Hindustan Times ST (Jaipur)

Rural India’s health care challenge

Managing Covid requires a revamp of rural curative care infrastruc­ture, and reorientat­ion of health personnel competenci­es and public expectatio­ns


Covid-19 made inroads into rural and peri-urban areas during the second wave, with rural districts accounting for 53% of new cases and 52% of Covid-19 deaths in May, according to a recent report. This could be an even bigger challenge during a subsequent surge. Set within the larger context of a poorly funded public health system, the inadequaci­es of rural health care are immense.

There is an 18% shortage of health subcentres (SC), 22% shortage of primary health centres (PHC), and a 30% shortage of community health centres (CHC) in rural India (2018), with just 3.2 government hospital beds for every 10,000 people.

In mid-may, the government released the management; mental health support; vaccinatio­n; and intersecto­ral coordinati­on, community mobilisati­on and behavioura­l change, led by gram panchayats and community-based structures. While commendabl­e in its approach, its implementa­tion will be met with gargantuan challenges.

It is important to understand the developmen­t philosophy that characteri­ses India’s rural health system. Traditiona­lly, rural health care in India has seen a prominent curativepr­eventive dichotomy. In contrast to urban areas, preventive care services, including maternal and child health services, family planning, and immunisati­on, have dominated rural health allocation­s, and curative care has been inadequate.

Rural health services constitute­d only 27% of state public expenditur­e on “medical and public health” in 2015-16, while urban health services constitute 44%. Combating rural Covid-19 will not only entail a revamp of rural curative care infrastruc­ture and manpower, but will also require a reorientat­ion of health personnel competenci­es and public expectatio­ns from the rural health system.

As of 2019, only 59.2% of SCS and 55.9% CHCS had auxiliary nurse midwife (ANM) and specialist­s’ quarters respective­ly, and 11.5% SCS lacked allweather approachab­le roads. As of 2020, 34.2% PHCS functioned 24x7, while CHCS saw a 76.1% shortage of specialist­s, with only 51.7% CHCS having a functional X-ray machine.

Similarly, many district hospitals, which act as dedicated Covid-19 hospitals for severe cases, remain highly deficient in critical care infrastruc­ture. While schools and community halls can be converted into makeshift Covid care centres, a lot would depend on how we empower ANMS and multi-purpose workers as nodal persons at these centres.

Turning a four-six bed PHC into a 30-bed dedicated Covid-19 health care centre (DCHC), with the provision of oxygen, drugs, and manpower, will be a mammoth task. Also, retraining medical officers and nurses would be pivotal since, in most cases, their clinical armamentar­ium remains largely restricted to simple ailments and maternal and child health care.

It is unrealisti­c to expect that such extensive curative care gaps could be filled even temporaril­y within a short span, which makes it even more important to focus on preventive efforts (including vaccinatio­n), with double the usual strength for rural areas. The SOP has provisions for risk communicat­ion and community mobilisati­on measures and envisages a prominent role for village health nutrition and sanitation committees (VHNSC) and gram panchayats. However, this has to be backed with sufficient finances, technical assistance, and local autonomy. Addressing the maldistrib­ution of Covid facilities between rural and urban areas is essential.

During the first wave, many grassroots­and middle-tier public health facilities catered to essential non-covid-19 health care requiremen­ts. Even a cursory examinatio­n of publicly available data reveals that such routine essential services suffered considerab­le disruption. With most rural health facilities involved single-mindedly in Covid-19 mitigation, the impact on routine essential care could get worse and can be disastrous unless adequate provisions are made. Haphazard management of other common febrile conditions in the Covid-19 scenario has been common.

Interactio­ns with grassroots health personnel reveal that even with a lesser caseload, segregatio­n of patients in outpatient department­s has been challengin­g. Further, while ancillary staff are recruited to assist in a range of activities from case monitoring to surveillan­ce, the burden of training and preparing them often falls on overburden­ed health personnel. It will be crucial to address these in a rural flare-up of the pandemic.

One important measure to facilitate surveillan­ce, early detection, monitoring, as well as community participat­ion in remote areas could be to involve the ubiquitous informal practition­ers (IP) through appropriat­e crash training. The West Bengal government recently announced such a measure. While this could be contested by the medical fraternity, an emergency of this magnitude warrants extraordin­ary steps as the benefits exceed the risks. It has been shown that apart from convenienc­e and affordabil­ity, cultural factors are an important reason for visiting IPS as they often have the faith of their communitie­s. The SOP already envisages involving religious leaders to facilitate Covid-appropriat­e behaviour.

The most favourable and enduring transforma­tions are often forged in the crucible of severe challenges. While the rural challenge looks insurmount­able, successful implementa­tion could provide scaffoldin­g for an exemplary rural health system that India has dreamt of ever since independen­ce.

 ?? ANI ?? There is an 18% shortage of health subcentres, 22% shortage of primary health centres, and a 30% shortage of community health centres in rural India, with just 3.2 government hospital beds for every 10,000 people.
ANI There is an 18% shortage of health subcentres, 22% shortage of primary health centres, and a 30% shortage of community health centres in rural India, with just 3.2 government hospital beds for every 10,000 people.

Newspapers in English

Newspapers from India