Gaps in Indian rural healthcare

Shyamal Santra, Public Health & Nutrition Expert, Transform Rural India highlights that while there has been significant progress in rural healthcare, it has been uneven across states and demographics. Epidemiological changes mean the country faces a double burden of disease and an ageing population

The story is a familiar one – the young village woman who goes into labour but must take a bicycle, bus and rickshaw to get to the hospital in time.

The good news is she has much more chance of surviving this harrowing journey and successfully delivering a baby now more than her mother or grandmother did. The maternal mortality ratio (MMR) is now 97 deaths to 100,000 births compared to 1946 when it was 2000.

The bad news is too many rural women – and men and children, for that matter – with all sorts of health ailments still have to make these harrowing journeys because the right help is not always close to hand.

While there has been significant progress in rural healthcare, it has been uneven across states and demographics. Epidemiological changes mean the country faces a double burden of disease and an ageing population. In rural India people depend on the public health system or untrained local quacks.

Lack of healthcare infra in rural India

Despite structural improvements, India’s health infrastructure does not compare well with other low- and middle-income countries (LMIC). For example, India had only about 5.3 hospital beds per 10,000 people, which is well below its peers Indonesia, Bangladesh, Brazil and Chinaⁱ.

It has been documentedⁱⁱ that there are not enough health facilities in India, which are broken down into sub centres (SC), primary health centres (PHC) and community health centres (CHC). Under the Ayushman Bharat Programme, the Government of India has taken an initiative to convert all the SCs into Health and Wellness Centres to deliver comprehensive primary care and wellness activities. But there is a shortfall of these centres – 24 per cent of SCs, 29 per cent of PHCs and 35 per cent of CHCs.

Limited access to healthcare facilities and trained medical professionals

Just getting to these facilities is tough at best for rural Indians too.

The multifaceted nature of healthcare access is best captured by defining it as the freedom to use health services. Access can thus be broken down into at least three dimensions – availability, affordability and acceptabilityⁱⁱⁱ Access is significantly constrained for other women due to poverty, residence in rural areas, levels of education and whether they belong to certain castes or tribal 228 groups. Over the past decade though, a remarkable rise in the share of deliveries in institutional settings has occurred, irrespective of caste, wealth or education^iv.

But getting enough doctors, nurses and other qualified medical professionals remains a challenge.

From March 2021 there was a 2.9 per cent^v shortfall of female health workers and auxiliary nurse midwives. This was mostly driven by shortfalls in Uttar Pradesh, Himachal Pradesh, Gujarat, Odisha, Tripura and Uttarakhand. Interestingly, in the case of male health workers there is a shortfall of 66.1 per cent^vi – and this despite sanctioned positions for them.

There is a huge shortfall of 4506 physicians and 302 pharmacists^vii at community health care centres in rural India. The shortfall is even greater in tribal areas – with 8503 subcentres^viii.

As for specialists, there is a shortfall of 83.2 per cent surgeons, 74.2 per cent obstetricians & gynaecologists and 80.6 per cent paediatricians. Overall, there is a shortfall of 79.9 per cent specialists at the CHCs compared to the requirement for existing CHCs. Again, the regional and state wise variations are very high^ix.

Physical access to and affordability of medicines, vaccines and diagnostic facilities are a primary concern. Government underfunding accompanied by weak procurement and logistics systems has meant that access to medicines and medical equipment in government health facilities remains poor.

Exceptionally, a few Indian states have adequately funded and set up mechanisms for an efficient procurement and supply of medicines and diagnostics. In the private sector, physical access to medicines is easier, but the “ability-to-pay” may inhibit access. Prices remain high for many essential medicines, leaving them out of reach for many households. Despite being the “pharmacy of the global south,” India’s branded generics market continues to be elusive or unaffordable to a majority in the population. Moreover, poor regulatory oversight has limited policymakers’ ability to control inappropriate prescription and use of medicine.

Poor quality healthcare due to a lack of resources and latest equipment

India’s spending on medical devices per person is still relatively low compared to other countries, like the USA (which spends USD$415 per capita) and China ($178) compared to India ($3) (Deloitte & NATHEALTH, 2016)^x.

Although many of the medical devices used in India are imported, domestic manufacturing of medical equipment and associated supplies has also increased in India (Datta and Selvaraj, 2019)^xi. Indian manufacturers specialize in low-cost, high-volume medical devices, especially disposables and consumables and export 60 per cent of their output^xii. (WHO, 2017a). Imports of high-end diagnostic equipment such as magnetic resonance imaging (MRI) machines, ultrasonography (USG) machines, X-ray machines and computed tomography scanners have also increased. In the period 2001–2011, 150 000 USG machines and 12 500 MRI machines for a value of Rs 29.2 billion and Rs 26.3 billion, respectively, were imported^xiii.

High-tech diagnostic devices are mainly concentrated in the larger cities and urban areas (Datta, 2013) and a large number of public health facilities of rural and tribal India lacks basic critical equipment like ECG and X-Ray.

Financial barriers preventing people from seeking healthcare services

Out-of-pocket (OOP) spending is only one dimension of the financial risks related to illness.

If treatment expenses are high, individuals may choose to go without treatment, with potential risks to their health and increased likelihood of earning losses. Household out-of-pocket (OOP) spending on health services accounts for nearly two thirds of all health spending, especially on medicines.

The resulting financial burden continues to push over 55 million people into poverty every year, with over 17 per cent of Indian households incurring catastrophic levels of health expenditures annually^xiv. India’s health system is overwhelmingly financed by out-of-pocket (OOP) expenditures incurred by households (around 63 per cent of all health spending)^xv

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