Despite outpacing its South Asian neighbours in economic development, India lags behind most of them in major health indicators. We have the second lowest life expectancy in the region.
Our infant mortality rate is higher than in Bangladesh and Nepal, and thrice as high as in Sri Lanka. Child immunisation rates in India are far lower than those of many sub-Saharan countries. While we need to improve the national health indicators as a whole, we cannot do so without bridging the huge health gaps between rural and urban India.
On every measure of health, rural populations in all states compare poorly with their urban counterparts. This reflects causes that undermine health, deny access to needed health care and disempower people from protecting their health. From rural poverty to inadequate supply of potable water and poor sanitation, the social determinants of health are adversely conditioned. Essential health care is not readily available, due to poorly accessible or poorly staffed government health facilities and a marked urban concentration of all categories of formally qualified health care providers.
The National Rural Health Mission (NRHM), launched in 2005, somewhat improved rural health care infrastructure, introduced village-level social mobilisers in the form of Accredited Social Health Activists (ASHAs) and placed a strong emphasis on maternal and child health services.
While institutional deliveries increased markedly, thanks to schemes like Janani Suraksha Yojana (JSY), there was no demonstrable association with reductions in maternal or neonatal mortality rates. This raises questions on the quality of care available in the institutions which women reach. If the facility does not have trained health care providers who can provide both routine and emergency obstetric care or revive a newborn in distress, merely shifting delivery from home to an institution will not help. If the health care facility lacks 24-hour supply of running water and electricity, the problem gets compounded.
Furthermore, the mandate of rural health care has expanded beyond maternal and child health and infectious diseases. Heart diseases and stroke, variety of cancers, diabetes, lung and kidney diseases and mental illness are rapidly rising even in rural areas and warrant attention.
This places even greater pressure on the rural health care system which is already constrained for human and financial resources. We need innovative solutions for these issues. Some of these will involve new categories and skill sets among health care providers and others will involve greater use of appropriate technologies.
As a solution to the shortage of doctors in rural areas, governments talk of compulsory rural posting for fresh medical graduates. Since majority of medical colleges in India are concentrated in the four southern states and Maharashtra, how will this scheme supply doctors to other states?
To overcome this mismatch, the Central government has to employ fresh graduates in a special cadre under NRHM and post them where needs are high. Even then, fresh graduates who were trained in well-equipped urban hospitals will be like fish out of water when posted in a poorly resourced rural health care facility. Only when medical education is reconfigured to provide a substantial part of training in district and sub-district health systems, will the fresh graduate be attuned to the demands of rural service.
Part of the solution will lie in the recognition that much of primary health care does not require doctors to deliver. Technology enabled frontline health workers (community health workers, nurse-practitioners, mid-level community health assistants and other allied health professionals) can competently provide many needed services, assisted by point of care diagnostics and decision support systems located on hand-held tablets, tele medicine and intermittent physician visits.
Trained in basic public health and clinical services, technologically adept, these categories of health care providers will greatly strengthen rural health care systems. firstname.lastname@example.org