Health Care Of Rural India- An essay

It makes me wonder how eligible I am with the mere knowledge for a 10 mark question from the chapters of Community Medicine, having visited an ENT surgeon for a small furuncle and the Dermatologist for acne under insurance coverage this morning to speak of the poverty my country is struck with, complex issues which affects the lives of millions, whom I might never encounter in my whole life and yet have an impact on mine.

While adopting the Constitution on January 26, 1950, we, the people of India, dedicated ourselves to the creation of a new social order based on equality, freedom, justice and the dignity of the individual and, to the end, decided to eliminate poverty, ignorance and ill-health.

They say India has a national health policy but doesn’t have a national health service. The first part of the statement, I understand through a look at my 800 odd paged Park’s textbook of Preventive and Social medicine. The latter part, anybody would agree when they take a stroll down Dharvi, one of the worst hit slums of the alpha world city- Mumbai or a far flung off village in Bihar where people still die off Diarrhea.

As may be easily anticipated, the overall picture of the current health care is a mixture of light and shade, of some outstanding achievements whose effect is unfortunately more than offset by grave failures.

India stands at 134th position in the UN Human Development Index. When it comes to healthcare or for that matter anything, there are two Indias: One India that provides high-quality medical care to middle-class Indians and medical tourists, and the other in which the majority of the population lives—a country whose residents have limited or no access to quality care. Nearly 74% of the rural population doesn’t enjoy all the benefits of modern curative and preventive health services. Also, 73.6% of the doctors are concentrated in the urban areas and a mere 26.4% in the rural areas where a near 75% of the population lives. Not only does the wide variation exist between the rural and the urban but also the geographical distribution of hospitals vary according to local socioeconomic conditions all across the country with a wide gap between Uttar Pradesh and Kerala.

‘Health by the people, placing people’s health in people’s hands.’

Primary Health care is considered one of the greatest milestones in the history of health care in India, the very basic roots of survival for millions. The building of PHCs- the 1^st level of contact, constitute the fundamental requirement of a sound referral system and the realization of ‘Health For All’. 

One driver of growth in the healthcare sector is India’s booming population, currently 1.1 billion and increasing at a 2% annual rate. India will surpass China by 2030 and by 2050, the population is projected to reach 1.6 billion.

Figures from Rural Health Statistics reveal some startling trends. Sub-Centers, Primary Health Centers and Community Health Centers — the bedrock of rural health delivery — have grown in absolute numbers since Independence: From 725 in 1951 to 57,353 in 1981 to 1,71,687 as of March 2007. They remain the backbone of rural health-care in the absence of private sector presence.

‘Rural health care in India faces a crisis unmatched by any other sector of the economy’. - Arvind Panagariya, The Economic Times.

 Besides tremendous progress, not all Health statistics are healthy for rural India. Considering the limited facilities available in a sub-centre, 50% of the sanctioned posts of Specialists at CHCs remaining vacant, run-down infrastructure, poor supply of drugs and equipment, illegal selling of the public welfare supplies and soaring rates of chronic employee absenteeism, commission practices that exist between the rural unqualified doctors and the doctors from the health institutions in the nearest cities or the district heads; quality health-care remains a mirage for much of rural India. There is no healthy Comparison of this with the hospital (public and private) beds available in the urban areas, which are greatly uneven. While the rural poor are underserved, at least they can access the limited number of government-support medical facilities that are available to them. The urban poor fare even worse in terms of primary health care and they cannot afford to visit the private facilities that thrive in India’s cities. 

The launch of National Rural Health Mission [NRHM] 2005-2012 is a giant in the creation of a national service whose need was conceived almost 30 years before; aims to provide effective healthcare to India’s rural population, with a focus on 18 states that have low public health indicators and inadequate infrastructure. Through the mission, the government is working to increase the capabilities of primary medical facilities in rural areas through Accredited Social Health Activists (ASHA) and Link Workers and ease the burden on tertiary care centers in the cities, by providing equipment and training. It integrates multiple vertical programmes and also embraces the Indian system of medicine [AYUSH].

