Getting the basics right: Rural healthcare in India awaits a paradigm shift

India houses more than 17.7 percent of the world population, 21 percent of the global diseases, and the largest burden of communicable diseases in the world. While our country has made significant advances over more than a decade, reducing the gap between rural and urban areas, the disparities and access to healthcare in rural areas still remains a huge challenge. Further, there is a personnel resource gap with a doctor-patient ratio of 1:1500 against the World Health Organization’s recommended 1:600. To make matters worse, 75 percent of qualified doctors serve urban areas, thereby restricting access to the rural population. This resource shortage has resulted in a lack of quality healthcare that is affordable to the masses.

In such a backdrop, there is a growing recognition that India needs to build a strong comprehensive primary healthcare system to accomplish any further advancements in the health status of the populations and to reduce these disparities. In order to accomplish quality healthcare for all, we would need to integrate affordability with accessibility, quality, and viability.

Another fact is that India spends 1.6 percent of its GDP on healthcare against the global 9.4 percent. In union budget 2020-21, there is INR 69,000 crore (US$ 9.87 billion) outlay for the health sector that is inclusive of INR 6,400 crore (US$ 915.72 million) for PMJAY. The Government of India aims to increase healthcare spending to 3 percent of the Gross Domestic Product by 2022.

While larger allocation in itself does not guarantee improved access to healthcare, the increased provision for basic health services besides balancing affordability to people and the viability of services could certainly help in correcting this imbalance. Ultimately, the key transformation lies in the hands of respective state governments.

Building a healthcare workforce with rural priorities  

Evidence suggests that improved living and working conditions, better salaries, use of disruptive technology, co-operative arrangements with other rural health facilities, and continued training help the doctors and nurses to provide high-quality care in rural areas.

If we look at the current graduate training of nurses and doctors, there is a heavy urban and tertiary healthcare bias. In such a scenario, there is a need for a paradigm shift in undergraduate medical and nursing curriculum to align it with rural priorities. The training of MBBS should be aligned toward producing rural family physicians, and nursing graduates, to produce rural primary care nurses.

In recent years, there has been a huge increase in postgraduate seats for medical graduates. Allocating them to family medicine, with appropriate training in rural health care settings, will bring about the change in focus from tertiary care to primary care, and from urban bias to rural focus. A large number of state-funded medical colleges are being set up in district hospitals, most of which are rural. Entrusting them with the healthcare of their respective districts, focusing on sourcing rural students, adapting their training curricula to meet local needs, and helping them place within the districts would help them fulfill their social accountability.

We must define improvements in training, living, and working conditions for rural healthcare professionals. Concerned authorities must identify and accredit rural training sites for rural health professionals. That would ensure sustained and high-quality training of a large workforce.

Action points for a strong ecosystem

Only the patients referred by Primary Healthcare Centres (PHCs) should be entitled for insurance cover under flagship scheme, Pradhan Mantri – Jan Arogya Yojna (PMJAY) for secondary or tertiary care. It would help in promoting access to primary healthcare and also reduce the overall expenditure on healthcare, by reducing unnecessary referrals and by treating diseases at an earlier stage.

In India, there is a need to provide a common ground for different stakeholders and work towards ensuring harmony among them. The trust deficit between the government and the private sector needs to be bridged. Rural settings require joint interventions and a model based on mutual understanding could be worked out. There is enormous pan India data available with the government in the healthcare sector which can be used for research and development through the Public Private Partnership model. This research can further help in developing various programs like effective patient safety programs in hospitals and improving healthcare service delivery.

There is a need to address the barriers that impede the building of a robust ecosystem for healthcare in the country i.e. issues of infrastructure, disease burden, and lifestyle diseases. There is also a need to address the demand-supply mismatch: availability, accessibility, and affordability with respect to lack of skill pool and hospital beds. The improved quality addresses patient satisfaction, reduces cost, enhances affordability, leading to sustainability.

The proper tracking of health inflation and expenditure could help in a realistic policy framework. The personal health records and screening of diseases amongst the population could help in catching up with trends. Lastly, the research and development to create innovative technologies and low-cost interventions are absolutely essential to ensure the last mile healthcare delivery we are aspiring for.