October 13, 2006 | Volume 3, Issue 2
Healthcare Delivery Systems in Rural India
Meeting the changing needs of rural populations
How will India’s delivery of healthcare impact its future success as a global competitor? The author assesses the ways in which India’s current healthcare system both fails and succeeds in serving India’s rural population and looks at the impact this may have on the country’s future.
The past twenty years have brought enormous change and growth to parts of India. Globalization, and a more accessible international marketplace, has afforded enormous opportunities to many of its citizens. Her competitive edge has been developed through an enormous focus on technical education in urban areas and a creatively entrepreneurial spirit amongst her people. Today, much of urban India is a showcase for the successes of globalization. However, as the citizens of urban India move forward, they must be very careful not to forget their brethren in the more rural parts of the country. While it is urban India that has sparked this economic success, we are far from being able to declare the country as fully developed. Rural India will have as much or more say in the country’s success or failure. It is rural India that makes up 71.3% (Government of India) of the population and holds 60% (CIA World Fact Book) of the workforce in her arms. Due to this majority, they will have the final say on how progressive the entire population becomes. If the country does not develop mechanisms to funnel the positive effects of globalization into rural India, then the negative consequences will overwhelm the current successes.
Therefore, as we look at how globalization has affected the country, we must also pay attention to the different effects on urban and rural populations as well. One of the most striking differences between these two faces of India is the healthcare delivery system for urban vs. rural populations. The availability and distribution of adequate health resources to the whole population should be a primary concern when analyzing the effects of globalization in India. As urban centers of the country leap forward in their ability and access to health, we must consider how to also make these services available to rural populations. The solution needs to be a collaborative effort between NGO‘s, the government, and health practitioners to develop a holistic, preventative and curative health model that is accessible by all levels of the population. Before undergoing any massive collaborative effort, we must first look at how the current system is failing, and succeeding, to deliver healthcare to the rural masses. The path to achieving this great feat will not be easy, and may end up changing India more than any effort at globalization ever will. It will require great coordination, commitment and effort at the national, state and local levels. However, the commitment is necessary if India is indeed going to show to world how a large developing nation can persevere. Otherwise, as the smaller urban centers of the country continue to push forward, the greater expanse of rural areas will be helplessly pushed backwards. The country has two choices, succeed together or fail together.
Globalization: Rural vs. Urban
For over twenty years now, India has been following a process of liberalization and privatization of the economy. As a result, today India is one of the fastest growing economies in the world. India is a case study on how embracing the new and globalized world market can bring great gains to a country. However, she is far from being able to declare herself a successful model of globalization because of the increasingly widening gap between rural and urban, rich and poor. True success can only be declared when the government and the Indian people begin creating successful processes that allow the rural populations and the urban poor to benefit as well.
Before looking at the current healthcare delivery system, we must first understand how globalization’s effects differ for rural areas vs. urban areas. Only then can we assess how to create better pathways to development for rural populations.
It is important to note that there is some evidence that shows that since economic liberalization, there have been improvements in the lives of the rural populations. In rural India, the number of people living below the poverty line fell from 63% to 42% between 1991 and 2001 (Bardhan). Life expectancy rates have also risen steadily since the country gained its independence from Great Britain. However, these changes went hand in hand with policies and movements, such as the Green Revolution, that focused on alleviating poverty in rural regions (Bardhan). In direct contrast, there have not been any health policies that have brought about sweeping changes in the country. Instead of improvements in healthcare delivery, we are actually seeing increasing costs and health related debt that is actually driving millions of people further into poverty each year.
One of the biggest changes that globalization brings into a country is the increasing activity of foreign capital. While urban areas are immediately effected by short-term capital flows, rural populations are much more effected by long-term capital flows that are brought into the country. The whims of short term capital do not often reach directly into rural regions. This maintains a relative amount of stability in rural regions. However it can also be the cause of widening gaps between urban and rural because rural populations do not get the benefits of technology and innovation that small term capital flows can bring (Bardhan).
Rural areas are also not very affected by unskilled labor flows that characterize globalization in urban areas. More often than not, globalization will draw labor away from rural areas and to urban centers. Relatively speaking, India has not seen a huge shift in population from rural to urban. Between 1991 and 2001 only 2.1% of the population shifted from rural to urban (Bulletin on Rural Health Statistics).
Open foreign trade is one factor that effects both rural and urban populations. In rural areas where agriculture is most often the dominate economy, open trade can mean more opportunities for growth for small farms. However, it can also mean greater competition from foreign goods.
Capital flows, population shifts, and foreign trade are just a few of a number of factors at play in both rural and urban areas of globalizing economies. How India chooses to manipulate these factors will play a large role in determining how well she succeeds in globalizing herself.