The new course (Bachelors of rural health care) for 3 year and six months that demands for a five-year service in a rural area is a potential solution as primary health care is the need of the hour but are we compromising rural health care just in the desperate attempt in making more doctors to bridge the gap is an intriguing question. The extension of regular MBBS study period for rural service raised a huge out cry from the students. Though it was a shrewd idea of the politicians to fill their vote banks by promising the rural population, doctors at their doorsteps; the consequences of such a bill would have changed the entire face of rural health.

Solutions including the National Rural Employment Guarantee Act (NREGA), Janani Suraksha Yojana(JSY),  fundamental reform of the long established Public Distribution System (PDS), a new Food Security bill under consideration by parliament which proposes to issue coupons direct to BPL families, Vandemataram Scheme, RCH programme and programs to encourage sustainable farming practices are being implemented for the overall development.

Indian health services have carved out meaningful programmes of health services, research and demonstration. Mobile based primary health care systems, Automated Medical records, and development of innovative roles for allied health professionals, Telecommunications and Telemedicine—the remote diagnosis, monitoring and treatment of patients via videoconferencing or the Internet. It’s only through solutions such as these that a rural population approaching 700 million can be benefitted with proper healthcare facilities. 

The misdistribution of biomedical services and the lack of penetration of public health services create a dilemma for Indian patients. They encounter a bewildering array of medical services, ranging from qualified traditional medical practitioners to untrained, self-taught purveyors of medicines and cures. This frequently accounts for this type of patient use, which may be described as “forced pluralism,” and for provider practice that is “unethical and dangerous”. This by-now entrenched pattern of inappropriate medical practice and patient abuse, calls for a review of policy, a plan for regulation, and action against the unqualified. The Government is undertaking strategies in order to harness the available local resources by incorporating the existing self -made rural health professionals to the mainstream of health care.

Private sector spending dwarfs the total healthcare being financed by the public sector. In 2003, fee-charging private companies accounted for 82% of India’s $30.5 billion expenditure on healthcare. Most of the population is forced to seek health care from the private sector and pay out of pocket at the time of illness. Eighty percent of our healthy care is met through individual household expenditure, one of the highest internationally. Studies show that an average of 24 percent of Indians are impoverished because of medical expenses.

In such circumstances there are two alternatives, either that government increases it’s spending on healthcare and to improve the quality of care in its institutions and thereby protects the poor from catastrophic health expenditure, or the poor resort to some mechanism that protects them when they fall sick. While the former option seems to be materializing in various forms in our country the only solution to provide health care facilities to the poorer sections of the society could be the community health insurance through which the basic health care needs can be taken care of.

Only 11% of the population has any form of health insurance coverage. The Employees State Insurance Act (1948), Janarogya Yojana (1996-97), Yashaswini Insurance scheme (2002)- a micro insurance initiative, in the state of Karnataka by a public–private partnership for the farmers who previously had no access to insurance. Recently launched government-sponsored health insurance schemes, such as Arogya Sree scheme (Andhra Pradesh) and Rashtriya Swasthya Bima Yojana (RSBY), target poor Indians, offering cashless cover while allowing beneficiaries to choose among empanelled public and private providers.

More state governments should pursue such initiatives so that most or all of the population can afford to purchase at least a minimum level of coverage. Also the problems such as reimbursement, a process that can take up to six months,

 should be efficiently tackled . The widespread availability of health insurance would help to drive demand for services and provide additional revenue to improve the quality of care.

‘There is a great difference between medical facilities available in Western countries and that in India. But there is a common thread — Indian medical professionals.’

The usual cycle of migration of health care professionals from villages to cities, cities to metropolitan and from the metropolises to the US and abroad where they believe are better amenities, better job satisfaction, better professional brethren, better adaptability, better experience and most importantly ‘Better Quality of Life”. Reports are that close to 38 per cent of practicing doctors and dentists in the US are of Indian origin. Ironically the migrating doctors do not hesitate to work in the rural areas of the developed nations, as the pay for doctors who prefer to work in their rural areas is more while it is just the opposite in India.

The term ‘health’ is not found in the US constitution but yet they have always taken extreme measures to provide their citizens with the 3 sentinel services- Defense, Education and Health care. In 2008, U.S. health care spending was about $7,681 per resident and accounted for 16.2% of the nation’s Gross Domestic Product (GDP); this is among the highest of all industrialized countries.

