Challenges and Innovative Solutions to Rural Health

Current national agenda calls for an immediate focus on the rural health delivery systems, Dr. Ashok Panagariya writes
Challenges and Innovative Solutions to Rural Health

The accessibility of healthcare as well as utilisation of available healthcare facilities especially in rural areas continue to be poor in India.The present health scenario is a toxic combination of uneven quality, high cost, frequent errors and limited access for marginalised population.Poor quality services at state-run hospitals force many people to visit private facilities.The current national agenda calls for an immediate focus on the rural health delivery systems including tribal and inaccessible areas, which constitute nearly 70 percent of the population hitherto deprived of the advancements in health and disease management.

Problems as opportunities

While I am not undermining some improvisation indicated by better health indices, corporate participation, available resources through the National Rural Health Mission, but it has been too little and too late. It is observed that 70 percent of population has no access to specialist care as 80 percent of specialists live in urban areas. As per National Family Health Surveys (NFHS), only 13 percent of rural population had access to Primary health center, 33 percent to sub-center and 9.6 percent to a hospital (NFHS-II). The overall health care utilisation is also low, only half of (52 percent) of Indian mothers received three or more ante natal checkups; Only 43.5 percent of children in India received all vaccinations {(NHFS-3), 2005-06}. At one side our peripheral health centres are under-utilised whereas on other side our Tertiary and secondary (District) level facilities are often argued as overloaded with the work that could have been done at lower centres, resulting into compromise in quality.

The under-utilisation of peripheral centres is attributed to varied factors related to accessibility, quality, affordability, deficient human resource, poor monitoring, lack of community participation and ownership. Vast and diverse geographical locations of India, inhibits proper penetration of health care delivery in such areas. Further, health care personnel are reluctant to work at block or below level areas, as they have to face two challenges, firstly absence of reasonable living conditions (eg. proper housing, 24 hour electricity supply, good school for their children, social isolation etc) and secondly under functioning of majority of health care facilities in such areas, hence no opportunity to practice their technical skills. Absence of stringent transfer policy leads to frustration among staff. Posting of Surgeons at under functioning facilities at the beginning of their carrier erodes their surgical skills and make them non-functional forever. The absence of accessible quality primary care services leads many poor people to either forgo medical care altogether or choose to seek expensive and unregulated care in the private sector.

Lack of adequate quality data on burden of disease and trauma for proper planning along with poor public health awareness are few more issues. MCI and Nursing Council of India in their current shape are inert to some extent as their main focus is only on quantitative assessment of staff, infrastructure, material and equipments rather than quality or treatment audit.

Raising the bar

Inequality in health delivery and changing pattern of disease in India are adding to the basic deficiencies. This has pushed India facing the characteristic parallel dual burden of communicable and non communicable diseases. Surge of coronary heart disease(CAD), diabetes and stress along with old age infections and malnutrition have become conspicuous by this change. Emergence of Scrub Typhus, Dengue, Swine flu further enhances the burden of diseases. While policy makers say that health is a priority but that is not reflected in their budget allocation. This needs to be strengthened either by continuous collaboration with lawmakers or inclusion of these stakeholders in the interdisciplinary regulatory bodies. Out of the overall spending of 5.1 percent of GDP (compared to 8-10 percent in developing countries), the major share (4.2 percent) comes from private sector. The negligible 0.9 percent public share has recently increased to 2 percent but remains far below the desired level. Increase in population constantly exceeds the increase in spending. High out of pocket expenses i.e. almost 70 percent of the per capita expenses is uncalled for. Another gap is a huge cut of spent on curative medical care compared to insignificant spending on preventive health.

The lack of clear vision, absence of inclusive strategies, lack of motivation, zeal and enthusiasm combined with failure of bureaucratic leadership are some of the reasons impairing rural health care delivery. The pride and status of medical professional of all cadres is waning. There is an utter disregard for the attempts to provide basic amenities to employees in rural areas from state side. Apathetic attitude of management for their staff and lack of professional protection during health care delivery further aggravates the problem. This holds back health care providers to take innovative steps suitable to local needs. There is an absence of reward for excellence or punishment for failures in the system.