Rural India Today: Economics and Health
Agriculture is still the primary economic driver in rural India, and still holds 60% of the workforce of the whole country. However despite having the greater percentage of the workforce, it only comprises about 20% of the GDP. It is service-based jobs and industrial jobs that comprise the majority of India’s GDP (51.4% and 28.1% respectively)(CIA World Fact Book). This has created an imbalance of economy and of opportunity. Urban India, despite having a smaller percentage of the overall workforce, is driving the economy and therefore controls where new opportunities in technology, lifestyle, and health are placed. In fact, 75% of the health infrastructure and medical personnel in India are concentrated in urban areas (Patil). This has translated into different health scenarios for rural vs. urban India.
When measuring health, the three factors that are considered most informative about standards of living are mortality, morbidity and life expectancy. These measures allow us to examine rate of life, death and disease in an area and draw conclusions about the population health in those areas. The conclusions we can draw about the differences between rural and urban India tell us that there is an urgent need to ramp up the quality of care for rural populations in order for them to catch up to their urban counterparts.
| Rural | Urban | Reference Year | |
| Population (%) | 72.2 | 27.8 | 2001 |
| Birth Rate | 26.4 | 19.8 | 2003 |
| Death Rate | 8.7 | 6.0 | 2003 |
| Infant Mortality Rate | 66 | 38 | 2003 |
Source: SRS Bulletin April 2005, Sample Registration System, Office of Registrar General, India.
In India, comparing health statistics of rural and urban areas tells a story of great inequality. Surprisingly, birth rates are nearly triple death rates in both rural and urban India. This tells us that the population is growing very quickly all across the country. The urban demand for health services that this population growth will put on the health sector could easily widen the already large gap between urban and rural. Further comparison shows us two more startling things. The population in rural India continues growing larger, and they are also dying at a greater rate than urban India. The death rate there is almost 50% greater in rural India, and Infant Mortality is nearly twice as much. Maternal mortality rates (MMR) are also significantly high at 407 deaths/100,000 live births. In fact, MMR has actually risen over the last decade (Deogaonkar). Research also shows that maternal child health is one of the largest health issues in rural India. There are many reasons for this, some of which are outlined below (Patil):
- 51% of deliveries are conducted at home by an untrained attendant
- 75% of women have their first pregnancy before they turn 18
- Only 67% of women complete their antenatal checkup
- Only 30% of women get postnatal check-ups
The good news out of all of this is that most rural deaths are preventable. They arise from infections and communicable, parasitic and respiratory diseases (Patil). The bad news is that mortality and morbidity rates in rural India have not shown significant improvement over time. Due to these failings, we need to focus on health care delivery systems that will reduce these glaring inequities.
Healthcare Delivery in Rural India
Healthcare delivery in India comes in three major forms. There is the public health system, the private health system, and the network of traditional healers that exists throughout the country. These three elements come together to form the health-care delivery system of the country.
Figure 1:
Public Health Systems
The Indian government has created an extensive network of public health centers throughout the country. While the network exists to serve rural and poor areas, these centers are grossly under funded and understaffed. Evaluating the public health system requires looking at the current infrastructure of the system, the resource allocation within each public health center, and at the qualifications (or lack thereof) of the staff. Finally, it is important to also look at public demand of the services provided by the public health systems.
Figure 2:
Source: Bulletin on Rural Health Statistics in India 2006
Let us first look at the structure of this system. The center of the public health system is primary health center (PHC). Each PHC has five to six sub-centers located closer to rural villages that are managed by an Auxiliary Nurse Manager. A PHC can also have a community health center that serves as a larger community hospital. Each sub-center is meant to serve three to four villages. Overall, one PHC can serve anywhere from 25,000 to 48,000 people. The National Health Policy report of 2002 found that the current infrastructure of public health needs to increase by 16% in order to adequately serve the population (Ministry of Health and Family Welfare). The basic infra-structure of the public health system has potential, but without proper funding and resources it will continue to fail to deliver on its promise of quality healthcare.
However, the PHC‘s and sub-centers that do exist find themselves severely understaffed and undersupplied. Only 38% of PHC‘s have the necessary manpower, only 31% have critical supplies (Deogaonkar). Since each PHC is supposed to have been given essential supplies, one possibility for the supply shortage is that some doctors have kept these supplies for themselves. For public health facilities in very remote areas, equipping and supplying is just difficult. Whether it is corruption, lack of funds, or location that causes public health facilities to lack proper supplies, the result is that many people now avoid using the existing public health facilities.