The National Health Account shows that India’s total expenditure on health amounts to 5.10% of the gross domestic product (GDP), while its per capita total expenditure on health is $80 compared to an average of over $220 spent by many other developing countries. Consider the contrast with the Bhore Committee recommendation of 15% committed to health from the revenue expenditure budget, against the WHO, which recommended 5% of GDP for health.  In this very year India spent 300 bn to hold the most expensive Common Wealth Games ever.

Does the elixir of dynamic economic growth distract us from acknowledging that the superpower status will be denied to us until our country can bestow social justice to its own citizens?

"Taking real time data and immediately feeding it back into the product, tapping local entrepreneurial talent, doing incredible marketing and education based on aspirations and not avoidance will make health care as ubiquitous as Coca- cola", said Melinda Gates in her TED talk. Only through real education can the masses be made to realize the ‘felt needs’ and they shall be more receptive to hear when their stomachs are full enough. It is through research into cheaper modalities of health care delivery like ORS, a revolution can happen.

I look forward for that day, when we can pride ourselves on our determination, enough wealth, organizational skills, intellectual and technological capacities to develop an ideal health care model such as the NHS and provide health care to every citizen in need.

Change appears to be the hallmark of this generation. This is fortunate, for change is the hope of the future. But let’s remember, true prosperity starts in the countryside.

P.s. This essay on the 'Health Care Of Rural India' has been a product of a hot furnace in my head for a 

National essay writing competition- DR. VISHWAS PATIL MEMORIAL ESSAY COMPETITION supposedly conducted by APCM, Dhule during my preparation time for the third year university examinations which included Community Medicine.

Like, all things are not appreciated in life, I never got a reply despite calls to Dr.Singh or my mails to their society.  Well, let there be a reader for this hard-made piece at the least!

                                                                                                                        -Raviteja Innamuri

My love!

I remember the first time I saw her. The evening was hot and the inners wet. The Sun poured down sweat that precipitated on the cooler mortals. She stood in the corner of the dark room along with her other friends. She was different. She smelled different. I couldn’t help noticing her. At first from the corner of my eyes and then, inevitably staring at her. The mirror glare from the rider passing by disturbed her grace. She noticed me and broke my stare, threw my head down and filled me with guilt to the brim. I had no reason, why? I stared at the Taj Mahal much longer and nobody said a thing!

I was at the same place the next day. Maybe, it was just coincidence.  She was there too. None of us said a thing. I was there the next evening and perhaps the next one too until all it took was a simple handle- shake.

I don’t really remember much after that. The ride was always pretty smooth with her. I could never get bored. The feeling was always like the wind sweeping through my hair making curls and sweet subtle music as it sensitively touched my eardrum as it left softly brushing my pinna. She took me to new places, introduced me to new fellas. There was always something to do, something new. She rarely complained and though there were a few misunderstandings; the mechanic was not far away. 

She always farted silently. She was always very polite and waited patiently for me. She always took hours long to clean up but always looked prettier than the last time I saw her. She intimidated the other girls. Oh boy! You could tell! She could never bear thirst. You had to get her the drinks else she wouldn’t budge.

She needs to be treated more delicate than a flower. I feared every second if I would bruise her if I hit, any harder. But she could endure any pain, race any distance and a great opportunist. She never backed down. For her, stamina is nothing more than one extra foot when your heart is ‘one hundred percent exhausted’ and your mind says ‘no more’. Man! She is a winner. 

In the many years I have known her I could never tell how special she is to me, until now. You are a miracle. Happy anniversary Laura! You are the most wonderful thing anybody could ever own!

p.s. Laura is a bike.

What make great quotations GREAT!

I have always wondered what made good quotations great. Is it really who said them or are they great because the ones who heard them have interpreted them greatly. Many times in life, we hear people say profound things just in the passing; things that are capable of igniting minds and changing lives.

As a tribute to my wonderful friends, here are some of my best catch!

"Cases are not stupid; only case sheets are."
- Priyanka Shuklae. 13/05/2011.

"We all just pretend."
-Krithika Singh  on her latest night out.

"You are distracting yourself."
- Roopa Patel on things distracting me.

