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Resource centre on India's rural distress
 
 

Providing low-cost healthcare to villages by Anupama Chandrasekaran

That hospital births curb mother and child deaths is probably a no brainer.

Convincing expectant mothers to get admitted to a hospital is only part of the problem in India’s rural healthcare system. The other challenge is abysmal infrastructure: There is just one hospital bed for every 10,000 Indians living in villages and one in 10 primary health centres in rural areas stumble along without doctors.

The result is a human tragedy. The rate of infant mortality in India is higher than neighbours such as Sri Lanka, Nepal and Bangladesh.

India’s healthcare malaise will be in the spotlight next month, when a public interest litigation accusing the Indian government of inadequate measures to beef up rural healthcare services comes for hearing at the Delhi high court. The case is important in a nation where medical costs continue to be the second major cause of rural indebtedness after farming, according to data from the National Bank for Agriculture and Rural Development (Nabard).

There have been smart solutions on the ground. Maharashtrian community health advocate Abhay Bang has trained locals to conduct deliveries and care for new-born children at low costs, with the result that the state’s tribal areas have seen infant mortality rates plummet below the national average.

Others are also experimenting with barefoot health schemes.

“What villagers need is a health provider within a short accessible distance so that when a child is sick, they should get some basic treatment,” says Meenakshi Gautham, a public healthcare activist and one of the litigants against the government, who has been pushing for a short-term course to train mid-level rural community healthcare providers. “An urban-educated doctor with a privileged background has never willingly fit into the rural health scenario.”

There are exceptions, of course, and Dr Regi George, who along with his wife Lalitha, moved to north-western Tamil Nadu to set up the Tribal Health Initiative (THI) in 1993, providing low-cost healthcare needs to tribals who previously travelled at least 50km to get to a hospital, is clearly one.

The largely impoverished malaivasis, or hill people, usually cannot afford to spend on unproductive sick elders. But, today, septuagenarians such as V. Sabhapathi who are normally fatalistic about their health, come to the hospital for treatment, thanks to a Rs30 insurance card provided by THI that guaranteed him free check-ups, surgeries and medications for a year.

“People are willing to pay for quality, affordable healthcare, otherwise why would an old person, who is not ill, willingly shell out Rs30?” says Dr George.

In March, nearly 500 elderly locals registered for the hospital’s new old-age-healthcare scheme that also offered monthly health supplements available for free at government-run primary healthcare centres, or PHCs.

“As part of the National Rural Health Mission (a 2005 government measure to revamp village healthcare facilities) all the PHCs are well painted and look nice but people’s health expenditure isn’t shrinking,” (see graphic) says Dr Yogesh Jain, a graduate of Delhi-based All India Institute of Medical Sciences and co-founder of the not-for-profit Jan Swasthya Sahyog (JSS) hospital in rural Chhattisgarh. “Any investment in healthcare should infuse skills into people and not just bring in machines.”

Nearly 450 patients wait in line on any outpatient day at JSS. One of the ways Dr Jain and his group of at least 10 other doctors keep patient costs low is by offering all treatment including surgery on the same day a patient sees a doctor. This policy at least keeps wage losses for patients in check.

“Rural healthcare is complicated. For instance, when we see cases of diabetes, we cannot ask the patient to eat limited meals because he or she is actually starved and exercise is out of the question since they are overworked,” says Ramani Atkuri, a tropical health specialist who has been with JSS for the past five years.

Lalit Narayan, 27, attests to this fact. Narayan spent two years at Sittilingi’s THI after graduating in 2007 from St John’s Medical College in Bangalore. He says treatments also get complex in situations where patients insist on returning home before recovery, as they cannot afford to be out of work.

This despite low hospital expenses as THI has a “pay-what-you-can” system for tribals with the balance being covered by a fund supported by contributions from friends that also pays for half of total hospital salary expenses.

Narayan, who completed the government-mandated two-year rural internship for medical graduates without wriggling out of it by paying a Rs3 lakh penalty, admits it was possible for him to function confidently as a newbie because he knew that either Dr George or his wife were just a call away.

Meanwhile, the debate of a three-year or four-year rural medical course continues and the issue of actual training and supervision of such practitioners is lost in the din. In January, the Union health ministry announced that the Medical Council of India (MCI) would chalk out a syllabus for a three-and-a-half-year Bachelor of Rural Medicine and Surgery to be offered by medical schools. But that issue now hangs in limbo after last month’s dissolution of MCI, following the April arrest of its chief Ketan Desai on bribery charges. 

Most fresh medical graduates thrust into rural areas soon after graduation don’t have help of a seasoned doctor on hand. Still, there’s been a national campaign to discourage at-home deliveries and push for hospital births.

Tamil Nadu claims to have 98% institutional deliveries spurred in part by an incentive scheme introduced in 2006 that offers Rs6,000 to mothers delivering their baby in only government hospitals and not at home or private clinics. This scheme was rolled into Dharmapuri district, under which the Sittilingi valley falls, last year.

Around the same time, the PHC at Kottapatti village about 10km from Sittilingi got a fresh coat of paint, new ultrasound equipment as well as a landscaped garden, thanks to funds from the National Rural Health Mission. 

But when this reporter visited the hospital, the oxygen tank in the delivery room didn’t have a knob or a mask, a must for any emergency action, nor did it have an incubator to maintain body temperature for premature babies.

Resident doctor K.S. Raja said the number of deliveries in his PHC quadrupled to 382 last year from just 92 in 2006. But infant deaths also rose to 21 from 16 in 2008. Dr Raja affirmed that the government sets targets for institutional deliveries and interrogates doctors if they aren’t met.

Earlier this month, a child delivered at the PHC was brought to THI, two hours after its birth, as the lone nurse at the PHC that evening couldn’t tackle complications arising from the umbilical cord being wound around the infant’s neck. A few months ago, a mother who had breached delivery was brought to THI from the PHC with the child’s legs dangling out of the mother.

THI’s Dr George saw infant mortality slip from 147 per 1,000 births in 1996 to 20 in 2008 in the valley, but this year he expects the numbers to be up.

“Our healthcare system stresses on institutional delivery,” says Dr Rakhal Gaitonde, who is a training and research associate at public health think tank community health cell. He recently conducted a social audit of mothers delivering at Tamil Nadu government hospitals. “But what really shrinks maternal and infant mortality is the presence of skilled birth attendants and the kind of backup they have during emergencies.”