Rural healthcare is in poor health

The primary healthcare system in India needs to be re-evaluated and concrete steps taken to revitalise it

By Author  |  Pallerla Srikanth  |  Published: 22nd Jan 2021  12:28 am

Health is a fundamental human right, a global goal, and also vital to the nation’s economic growth and internal stability. Over 70% of the population living in rural areas are struggling for basic health services. Rural health problems have worsened due to existing malpractices, magico-religious practices and unsafe and unhygienic conditions.

Rural health care (RHC) services in India are mainly based on primary health care (PHC), which is an important constituent of the healthcare system. The PHC is regarded as the key to attaining an acceptable level of health for all, and as a means of removing widespread inequities in healthcare services, particularly in rural areas. It provides integrated promotive, preventive, curative and rehabilitative services. The RHC is one of the biggest challenges and remains a major concern.

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The three pillars of healthcare — availability, accessibility and affordability — are different in urban and rural communities. The allocation of healthcare as a percentage of gross domestic product remains at 1.5%. Qualitative and quantitative availability of PHC facilities is far less than the defined norms of the World Health Organisation.

Falling Short

To strengthen the RHC delivery systems, the Indian government launched the National Rural Health Mission (NRHM) in 2005. The mission’s goal is to improve the availability of and access to quality healthcare for the rural population, and make healthcare more accountable, affordable, and customised. The Indian RHC is a three-tier system comprising sub-centres (SC), PHC and community health centres (CHC).

There was a shortfall in health facilities — 18% at SC level, 22% at PHC level, and 30% at CHC level, as of March 2018. Rural India has just 3.2 government-bedded hospital beds per 10,000 people. The number of PHC is limited in rural India; 8% of the centres do not have medical staff, 60% of the PHCs have only one doctor, 39% do not have lab technicians and 18% do not have a pharmacist. There is a shortage of specialists even at CHCs.

Most health workers, especially the ‘doctors’, do not want to serve in rural areas due to infrastructural inadequacy and lack of incentives. Their participation in providing health services may not be at a desirable level, as indicated by relatively higher infant mortality and maternal mortality ratio.

Moving Away

Since the PHCs and CHCs are few and far between, people have to incur a heavy daily loss of wages to reach them. Resultantly, they prefer private healthcare practitioners, even though they are expensive and often unregulated. In 2014, according to the National Sample Survey, 58% of the people in rural areas said they use private facilities for in-patient care. The underutilisation of human and material resources at these levels leads to ineffective functioning of the RHC system.

Only 20% PHCs complied with the public health standards of the NRHM, which aims to improve the quality of healthcare delivery in terms of human resources and infrastructure. Only 0.5% of rural citizens enjoy basic sanitation facilities. The cost of medicines constitutes a major part of out-of-pocket expenditures. To provide medicines for the poor, the government introduced the Jan Aushadhi Yojana, but the situation remains the same.

Mental Health

There have been many legislations pertaining to mental health like the National Mental Health Programme, Rights of Persons with Disabilities Act, Mental Healthcare Act and National Trust Act. Yet the national prevalence rates for ‘all mental disorders’ are 70.5 (rural), and 73 (rural + urban) per 1,000 population. The issue is critical in villages because of the high concentration of mental health specialists in urban areas. Barring Kerala, all other States fall short of the WHO’s requirement of at least one psychiatrist for every 1,00,000 persons. According to the National Mental Health Survey (2015-16), there are just 0.05-1.2 psychiatrists in the country for every 1,00,000 persons.

Proper implementation of national and district mental health programmes in rural areas is mandatory. The stigmatisation of mental illness is high among rural population. The Central government recently started a nationwide free mental health helpline KIRAN (1800 599 0019) to provide counselling for various mental health issues in 13 languages.

To deliver mental health services to the rural population, it is important to initiate taluka-level mental health programme across the country with adequate manpower like psychiatrist, psychologist, psychiatric social worker. This will help enhance the accessibility, availability, and affordability for rural people. It is vital to conduct awareness programmes about mental well-being and eradication of stigma in the rural community.

Plug Gaps

Moreover, poor coordination between allied departments makes it difficult to tackle, control the spread of public health emergencies/pandemics such as Covid-19. We still do not know the real statistics of the pandemic in rural areas.

Several health schemes and insurance services have been initiated for improvement in the rural health scenario, the details of which can be accessed from https://www.acko.com/government-health-insurance-schemes-in-india. Specifically, the following challenges should be addressed for better healthcare services in rural areas
• Low quality of services
• Poor accountability, infrastructure, surveillance system
• Underutilisation of existing rural hospitals
• Apathetic attitude of medical professionals, non-availability
• Non-preparedness to fight with epidemics in rural areas
• Lack of awareness
• Limited access to facilities, medicines
• Workforce shortages
• Absenteeism
• Unpredictable pattern of the closure of centres
• Dearth of staff
• Reluctant community participation and intersectional coordination
• Poor monitoring of staff
• Untrained staff in caring and handling of patients
• Huge shortage of beds and equipment

The PHC system needs to be re-evaluated and concrete steps should be taken to reform them immediately. It is imperative for us to revitalise the existing RHC system from both structural and functional points of view. The administrative measures should aim at regulation and enforcement in public health, human resource development (NGOs) and capacity building, population stabilisation, micro-planning, strengthening of disease surveillance machinery, etc. Healthcare centres should function as one-stop information resource centres as well to provide information about the legal aid and welfare benefits, legislations and suicide prevention.

(The author is PhD scholar (UGC-SRF), Department of Psychiatric Social Work, National Institute of Mental Health and Neurosciences [NIMHANS], Bengaluru)


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