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 1st 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.
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