"The vaguest of symptoms precipitate the sophisticated of investigations."
- Me; on the patient's investigation report for 'giddiness'.

"Teach me something."
-Miss Ann in her intermittent awakening phases of her sleep- wake cycles at clinical postings.

"There is an old dictum of mine. If you know, write. If you don't; write more."
-Anonymous; who had taken 8 additional s for the OBG exam.

"Off the eyes is off the mind."
- Re-quoted by Mr. Roy.

5 ways to know if an Indian women is anaemic. . .

The content below is extremely offensive under United States Code, Title 18, Section 2257-

1. All FAIR Indian women are anemic unless proved otherwise.

2.They have always wanted to donate blood but never did.

3. They speak of bearing 'red plump' children, all the time.

4. They eat chicken though never touch real foood. [Controversial]

5.They pay close attention to the indicator as they pass through the walk through metal detector.

Find more and get a personalized signed copy of Nikil Nandineni sleeping in LR's class.

p.s.A walk through metal detector detects the metal on your body. Here, we speak of the Iron in Haemoglobin ;p ;)

One step further. . .

It was a cold winter morning. As the breeze was busy cracking the tender dry skin, we were preparing for the cross-country race for the early Sunday morning. The bells rang with no indifference like any other weekday as everybody left their laziness in their previous day night clothing.

The first boy and the first girl who make it across the entire village, the valley down the bridge and into the forest and back will be declared champions for the week’s cross country race will proudly hoist the national flag upon the school’s administrative office and will have their names in red bold letters on the main notice board for an entire week until somebody else will run his ass off!

As we assembled in those lines according to heights and spacing each other with our hands as rulers, I realized that I was standing next to the all time cross country champion! Who wouldn’t dream of being a person like that of him?! I had to satiate my share of curiosity and so asked him the question that had been so tirelessly running round & round in my head,

“Do you ever get tired?”

He turned towards me and gave me a weird look. I know it was a stupid question but I had a reason- I was just too young!

Then, more questions hit my head.

 “Aren’t you scared of entering the forest alone before the entire group makes it?”

“What do you do when you feel really thirsty and when your legs ache very badly?”

“Do you take breaks?”

“How do you build your stamina?”

I didn’t know what to ask. He waited as I simply stared at him. I finally asked-

“What do you do when you when you feel like stopping?”

“Take a step further”; he simply answered.

The whistles blew and we ran in colorful shorts to entertain the drowsy on looking villagers. As I took the first breaths of the unused air scented with Eucalyptus, all I could think of is what he said.

Alas! It is not who that is stronger or who with the greatest potential that matters. The question that matters is, “ who endures it the hardest and the farthest of all?” When every cell in your very existence is devoid of energy; when the very breath is about to run out; when every iota of energy is spent- Can you dare to take one step further?

Stamina is no virtue or skill, my friend. It is just the will to take one another steps further!

p.s.  Dedicated to Madhusudhan Reddy and to the conversation at the Amphi theatre hill on the Sunday morning.

Aamchi Mumbai!

My life in Manipal begins at the Syndicate circle and ends at Tiger Circle or might go as far as Kamath Circle if my delicate time permits me to travel to the campus buzzed MIT for some sumptuous dinner at the new food court.

I began scribbling this piece as I told my Dad I would, sitting in a Mumbai local train from Borveli to Andheri, which is now far different from what I experienced this morning. The cabin presently is accommodating an accurate 21 that in the morning carried a near 250, with each person’s face shoved into someone else’s armpit, literally! What you really need to be worrying about is the odor produced by the mixture of sweats as a collective collaboration rather than the individual contribution. Everybody talks to the other as if nobody else is listening. They sing songs in choir as if nobody else exists. That’s what seeing soo many people everyday does to you, I guess. Some old man talked of his retirement and his son leaving to the U.S for a high pay job. A woman complained about her husband. Young men discussing about their jobs, making more money and new weekend plans.  Some girl just wanted some Vodka! Well, I was listening. Nobody cared if you; the stranger is eavesdropping not.

Bombay is prosperous. All they repeated was- ‘Bombay, the city of dreams, where everything is possible. A city that never sleeps.’ The locals run beyond 1:30am into the night!