Staffing PHC‘s with properly trained personnel is extremely difficult. Comparatively, rural areas already have much fewer staff and beds than urban areas. Doctor to patient ratio’s are six times lower in rural areas, and doctor to bed ratios are fifteen times lower (Deogaonkar). A 2004 health survey in rural Udaipur found that each PHC served over 45,000 people and had on average of 5.8 medical personnel and 1.5 doctors appointed (Banerjee). However, the same survey found that very few of the PHC‘s reported vacancies. Having such few staff serve such large populations no doubt contributes to their inefficiencies. The rigidity of the staffing structure throughout the country also makes it difficult for the public health system to respond to the different needs of different areas. Some states have fertility levels twice that of others, and yet one ANM per sub-center is all that each state is allocated2. Even more alarming than the low levels of staffing at PHC‘s is the statistic that 80% of general practitioners practice allopathic medicine without proper training (Patil). Allopathic medicine is conventional medical care. Even though most PHC‘s seem to have qualified staff, the low levels of staff and insufficient supplies are driving demand into the private sector where quality is a big issue.
The sub-centers that are often the first point of contact for the rural ill are only staffed by Auxiliary Nurse Manager’s (ANM). An ANM is required to have completed at least twelve years of education plus a certification program that trains them to handle a limited set of health conditions (Deogaonkar). Those that they cannot handle get referred to a PHC. This staffing system brings forth another challenge of location and distance from villages. The Udaipur survey found that the average distance to a public health facility was 2.09 km and to a PHC was 6.7km (Banerjee). For many rural people, who don’t have transportation, traveling 6.7km to closest doctor when ill is a great distance and could be a factor in their choosing traditional healers or unqualified private practitioners who are closer. Furthermore, there are many areas of the country that are even more remote and removed from access to a public system. Incentives for doctors and nurses to move to these areas are even lower and less effective.
The difficulties of location, the uncertainty of supplies and the varied qualification of different personnel have all combined to make demand of public health services very low, even in those areas where public health centers offer adequate services. The data shows that even though it is more affordable, poor and rural populations will pay more money to use private health services and traditional healers, rather than go to public health centers. The rural Udaipur survey showed that the people chose to go to private doctors almost twice as much as public facilities. In fact, the data shows that the rich visit public facilities more often than the poor, though no one uses the public facilities very much (Banerjee). The results from the Udaipur survey are further supported by national figures, which show that one of the most common causes of poverty in India is individual healthcare spending (Deogaonkar). In fact Patil tells us that 70% of rural families spend 60% of their annual income on health (Patil).
Private Healthcare
The majority of growth in the health sector over the last two decades has been in urban areas, with 75% of health infrastructure now being located in that area. Between 1991 and 2000 7,044 new hospitals opened up in the country, most of them in the private sector. 20,000 new doctors are trained each year and the pharmaceutical industry has grown enormously in the country (Deogaonkar).
Numbers like these paint a very rosy picture of growth in the country. However, the reality is that this growth is rooted in the inequalities that exist between urban and rural India. The private sector growth we have seen is based on western principals of hospital-based medicine. This means that the medical schooling system is concentrating on training specialists and not general practitioners. In his paper on rural healthcare, Patil points to a study by the Rural Medical College on general practitioners in rural India. He states that (Patil):
- 80% of general practitioners that practice allopathic care are not properly trained
- 73% use cost as their first point of reference when prescribing medicine
- 75% were aware of the PHC in their area but did not have information on who the health workers there were
- 29% know how to make Oral Re-hydration solution to treat diarrhea, but almost all of them handle that condition regularly
The rural Udaipur health survey supported this data by finding that only 37.7% of private doctors had an MBBS (qualifications to practice allopathic medicine) or higher specialty degree. 13.9% of “private doctors” in this survey had no formal qualifications and 36% did not have a college degree in any subject. Even more alarming was that this survey also showed that a large majority of non-medical staff also saw patients (Patil).
There is a distinct lack of quality in the delivery of private healthcare in rural India. As Deogaonkar so elegantly puts it, “the dominance of the private sector not only denies access to poorer sections of society, but also skews the balance towards urban-biased, tertiary level health services” (Deogaonkar). While legitimate growth of the private sector occurs in urban areas, rural areas are seeing a private sector dominated by poorly trained “doctors” and are receiving low-quality healthcare as a result.
Traditional Healthcare
Traditional healers are a prevalent part of healthcare delivery in India. They can practice a variety of different types of healthcare. Homeopathy, Ayurvedic care, Unani, Siddha, and Bopha are just a few types of traditional medicine practices in India. Traditional healers are often closer in proximity to rural villages. In general, they succeed because they have been able to tap into the belief systems of local populations and have engendered their trust. The historical development of traditional medicine has focused on maintaining health through healthy living. However, as India continues to globalize, rural populations are having to battle with unsafe drinking water, polluted air, lack of nutritious food, and breakdown of traditional communities (Patil). Conditions such as this work against the principals of traditional healers. This should not mean, however, that the solution is to try and phase these healers out of the healthcare system. They have a long standing tradition of working with communities and they often have a strong trust-based relationship with their communities. Traditional healers are an important part of the medical system in India and must be treated as such as the country moves forward. By working with these healers, and teaching them how to diagnose and treat the more common illnesses in rural India, some doctors and NGO‘s are successful creating new pathways to treatment.
