Primary care facilities in India are not well prepared to provide high-quality obstetric and newborn care, and facility capacity is worst in States with the worst health outcomes, a latest study has said.

The Indian government will need to increase investment in the health system, in providers and in research to harness the full benefit of its public health infrastructure. Research on regionalisation is a priority as this may offer an innovative approach to ensuring quality services for mothers and newborns, according to the study “Can IndiaÂs primary care facilities deliver? A cross-sectional assessment of the Indian public health systemÂs capacity for basic delivery and newborn servicesÂÂ by Jigyasa Sharma, Devaki Nambiar and others.

The impact of regionalisation strategies on facility overcrowding, performance incentive structures for front-line workers, as well as equity in service access should be important considerations of such research.

Over the past decade, IndiaÂs health system has operated in an extremely resource-constrained environment: from 2004 to 2014, government health expenditure has remained approximately around 1% of countryÂs gross domestic product. 

ÂImproving quality of care and strengthening public health infrastructure is integral to IndiaÂs path to universal health coverage: without an explicit focus on quality, a push towards universal coverage is unlikely to lead to better health for mothers and newborns.ÂÂ The study says.

The aim of the study was to assess input and process capacity for basic delivery and newborn care in the Indian public health system and to describe differences in facility capacity between rural and urban areas and across States.

The researchers used data from the nationally representative 2012Â2014 District Level Household and Facility Survey, which includes a census of community health centres (CHC) and sample of primary health centres (PHC) across 30 States and Union Territories in India. It covered 8536 Primary Health Centres and 4810 Community Health Centres.

About 30% of PHCs and 5% of CHCs reported not offering any intrapartum care. Among those offering services, volumes were low. Both PHCs and CHCs failed to meet the national standards for basic intrapartum care capacity. While in CHCs, capacity was slightly higher in urban areas, gaps were most striking in availability of skilled human resources and emergency obstetric services. Poor capacity facilities were more concentrated in the more impoverished states, with 37% of districts from these States receiving scores in the lowest third of the facility capacity index.

Improving maternal and newborn health outcomes will require focused attention to quality measurement, accountability mechanisms and quality improvement. Policies to address deficits in skilled providers and emergency service availability are urgently required, the study has said.

Increased coverage of facility-based births has not successfully translated to desired improvement in health outcomes for mothers and newborns. Under IndiaÂs National Rural Health Mission (NRHM, now called the National Health Mission or NHM), a variety of interventions were introduced through architectural improvements in the fund flow and design of services: increased number of maternal care facilities, particularly primary health centres (PHC) and community health centres (CHC); a strengthened supply chain for essential medicines, equipment and supplies; and Janani Suraksha Yojana, a financial incentive programme to increase institutional deliveries.

Following the launch of NRHM in 2005, institutional deliveries in rural areas have more than doubled, and a declining trend in maternal and newborn mortality has been noted, although strong causal evidence linking NRHM efforts to improved health outcomes for mothers and newborns is lacking. Annual decline in neonatal mortality between 2005 and 2015 was faster than in the preceding years; however, the rate of decline is not sufficient to meet the 2030 SDG targets. Inadequate quality of care, including insufficient facility readiness, and low provider skill and clinical management capacity, as evidence from low/middle-income countries (LMIC) indicates, may explain why increased utilisation alone may not have resulted in the desired reduction in adverse intrapartum outcomes. Moreover, quality of care itself also affects utilisation.

Evidence indicates that the availability of a labour room and adequacy of essential equipment and laboratory services for childbirth at public health facilities have a significant effect on service uptake. Describing and improving quality of intrapartum care is relevant to increasing service uptake in India, where maternal and newborn services are underused despite the availability of primary healthcare in public health facilities free of charge, the study has said.

Public health facilities are a significant provider of care in India, especially for rural and vulnerable population segments. About 80.1% of all deliveries in rural India are facility based, of which about 70% are in public facilities. For urban areas, 89.5% of births are institutional, 47.4% of which are in public facilities. In the majority of IndiaÂs States, more facility-based deliveries happen at government health institutions than in private facilities. Additionally, quality of care in the public sector affects the poorest segment of the population the most, as the poorest wealth quintile is more heavily reliant on public health facilities than the richest, in both rural (58% vs 29%) and urban areas (48% vs 19%).