A Case Study
Munsiyari is a remote tehsil located in district Pithoragarh of hill-state Uttarakhand in India. Situated at an elevation of about 2,200 meters (7,200 ft), it is extremely daunting place for ailing patients when it comes to trauma and speciality care. The village has just one community health centre (CHC) which lacks even the primary healthcare facilities. The centre is a morbid place with no operating theater, X-ray, labor room and well-equipped pathological laboratory. It also doesn’t meet the prerequisite of 30-beds prescribed by NHRM. There are no sub-centres (SC) in the far-flung areas of the village and the villagers who require speciality care flock towards nearest towns Pitthogarh and Nainital.
Dr. Manish Maurya is Director Orthopedics and Joint Replacement and Arthroscopic Surgeon providing his services at Central Hospital in the nearby town Haldwani. He along with his hospital’s team organizes chargeless health camps bi-annually in the distant villages of Kumaon hills such as Champawat, Munsiyari, Pitthogarh, Kotabagh etc with no aid from the state government. He confesses that these villages don’t have tertiary care centres. He further adds that in the absence of tertiary care centres, it would be difficult to induct specialists for villagers because every speciality doctor requires equipments and facilities such as ICU, ECG, MRI etc to treat his or her patients.
He finally resolves, “We organized a camp in December 2016 in Munsiyari. It had snowed that day and the air was frosty cold. We had expected very few patients but approximately 800-900 patients came that day. The patients there can’t afford the specialist treatment and hence are dependent on medicines. Cold-related ailments like osteoarthritis, bronchitis, asthma, and neurological disorders are rampant there. Almost 100 patients in each camp suffer from neurological disorders while approximately 150 patients suffer from osteoarthritis.”
Indian independence has now witnessed seven decades. Several proposals, plans, and reports have been presented that emphasize the significance of rural health in India but it still continues to be a predicament despite enormous economic growth. Even the slogans of WHO such as ‘Health for All’ and ‘Universal Health Care’ have not substantiated on the ground. The accessibility of health care centres and availability of facilities is apathetic in rural areas. Dr. (Prof) Anant Kumar, Chairman, Max Healthcare, Department of Urology, reclaims, “There is a need to change the entire infrastructure of rural healthcare. There should be good hospitals in the form of CHCs in which specialist doctors and well-equipped pathological labs should be readily available so that doctors practising there can provide good services.”
Problems and Areas of Improvement
It is observed that almost 70% of Indian population doesn’t have accessibility to specialist health services since 80% of specialist doctors live in urban areas. National Family Health Survey (NFHS-II) states that only 13% of the rural population has access to primary health care, 33% to sub-center and 9.6% to a hospital. According to the 10th Common Review Mission under NHRM, communicable diseases continue to be a major public health problem in India. But, consistent decline in malaria incidents has been observed, with a 40.8% decline in malaria-related deaths. Dr. Sonam D Bhaduri, renowned medical writer reinforces, “Not only has unregulated commercialisation and privatisation made quality healthcare a prerogative of the rich, it has also severely curtailed the inflow of resources (including doctors) into the rural healthcare sector. It lacks not only human resources but also essential infrastructure, a credible referral system, and an effective healthcare manpower policy.”
Few such obstacles in the way of development of rural health in India are listed in the table below:
| Hurdles in Rural Healthcare | What the situation on the ground is? | What do statistics say? |
| Deficient Infrastructure | Most of the primary health-care centers in rural areas run without basic life-saving infrastructure, essential medicines, therapeutic or diagnostic equipments, and ambulatory services. The lack of basic amenities like electricity and potable water makes the situation worse.
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According to the report of the Working Group on National Rural Health Mission (NRHM) for the Twelfth Five Year Plan (2012-2017), from the sanctioned facilities 38% of sub-centres are not in a government building, and 13% of PHCs and 3% of CHCs are not in their own building.
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| Underutilization of peripheral centres | While peripheral health care centres are underutilized, the secondary and tertiary (District) level facilities are overloaded with patients since diseases are not diagnosed at lower level health care centres (PHCs and CHCs).
Peripheral centres are underutilized due to varied factors such as quality, lack of specialized human resource, affordability, poor supervising, and lack of community ownership.
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According to Health and Family Welfare – Statistical Year Book India 2017, there were 5,500 CHCs and 25,354 PHCs and 1,55069 sub-centres all across India but due to lack of resources majority of the rural population is deprived of basic healthcare.
