a positive impact of the HWCs in the provision of UHC, although the results were not uniform. The study concluded that by increasing the awareness of people about the HWCs, providing the necessary infrastructure and drugs, building a population-based registry, and linking the state government scheme for door delivery of drugs to the HWCs fully, there was potential to improve the performance of the HWCs further.
