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Rural Health for All
By Anuradha Karmakar, Social Work Intern, CHIRAG, Mumbai

The rural healthcare system is grossly inadequate and unable to provide a minimum level of health care, to a majority of the very poor people in remote rural areas, with only 13% having access to a Primary Health Centre, 9.6 % to a hospital and only 28.3% to a clinic or dispensary. 72% of the total population of 1.21 billion fights a constantly losing battle for survival and good health. 92% of all deaths from communicable diseases occur among the poorest 20% of the population! Infectious diseases and water-borne diseases take a heavy toll of human life among the rural poor. Malnourishment is rampant among children, especially girls and 5% of all rural children (estimated at 1.5 lakh children) die every year due to lack of proper food. About 7415 community health centers per 1 lakh population are needed but our availability is limited to about 50% coverage only. In underdeveloped and tribal areas, there are hardly any dispensaries and health facilities and most remote and poor villages are usually attended by ‘quacks’ and non-licensed medical practitioners.

Despite a National Health Policy formulated in 1983 and updated in 2002, and the Constitution stating that every State should raise the level of nutrition and the standard of living of people besides improvement of public health, among its primary duties, 60 million children in India continue to be undernourished despite a strong economic growth! This compromises our future as the social/cognitive development of 47% of our children is severely hampered and this affects further education and future income-earning capacity, besides ensuring low productivity throughout their lives. Rural hospitals and primary health centers continue to function without necessary staff, equipment or medicines. Lack of roads, drinking water and sanitation are essential infrastructure gaps to be plugged and all this leads to high infant mortality and high maternal mortality rates.

Only 25% of the population has piped drinking water in their homes and 50% of the rural people are forced to defecate in the open due to non-availability of latrines! With falling ground-water levels, contaminated by fertilisers, excessive arsenic, iron and fluoride levels and increased salinity levels, water pollution is a major issue left to be tackled. Public spending on health has actually declined after liberalisation of the economy in 1992, from 1.3% of GDP in 1990 to 0.9% in 1995 (The WHO, Geneva   recommends that every nation spends a minimum of 5% of GDP for health). Only 17% of all health expenses are borne by the Government while the rest is borne by the people.” There are 22,670 primary health centers in rural areas with 8% not having any doctor, 37% without lab technicians and 18% without pharmacists while many of the PHCs have no labour rooms or operation theatres.

A matter of serious concern is the rise of infectious or chronic diseases such as dengue, hepatitis, T. B, malaria pneumonia and many of these diseases have developed a stubborn resistance to drugs. While polio, leprosy, tetanus are being eliminated, inadequate rural infrastructure such as housing, sewerage system, open air defecation, polluted water and a crumbling public health infrastructure, will not be able to improve public health levels. Only 25% of the people have access to allopathic medicines while another 11% have health insurance. The National Rural Health Mission (2005-20012) has been set up to provide health care in 18 deficit States, with poor rural health facilities. The four major Southern states have set up excellent schemes for meeting health insurance expenses of poor people. Now, telemedicine centers are being opened to provide care to patients at centers connected by satellite to well-known hospitals, Better hospitals, nursing homes and diagnostic centers are needed. The quality of Indian health-care can be assessed from the data below:

Description Hospital Beds per Thousand population Doctors per thousand population Nurses per thousand population
Low Income Countries
(Sub Sahara Africa etc)
Middle Income Countries
(China, Korea, Brazil)
4.3 1.8
High Income Countries
(USA, Western Europe, Japan)
7.4 1.8
World Average 3.3 1.5
Source: Health Infrastructure, 2001

Health Infrastructure in India
However, over 65 years after Independence, life expectancy in India has increased from 50 to 64.The rural health network comprises of 1.16 lakh sub-centers (with average staff at 1.27), 22,975 Primary Health Centers (24,000 doctors), 2935 Community Health Centers (35000 specialists), 22,000 dispensaries and2800 hospitals for Ayurvedic and Unani medicines are set up, besides 6 lakh Anganwadis for children and expectant mothers. But there are only 0.9 nurses per 1000 population, 1.5 hospital beds per 1000 population and only 0.5 doctors per 1000 population and these numbers reveal the wholly inadequate and inferior health care infrastructure in rural India.

