Revitalizing rural health care delivery: Can rural health practitioners be the answer?

The rural health system of India is plagued by serious resource shortfall and underdevelopment of infrastructure leading to deficient health care for a majority of India. The differences in urban-rural health indicators are a harsh reality even today; infant mortality rate is 62 per thousand live births for rural areas as compared to 39 per thousand live births for urban areas (2007). (1) Only 31.9% of all government hospital beds are available in rural areas as compared to 68.1% for urban population. When we consider the rural-urban distribution of population in India, this difference becomes huge. Based on the current statistics provided by the Government of India, we have calculated that at a national level the current bed-population ratio for Government hospital beds for urban areas (1.1 beds/1000 population) is almost Þ ve times the ratio in rural areas (0.2 beds/1000 population). (2,3) Apart from this shortfall in infrastructure, shortfall in trained medical practitioners willing to work in rural areas is also one of the factors responsible for poor health care delivery systems in rural areas. The number of trained medical practitioners in the country is as high as 1.4 million, including 0.7 million graduate allopaths. (4) However, the rural areas are still unable to access the services of the qualiÞ ed doctors. A total of 74% of the graduate doctors live in urban areas, serving only 28% of the national population, while the rural population remains largely unserved. (4) There’s shortfall of 8% doctors in Primary Health Centres (PHC), 65% for specialist at Community Health centres (CHC), 55.3% for health workers (male), 12.6% for health workers (female) (2007). (5) This shortfall in human resources in rural areas is only going to increase in future, more so with corporatization and privatization of health systems. The already dwindling number of doctors in government sector and rural areas would further decrease owing to greater opportunities in private sector both in urban and peri-urban areas, and much higher remunerations. In absence of qualiÞ ed doctors, predominant providers of health care in rural areas are unqualiÞ ed private practitioners, who have either no training or training in alternate system of medicine but prescribe allopathic medicines. Such providers are able to attract clientele for two reasons: Þ rstly, non-availability of qualiÞ ed doctors; and, secondly, because most of the medical conditions for which services are sought are of the common type, for which the quasi-trained practitioners can often offer some relief. However, the medical services provided by practitioners, who largely practice in a discipline in which they have no training is, in the broader context, highly damaging. For example, indiscriminate and injudicious use of antibiotics by these unqualified medical practitioners is giving rise to new mutant resistant micro-organisms. All of us in the country, and particularly the graduate doctors’ fraternity, need to reflect on why such an iniquitous and harmful mode of health service delivery exists over much of the country. Often it is argued that the Þ nancial rewards in the public health sector are too low to attract the graduate doctors to the scattered rural areas. Another reason cited is that the absence of minimal physical and social infrastructure makes it impossible for young medical graduates to serve in the rural areas, whether in public or private assignments. The qualiÞ ed medical professionals willing to serve in rural areas are scarce and whatever trained doctors are available in rural areas are in government service. It is important to note here that doctors/specialists in position do not necessarily mean that doctors/specialists are physically present at their respective centres and performing their duties; in fact, absenteeism is very high. We have to be realistic and accept that trained doctors who have put in 10 years or so in training and are predominantly from urban areas are unlikely to want to go to villages. It has been suggested in various quarters that to ensure medical personnel’s stay in rural areas they would have to be provided special incentives, pay hike or the basic amenities like electricity and water have to be improved