There is a gross disconnect between primary, secondary and tertiary care facilities. This is high time that we redefine healthcare, provide the clear vision and make a determined effort by politicians and bureaucrats working together as an interdisciplinary team allowing the technocrats to freely and independently provide clinical input. In democracy, the remedial approach needs to be innovative, pragmatic and actionable that can resurrect the system, bypassing corruption, overcoming complacency and inefficiency. There is a need to incorporate “cooperate thinking” in the system by diverting efforts towards provision of universal basic care i.e. “Good for most rather than best for few”. System now requires a radical surgery, no palliation. We need to bring the authority of public sector and efficiency and energy of private sector together.

Models of governance of rural healthcare delivery

The RURBAN initiative of developing villages can be gainfully used for innovative medical manpower management in primary healthcare. Thus the concept of Model Group Housing at block level/ PHC level should be considered where government employees of all the departments could be provided accommodation where required facilities like school, playground, community centre, supermarket etc. could be provided in the neighbourhood. This would take care of the “Doctors Deficiency” argument very often put forward as an excuse for non-availability of medical and health facilities. This concept would allow holding, retaining and recruiting fresh talent by facilitating their stay and improvising their quality of life comparable with their counterparts in the city. Thus feeling of being deprived and frustrated could be compensated.

The critics might argue that it is a very optimistic project and shall require long time to complete while consuming lot of resources. While one has waited for solutions including conditional provisions of rural posting, increased allowances or even making the rural services compulsory to doctors or other skilled workers, for more than several decades, the project looks worth initiating. The resources under RURBAN model, the Prime Minister’s, Member of Parliament, Village Development Project, funds under the National Rural Health Mission and low cost housing along with several other projects could be merged to give impetus to the newer solutions.

The model housing township should also harbor the first referral unit (FRU) consisting a gynecologist, anesthesiologist, pediatrician and surgeon with facility of ICU. Such team effort would provide cohesive and coordinated medical services. The primary health centre physicians could also stay at the model township and may be allowed to run the OPDs and the National Health Programmes or other specific responsibilities by a ‘to and fro’ movement every day. The initial phase of populating such hospitals in such model villages (or townships) can happen by way of temporary deployment of skilled manpower from larger govt hospitals or tertiary care centres that feed such rural areas. Emergencies at the PHCs can be either transported through ambulance 108, or the mobile surgical services stationed at the model township can periodically conduct camps and handle necessary medical, surgical, emergency and blindness control programme. The proposal to effectively mainstream AYUSH in present rural health delivery systems would go a long way and also pave way for looking into the deep rooted indigenous system of medicine well accepted among people.

Further, the model townships could be connected through telemedicine to the tertiary care centres for availability of speciality/ super-speciality consultation and also continuing medical education.

Affordable health care by research

Finally, provision of healthcare for rural areas hinge on the affordability of treatment and diagnostic costs. In order to propel the indigenous production of medical devices, drugs, surgicals and diagnostics, the biomedical scientists in the hospitals, research institutions and elsewhere can come together and translate their knowledge into affordable medical products. By instituting ‘innovation clinics’ the consulting scientists and doctors could join hands in order to translate their respective knowledge useful for bedside of patient around the Model Rural Research Centre of ICMR.

Thus, while the innovative do able solutions are available within the existing financial and human resource, one would look forward to the grand initiative from the determined Prime Minister to act as a radical plastic surgeon rather than the cosmetic one to make the life beautiful of the poor, deprived sick and ailing population in the rural areas.

Dr. Ashok Panagariya is Prof. Emeritus SMS Medical College, Former Vice-chancellor of Rajasthan Health University and Member, State Planning Board on Health Issues, Rajasthan

The Changing Face of Rural India