The Role of the Government
In looking at the three facets of healthcare delivery in rural India, we can see that no one branch alone is enough to handle the health needs of the majority of this country. Public health facilities have proved to be inadequate in meeting the needs of rural Indians. One of the primary reasons for this is the lack of healthcare spending by the Indian government. The majority of healthcare costs in the country are borne by the states. Throughout its history, the Indian government has spent successively less on healthcare costs. The latest figures show that the country only spends 0.9% of its total spending on health. In fact, the majority of health-care spending comes from out-of-pocket payments of the people. 82% of healthcare spending comes from the patients’ themselves (Deogaonkar). While the public health system is designed to try and mitigate the cost of healthcare, private facilities have no such design. They are, in fact, profit making machines. Since there is no real privatized insurance scheme in India, and since demand is shifted towards the private system in rural India this has resulted in over 20 million Indians per year being pushed below the poverty line every year because of health-care costs (Deogaonkar). Since the majority of rural Indians are served by either private providers or traditional healers, this is a major issue that needs to be addressed. Otherwise, not only will the health of rural populations start affecting the economic gains of the country, but the economic conditions of these populations will reverse those gains as well.
Possibilities and Solutions
The healthcare issue is going to be key in deciding whether India becomes a success story of globalization or an almost-was in the history of developing nations. Looking at the data on the state of healthcare and its delivery systems in rural India, it is apparent that the current system is not working. The possibilities for success would increase greatly if there was more collaboration between the three branches of healthcare delivery. Cooperation between the public, private and traditional sectors would allow for greater awareness of the general state of healthcare and for cross-training between practitioners in the same geographic areas. It would allow for the government to gain more information about the state of rural health. This would allow them to know what policies and strategies would most improve rural healthcare in India.
The Indian government has indicated that it recognizes this problem with the recent formation of the Rural Health Mission. In 2005, this branch of the health department was formed to specifically address the health of rural India. As stated on its website, “the goal of the Mission is to improve the availability of and access to quality health care by people, especially for those residing in rural areas, the poor, women and children.” (National Rural Health Mission).
Another avenue for improvement is the many NGO‘s and hospitals throughout the country working to address this issue. By working with larger hospitals and NGO‘s, the government can begin to create solid pathways between urban and rural areas.
Figure 3:
In fact, in order to achieve great gains for rural communities, there needs to be an integrated approach to health and social development. Such an approach would allow for economic gains, improved healthcare delivery and greater health education for rural communities. It is up to time and the future to decide whether or not India will survive the globalization game. However, with greater intentionality and attention to the state of rural India, the country will go a long way to assuring a more stable future.
Works Cited
1 Banerjee, Abhijit, Angus Deaton and Esther Duflo. “Health Care Delivery in Rural Rajasthan”. Economic and Political Weekly. February 28, 2004. v.39, iss. 9. pp. 944–949.
2 Express Healthcare Management. Rural Healthcare. 16th August 2005. http://www.expresshealthcaremgmt.com/20050831/ruralhealthcare01.shtml.
3 Patil, Ashok V., K.V. Somasundaram, and R.C. Goyal. “Current Health Scenario in Rural India”. Australian Journal of Rural Health. January 2002. pp. 129–153.
4 Deogaonkar, Milind. “Socio-economic inequality and its effect on healthcare delivery in India: Inequality and healthcare”. Electronic Journal of Sociology. 2004. http://www.sociology.org/content/vol18.1/deogaonkar.html.
5 CIA. CIA World Fact Book 2002. 2002. CIA. 1 January 2002. http://www.faqs.org/docs/factbook/geos/in.html.
6 Bardhan, Pranab. “Globalization and Rural Poverty”. World Development. December 2005.
7 Government of India. Ministry of Health and Family Welfare, National Rural Health Mission Document. 2005.
8 Government of India. Ministry of Health and Family Welfare, Bulletin on Rural Health Statistics in India 2006. 2006. http://mohfw.nic.in/dofw%20website/Bulletin%20on%20RHS%20—%2006%20—%20PDF%20Files/bulletin_on_rural_health_statistics.htm
9 Government of India. Ministry of Health and Family Welfare, National Health Policy-2002. 2002. http://mohfw.nic.in/np2002.htm.