And with rising medical expenses, it has been indicated that about 4 crores of our population are impoverished annually, due to unavoidable health spending for serious diseases. Some states like Karnataka, T.N, A.P, Kerala and Maharashtra have provided health insurance for the poor at nominal charges (Rs. 100 per person per year) and these have been very successful as these schemes have actually benefitted the rural poor. Despite an advanced pharmaceutical industry, fake medicines and fake doctors continue to create havoc in the lives of the poor suffering people. One of the great decisions taken by the Medical Council of India has been to permit the 3.5 year s medical course which will enable licensed doctors to practice in rural areas.

Over the years the rural health care system that has evolved, is a 3-tier system with a sub-centre as the primary focal point of interaction while the Primary Health Centre (PHC) caters to 6 sub-centres, while the Community Health Centre is the apex for 4 PHCs. The norms for population and services are as under:

Facilities Pop. Norm Services Min. Staff
Sub-Centre 3000-5000 most peripheral contact point 1 Health Worker(Female) Or Aux. Nurse+1 HW (Male)
PHC 20000-30000 4-6 beds hospital +drugs 1Medical Officer (MO) + 14 sub-para-medical staff
CHC 80000-120000 30 bed hospital 4 M.Os, Operating Theater, X- ray, labour room + lab.

The coverage of the Rural Health System is grossly inadequate as about 25% of the centres are operating from rented buildings, suffer from infrastructural constraints, shortage of drugs and medicines and equipment, 75% shortage of doctors, and 10-25% shortage of other staff. The poor coverage of health facilities in tribal areas and poor under-developed districts is pathetic especially as due to poor communications and lack of roads and bridges, many patients die en-route to hospital before any medical aid can be made available. In Districts like Kalahandi and Bastar and in Naxalite-affected districts, Doctors and other medical staff rarely are available on-site, along with Teachers.

Facilities Pop. Covered Area Covered Avg. Dist. In Kms. Villages No.
Sub-Centre 5624
21.05 2.59 4
PHC 34876 130.54 6.44 27
CHC 173235 648.43
14.36 133

The progress of creating adequate health infrastructure in rural areas has been taken up but the rapid population increase has ensured that remote rural areas remain inadequately served. The growth of rural health infrastructure ensured that the 84376 Sub-Centres at end-1985 had increased to 148124 by end-2011 while the 9115 Primary Health Centres had increased to 23887 by end-2011 and the 761 Community Health Centres had increased to 4809 by end-2011.But this system is inadequate due to the massive population increase and poor health and hygiene standards in poor rural areas. Health for all is not easily feasible.

Strengthening Rural Health Infrastructure: The National Rural Health Mission
The National Rural Health Mission (2005-12) sought to provide effective healthcare to rural people throughout the country with special focus on 18 states, which had weak public health indicators and/or weak infrastructure. These 18 States are Arunachal Pradesh, Assam, Bihar, Chhattisgarh, Himachal Pradesh, Jharkhand, Jammu & Kashmir, Manipur, Mizoram, Meghalaya, Madhya Pradesh, Nagaland, Orissa, Rajasthan, Sikkim, Tripura, Uttarakhand and Uttar Pradesh. The Mission was an articulation of the commitment of the Government to increase public spending on Health from 0.9% of GDP to 2-3% of GDP.  NRHM aimed at undertaking architectural correction of the health system to enable it to effectively handle increased allocations as promised under the National Common Minimum Program and promote policies that strengthened public health management and service delivery in the country. It had as its key components provision of a female health activist in each village; a village health plan prepared through a local team headed by the Health & Sanitation Committee of the Panchayat; strengthening of the rural hospitals for effective curative care and made measurable and accountable to the community through Indian Public Health Standards (IPHS); integration of vertical Health & Family Welfare Programs, optimal utilisation of funds & infrastructure, and strengthening delivery of primary healthcare. It seeks to revitalise local health traditions and mainstream AYUSH into the public health system. Effective integration of health concerns with health determinants like hygiene, sanitation, nutrition and safe drinking water, are being taken up. Decentralisation of health programs at the district level especially in the 18 priority states is being fast-tracked so as to enable women and children to access health facilities and primary
health care. But the efforts made are grossly inadequate especially in the BIMARU states and & NE states and hilly states of J and K, HP and Uttarakhand. There is need for civil society organisations to supplement Government efforts and work jointly with the district administration to provide timely, affordable and adequate health care facilities to the very poor rural people.