Bombay is cheap. Anybody can survive in Mumbai. A vadapav for Rs. 6, Nimbu pani Rs.4 and there is food everywhere. There are these, amazing stuff just made out of bread and hand-made like the mini pizza and sandwitches that are a big hit with the aam aadmi.

Bombay is luxurious. There are cafes at bay and alongside popular streets like the European style (the way, I like to call them) flooded with the fair skinned foreigners. They are a true bliss. The buildings grow notoriously longitudinally, oh, what do you think, we have no other choice, the only direction left, they will say! The night before on my way to Mumbai, the co-passenger suggested me to sit by the Marine drive where romance is high even under the hot commercial Sun and stare at the cars that pass by. He said, at first you’ll say this to yourself and then out loud; “fuck, when has India got so rich man?!”

I randomly remarked in my RABITS that I can’t eat too much cheese and a maximum of 5 spoons of pasta that I can relish in one sitting. I hate beer too; too much of a time and calorie consumption to get to a 50ml high spirits. But the combination of these at the Leopold’s was something I never tried before and I must admit, it was amazing. It’s that weird feeling of your stomach burning with hunger and the temperature rising with the beer and you satiating it with the cheese paparika sprinkled cream Chicken pasta alongside!

Life in Manipal may begin from TC and ends in KC but life in Bombay is beyond Borevili to Churchgate. . .

Back to square one!

 

My dad is a simple man. He has been a practicing general surgeon for decades now. He enjoys his government job like any other chronic government official.  He sleeps late, almost everyday and wakes up a bit late for his office. With a towel round his belly, and an old song on his lips, he goes directly to the pooja room after bath and lights an agarbathi that’s fills the house with its fragrance. 

He is that kinda person who socializes extremely well and cracks good jokes for everyone to laugh. People love to have him around. I learnt the socializing part well but when it comes to my poor jokes, I end up laughing at most of them, inevitably alone. He is always, well, most of the times in a constant thought loop, unable to hear you talking to him even though you are standing right beside him. Hell, once, he even asked me, who I was and what did I want as I stood at his cabin door waiting for him to finish talking to the other white coat bearers. That’s a different story all together!

He never did really beat me when I was a kid like my mother used to (to teach me the hard lessons) but the few times he got angry, I used to feel real bad. He used to let me enter the OT in those long scrubs while he was operating and let me stare at the blood soaked meat and the puddles of pus. He got me an ice cream each time I fainted off the stool and whenever I visited the dentist. I always preferred him for injections. He knows the ‘pain free’ way, believe me.

He made crazy bets with me for all sorts of change and got me speaking on topics to earn my prize money that went in my Santa bank.

He is a workaholic.  He loves the share market. He is also very generous to his poor patients. He spent years away from home, my mom and me for studies and clinical experience. He is always there to join me into an institution and re-visits the place to take me home only after the course is over, years later. He was there for my medical college counseling but he hasn’t visited Manipal, since then. I go home for vacations, of course! Yesterday, in one of his enlightening hour-long/once-in-a-week conversations he shared with me something that goes like this-

(Do leave your comments; I’m sure he would love to hear from you)

Into a mysterious world I entered naïve and innocent with perhaps a vacant head. All these years I continued to live in the same mystery and yet again I feel the same, fearing atrophy and turning vacant, as I can’t recollect names and dates which once I did so well. I wouldn’t compare to say that an unripe and a rotting ripe fruit are the same but I’m back to square one, I would say.

I fought with my father to get what I wanted and the world thereafter. In little arguments I spent so much of my life and all I learnt was to learn to compromise in the end.  I flew away from my native town in search of life and now, I fear my children will fly away from me. Back to square one.

They failed me in my final MBBS for not delivering the answer for a single question. I wondered why? Maybe, all the others did well and they needed someone to flunk and they found me and I convinced myself to reading the same for another six months. Back to square one.

I struggled in my government job for many years as a doctor and saved enough to invest in the share market to make some good money. I created many occasions and shared enough drinks to impress those expert brokers and businessmen and spoilt my health alongside. I made a lot of money but now; I invest it all to enjoy good health. Back to square one.

When our lifetime is almost spent and all the time is gone. What is that we see when we look back to? Life teaches us both good and bad. It leaves us experience to teach but aren’t we back to square one?