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| The inability of rural staff to handle healthcare | The deficiency of specialists in rural healthcare is as high as more than 90 per cent in Chhattisgarh, Jharkhand, and Rajasthan, while being at nearly 86 per cent in Uttarakhand, and Odisha. | The annual report by the Department of Health and Family Welfare (2016-17) states that there was an enormous shortage of human resources in the rural and public healthcare arena. National Health Mission (NHM) had therefore recruited 7,363 General Duty Medical Officers (GDMOs), 3,308 specialists, 70,674 auxiliary nurse midwife (ANMs), and 36,383 staff nurses. |
Infrastructural facilities planned/constructed in 2016-17
Source: Chapter 2, Annual Report of Department of Health and Family Welfare 2016-17
| Facility | New Construction(Sanctioned) | Completed | Upgradation(Sanctioned) | Completed |
| SC | 26613 | 17871 | 15850 | 14071 |
| PHC | 2139 | 1534 | 9517 | 8673 |
| CHC | 554 | 401 | 3770 | 2895 |
| SDH | 101 | 59 | 677 | 626 |
| DH | 92 | 58 | 1137 | 937 |
| Other | 1646 | 886 | 940 | 690 |
| Total | 31145 | 20809 | 31891 | 27892 |
Models of Governance in Rural Healthcare Delivery
Community Health Centre: A 30-bedded hospital/referral unit for 4 PHCs with specialised health services; should be manned by 4 medical specialists namely surgeon, physician, gynaecologist and pediatrician.
Primary Health Centre: A referral unit for 4-6 sub-centres; manned with Medical Officer in-charge and 14 subordinate paramedical staff; equipped with specialised health services.
Sub-centre : Most peripheral point of contact of community with the primary health care system; manned with one multi-purpose worker MPW(M) and one MPW(F).
How can students contribute to rural healthcare?
Undergraduate medical students organize medical fairs and health camps under the supervision of trained physicians. Patients in such health camps meet medical students first who first determine health service a patient should receive and diagnose the ailment. After conducting all tests, patients are provided health education and referral. This reduces the cost for clinics in rural areas and workload of patients on trained physicians.
The nursing and paramedical staff is fairly well equipped and can conduct various medical procedures like mid-wifery, vaccinations, deliveries, first aid, and treating primary infections like cough, cold and fever. They can also perform small interventional surgeries like removing foreign bodies from external organs like eyes and nose. Hence, at primary level they act as full-fledged doctors taking care of every ground level requirement and ailments of villagers at the primary level.
Dr Richika Sahay Shukla adds, “In the initial years of my practice, I have worked for rural areas such as in Rewari, Nooh, and Taoru in Haryana to tribal areas of Jharkhand. People there don’t have even basic healthcare facilities. Specialists doctors should be posted there only if they have CHCs have proper facilities. Basic healthcare can hence be taken care by a general practitioner or paramedical staff.”
Administrative Reforms
Development of RURBAN Townships
RURBAN townships should be established in nearby developing villages which can accommodate healthcare professionals meant for PHCs and CHCs in a village. A concept of model group housing at PHC/block level should be considered not only for speciality medical practitioners meant for an area but also for government employees. Dr. Vinay Agarwal, Former President, Indian Medical Association proclaims, “Opening of RURBAN townships in far-flung areas can prove to be a good step towards improving rural healthcare in India. Moreover, new medical colleges should also be opened in such areas which are already deprived of such colleges. Instead of providing marks for serving in the rural areas, students should be incentivized during the practice as well as it should be made mandatory for them to compulsorily visit the PHCs and CHCs of such townships for at least one hour on daily basis.”
Establishment of First Referral Units
The model group housing should also contain a first referral unit (FRU) consisting of basic specialists such as an anesthesiologist, gynaecologist, surgeon, and paediatrician. ICU and a well-equipped pathological lab should also be a part of it. The primary healthcare physicians should be allowed to conduct OPDs, National health programmes, or a health camp for nearby villages every day. Dr. Sudhir Seth, Director and Orthopaedic Surgeon at Ortho Point, and former alumni of Maulana Azad Medical College says, “Every specialist or super-specialist should be provided all the facilities he or she requires at First Referral Unit(FRUs). If red-tapism is not there and facilities are proper, specialists will be encouraged to work in such areas”
Involvement of Other Bodies
The sub-centres in deep recesses of villages should be well-connected to FRU. This can be facilitated by the ASHA worker or the in charge, who could be one from the AYUSH staff. If AYUSH staff is trained for national health programmes, they can help in identifying emergencies which can thereby reduce Infant Mortality Rate (IMR); Measles, Mumps, and Rubella (MMR) and IFR. The ‘electronically’ proposed instant health advice by NIDAN would improve the standard of rural healthcare. Dr. Manish Maurya, Joint Replacement and Arthroscopic Surgeon, Central Hospital, Haldwani adds, “Tertiary care centres are not available in peripheral areas. Most of the health services are provided at PHCs in these areas. If the government posts specialized doctors in these areas, he or she would not be able to provide medication to most of the villagers. Hence, a general physician along with a good number of paramedical staff should be posted at PHCs. These centres should be further well-connected to bodies like AYUSH, NIDAN etc”
While innovative solutions can empower the existing rural health care infrastructure, a grand initiative from a determined government can surgically improve the ailing health care system in remote hinterlands of India. Concrete measures on the ground can also make this system affordable for the poor, deprived, and sick population. Hence, rural health care delivery is still at the crossroads of guidelines issued in proposals and the implementation on the ground.