Inadequate Health Coverage for Rural Women
Rural women play a key role in supporting their households and communities in achieving food and nutrition security, generating income, and improving rural livelihoods and overall well-being. They contribute to agriculture and rural enterprises and fuel local and global economies. As such, they are active players in achieving the MDGs. Yet, every day, around the world, rural women and girls face persistent structural constraints that prevent them from fully enjoying their human rights and hamper their efforts to improve their lives as well as those of others around them. In this sense, they are also an important target group for the MDGs. Over the years development planning in India has focused on reducing the burden of illness and mortality among women and children. A large number of development and public health programs such as the Integrated Child Development Services (ICDS) have been geared towards this, since a long time. India is committed to achieve the Millennium Development Goals, particularly with respect to maternal and child health. Awareness generation is a major responsibility and fundamental importance, to ensure utilisation of various healthcare programs implemented by Government.

Innovations in ICT–enabled Healthcare
It is necessary to promote better appreciation of the stakeholders in interdisciplinary and team-based IT-enabled healthcare projects for underserved rural communities and the need for development of a shared understanding among the Government, professional organisations, the Health Information Technology (HIT) industry, academic institutions, policy bodies, hospital and funding agencies. To realise HIT's benefits, all cohorts must work together. The challenges of providing care in rural areas especially for women in underserved rural areas can be partially overcome by enhancing the number of nurses and using technology innovations to help improve health in these areas. Finally there is a need for changes in nursing practice, policy, funding, and education to better prepare nurses to assume leadership roles in the design, implementation, and evaluation of HIT-enabled care in underserved rural areas.

Health care in rural India is highly fragmented, too often unsafe, and infrequently absent as there are inadequate doctors and nurses in Primary Health Centres and District Hospitals. In rural communities, the severe shortage of healthcare providers highlights these problems. About 70% of the population lives in rural areas, but only 9% of physicians practice there. Nevertheless, the most acute rural healthcare workforce shortage involves non-physician providers, including nurses, dentists, and technicians and hospitals in underserved rural areas often have higher workloads, cover large geographic areas, have lower access to specialists, encounter problems in recruiting and retaining clinical staff, and treat a broad array of very poor patients most of whom cannot afford any health-care. Rural healthcare shortages should come as no surprise, given the lower pay, lack of educational and training opportunities, high turnover rates, and isolation with often large distances to acute care facilities and specialists. Although the cost of living in rural areas may be lower, patients in these areas are typically destitute and have less access to transportation. They also have lower levels of education, poorer housing, higher poverty rates, poorer health, and more disabilities than their urban counterparts.

The current rural workforce crisis, coupled with the persistent decline in the production of family medicine physicians, creates a mandate for healthcare planners to design and implement new, technology-oriented collaborative models for interdisciplinary care delivery. The ability of such models to improve care and reduce staff attrition will depend on the effective use of HIT and Information and Communication Technologies (ICT). However, to realise the benefits of HIT, competent software providers must drive development and use and the use of low-cost, computerised hardware has to be encouraged. Given the requirement for more technologically competent midlevel providers, educators need to create new professional roles, opportunities, and expectations within the medical and especially the nursing profession. In part because nurses, nurse practitioners and other midlevel providers already comprise a significant proportion of the rural health care labour force, maximising their roles in new HIT-enabled delivery models, is both prudent and overdue.

The nursing shortage, the low informatics competency of the healthcare workforce and the low penetration of HIT in underserved communities, comprise barriers to achieving these goals. To overcome the barriers requires competent medical leaders who can envision how technology can best support care management. Those leaders also must guide the interdisciplinary effort needed to deliver IT solutions for the underserved. Improving health and health care in underserved rural communities is a complex issue that will require system-wide solutions and attention to social determinants of health. Focusing on solitary issues in rural health care (e.g., use of Health Information Technology packages) without addressing the systems and context in which the issues occur will impede rather than enhance the ability to improve health. The challenges to providing effective health care in underserved rural communities are huge, but not are manageable. Changing the rural medical scenario will require new ways of thinking, innovative technologies, removal of inter-professional barriers, and more investments.

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