Revitalising rural healthcare

We are a nation with the majority of our populace living in villages. So, when we aim for first-world credentials in every field and also want to become a developed economy in Amrit Kal, we cannot be insensitive to the basic medical requirements of the majority, who live in over 6.38 lakh villages. A healthy and wealthy India is not possible without transforming the lives of those who live across different villages of our country!

As per census data, some 69 per cent of our people were living in villages at the end of 2011, as opposed to 83 per cent in 1951, as at the end of the first census post-independence. As per provisional data, now some 65 per cent of our 1.4 billion people live in 6,38,000 odd villages in different parts of the country. Thus, although urbanisation has gained pace, it has only reached an extent of 18 per cent in seven decades, or at the rate of about 2.5 per cent per decade. Maybe the shift will gain traction in times to come, and more and more people will move from villages to cities in search of jobs; for various other reasons, it may take another three decades or so before we have an equal number of people in villages and in towns or cities. There are two basic infrastructural facilities, and everyone agrees with this: health and primary education, which are the prerequisites for any kind of transformation that we may think of in villages and in the country as a whole. Against this backdrop, let us reflect on how much we have done for the villages to keep them healthy.

We have a three-tier system to provide medical services in rural areas. As per the rural health statistics for 2021–22 released by the Ministry of Health and Family Welfare (MOHFW), we had 1,57,935 health sub-centres (SCs), 24,935 primary health centres (PHCs), and 5,480 community health centres (CHCs) functioning as at the end of March 2022. So, while we have a sub-centre for every 4–5 villages, we have a PHC for every 25 villages. We have at least one CHC at every block. There is no uniformity in the size of villages or the distance between a village and the nearest health centre. Each SC catered to an average of 5691 people, and each PHC catered to, on average, 36,049 people. Each CHC caters to 16,427 people. This is much above the norm for each category.

The other findings of the report are more disturbing. The CHCs have a staggering paucity of medical staff (83 per cent surgeons, 82 per cent paediatricians, and 79 per cent general physicians). The CHCs are 30-bed block-level health facilities that are supposed to provide basic care relating to surgery, gynaecology, paediatrics, and general medicine. These are the health centres that 65 per cent of the population depend on primarily because of their reach and affordability. The sub-centres hardly have any infrastructure, both human and material, and the PHCs, as their name suggests, are there to provide first-aid-type services. Apart from specialist doctors, there is also a shortage of female health workers and auxiliary nursing midwives, with up to 15 per cent vacancies in PHCs and SCs. Operation theatres, X-ray facilities, and laboratories remain non-functional as the required personnel and facilities are missing for the most part. A functioning healthcare system requires both men and materials: infrastructure facilities and qualified personnel — doctors, nurses, and support staff — and also regular medical supplies. On each count, we have failed miserably. The three-tier system is not only characterised by paucity; absenteeism is also rampant. All SCs and PHCs should have a general practitioner, an auxiliary nurse or midwife, and health care. But they are heavily understaffed, even on paper.

We — both the centre and the states — spend about 1.5 per cent of our GDP on health. All states put together spend nearly three times what the centre spends on health and family welfare. While advanced countries like Japan and Canada spend 10 per cent of their GDP, the United States spends 16 per cent. Even the least developed countries like Bangladesh and Pakistan spend about 3 per cent on health. The government plans to increase spending and raise the level to 2.5 per cent by 2025.

More funds are no doubt needed to fix this complex issue; that alone perhaps may not be sufficient. A functioning system with strong and transparent accountability is required to ensure that appointed medical staff actually do their jobs. Of course, before that, we need to fill up the huge vacancies at each level of the three-tier system. If we are serious about reaping the demographic dividends and reducing the rural-urban divide, we must invest in building and maintaining a robust rural healthcare system in India! Ensuring that each level of health care is staffed will require providing incentives, making it a condition for admission (in both government and private medical colleges) and a requirement to access fellowships and scholarships of any kind. A programme that gives a 5-year minimum employment contract to young medical graduates and also newly retired health practitioners could get healthcare staff to serve in rural areas.

We have some 25 All India Institute of Medical Sciences (AIIMS) — super speciality hospitals — all over the country. Every state has at least one such hospital; some of them are functional and others are under construction. Given the size of our country, we need to have a similar arrangement in every rural district headquarters. The district headquarters hospital should get upgraded to have all specialities under one roof. As per the national medical journal of India, although we have the highest number of medical colleges, followed by Brazil and China, the density of physicians in rural India is 3 per 10,000 people, as opposed to 13 in urban areas. Worldwide, studies show that medical colleges play an important role in overcoming the shortage of physicians. We need to have more medical colleges, especially in rural districts.

Thus, fixing the rural-urban disparity will require a series of measures, including filling up the vacancies, improving and creating additional infrastructure — people and materials — a system of incentives and disincentives, and ruthless accountability at all three tiers.

The writer is Senior Advisor, Indian Banks' Association. Views expressed are personal