The rural healthcare challenge | Hindustan Times


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

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

In mid-May, the government released the SOP on Covid-19 containment & management in peri-urban, rural & tribal areas. It lays down a comprehensive range of measures including surveillance, screening, isolation, referral; home and community-based isolation and monitoring; a three-tier constitution for institutional Covid-19 management; post-Covid-19 management; mental health fortify; 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.

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It is very important understand the development philosophy that characterises India’s rural health system. Traditionally, rural health care in India has seen a prominent curative-preventive dichotomy. In contrast to urban areas, preventive care products and services, including maternal and child health products and services, circle of relatives planning, and immunisation, have dominated rural health allocations, and healing care has been insufficient.

Rural health products and services constituted only 27% of state public expenditure on “medical and public health” in 2015-16, while urban health products and services constitute 44%.

Combating rural Covid-19 will not only involve a revamp of rural healing 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 all-weather approachable streets. As of 2020, 34.2% PHCs functioned 24×7, while CHCs saw a 76.1% scarcity of specialists, with only 51.7% CHCs having a functional X-ray machine.

In a similar fashion, many district hospitals, which act as committed Covid-19 hospitals for severe cases, remain highly deficient in critical care infrastructure. While schools and community halls can also 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 committed 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, normally, their clinical armamentarium remains in large part restricted to simple ailments and maternal and child health care.

It is unrealistic to expect that such extensive healing care gaps could be filled even temporarily inside a short span, which makes it even more important to concentrate on preventive efforts (including vaccination), with double the standard 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. On the other hand, this must be backed with sufficient finances, technical assistance, and native autonomy. Addressing the maldistribution of Covid facilities between rural and urban areas is very important.

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All the way through the first wave, many grassroots- and middle-tier public health facilities catered to fundamental non-Covid-19 health care requirements. Even a cursory examination of publicly to be had data reveals that such routine fundamental products and services suffered appreciable disruption. With most rural health facilities involved single-mindedly in Covid-19 mitigation, the affect on routine fundamental care could get worse and can also 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 frequently falls on overburdened health personnel. It is going to be an important to address these in a rural flare-up of the pandemic.

One important measure to facilitate surveillance, early detection, monitoring, in addition to community participation in remote areas could be to entail the ubiquitous casual practitioners (IP) through appropriate crash training. The West Bengal government recently announced one of these measure. While this could be contested by the medical fraternity, an emergency of this magnitude warrants abnormal steps as the advantages exceed the risks. It has been shown that except convenience and affordability, cultural factors are a very powerful reason for visiting IPs as they frequently have the faith of their communities. The SOP already envisages involving devout leaders to facilitate Covid-appropriate behaviour.

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

Dr Soham D Bhaduri is a physician, health policy expert, and chief editor, The Indian Practitioner

The views expressed are personal

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