India is set to overtake China as the most populous country sometime this year, it has admirably navigated through a global recession and various estimates indicate GDP growth will average 6% + over the next projection that India’s annual nominal gross domestic product growth will average 6.3% through the 2030s making it the third largest economy by 2030. On multiple health parameters, India has seen enormous improvements; life expectancy at birth is 70.42 years, inching closer to the global average life expectancy; infant, maternal, and neo-natal mortality; rate of disease incidence all registering impressive declines. However, rural India continues to lag behind on key drivers of quality of life, these include continuing nemesis of communicable diseases, and vector-borne diseases contributing to morbidity and mortality. In addition, pandemic and non-communicable diseases (NCDs) have now become the leading cause of death. The epidemiological transition is fuelled by the social and economic determinants of health. Our biggest challenge is now the widening gap between those living in urban and rural areas access to health services, with disproportionately greater risk for communicable and NCDs and much lesser capabilities to cope with the diseases.
Basal poor health levels reflected in child undernutrition and low birth weights with the rate of decline remaining slow compounds long-run challenges to the quality of life. Niti Aayog’s Health Index 2022 shows no to low progress in high rural states of Bihar, Uttar Pradesh, Madhya Pradesh, and Odisha with close to 40% of the national rural population in these states – Bharat is not doing well. The pandemic made stark urban-rural disparity in infrastructure, and services very visible; the over-stretched and often missing public healthcare system is pushing millions into poverty and indebtedness; 71% of healthcare expenditure is through private sources.
The recently published Rural Health Statistics 2022 by Union Ministry for Health & Family Welfare corroborates the shortfall on two critical fronts — doctors and infrastructure. Less than half the Primary Health Centres (PHC) function on a 24×7 basis and of the 5,480 functioning Community Health Centres (CHC), only 541 have all four specialists – even for physicians there is a shortage of 79.1%.
Budget 2023 is an opportunity for rebuilding the confidence and trust of the community in the public health system rather than announcing mega schemes. The scale of India’s public health challenge is the scale of opportunity to transform the quality of life in villages and for India to lead on the global SDG commitments. The budget could do well to remember that the unprecedented demographic changes can give an edge only when the population is healthy. The country at present suffers from the triple burden of disease — the unfinished agenda of infectious diseases; the challenge of noncommunicable diseases (NCDs), linked with lifestyle changes; and the emergence of new pathogens causing epidemics and pandemics.
The government has provided comprehensive health coverage for all, however, with disparities in health and health care systems between poorer and richer states and underfunded health care systems that in many cases are inefficiently run and underregulated; so while government-financed health insurance coverage increases but insurance remains limited. “Public Trust” is central to a well-functioning care system, it is a two-way street; communities need to have faith in the system and authorities need to trust communities. The pandemic response in Bharat, rural India showed it is possible to have bonds of trust. The Budget 2023 should become a tool to renew the hope of millions living in rural India. While many may ask for new allocations in new areas, justifiably so; however, given the centrality of health to quality of life, I will urge and hope for a paradigm shift in our outlook to focus on “walk the talk”, rather than more talk; focus on last-mile delivery. Few areas requiring our collective attention includes:
Ensuring basic services at Health & Wellness Centre:
Augmenting the frontline primary healthcare system is a commitment, special funds have been allocated under PM-ABHIM and XV-FC Health Sector grant; unfortunately in the absence of critical services the conversion to Health & Wellness remains physical-infrastructure driven only; dedicated resources are needed to immediately fill the equipment and service gaps in already converted facilities. As per Rural Health Statistics (RHS) 2021-22 of MoHFW, there is a shortfall of 48,060 (25%) sub-centers, 9,742 (31%) PHCs and 2,852 (36%)* CHCs. The recent RHS 2021-22 reveals that there is a shortfall of 17,435* specialists at CHCs in rural areas. Our ground experience shows we need an additional one-time investment of Rs.2.5 Lakhs per facility to meet the shortage of equipment, this will also help in achieving the goal of comprehensive primary healthcare at the nearest facility.
Special fund for supporting Small Private Nursing Homes and Clinics:
In absence of public health infrastructure rural poor depend on the neighborhood mushrooming nursing homes. Most lack basic infrastructure, these are run by entrepreneurial medical practitioners, with an average of less than 10 beds, these facilities are not covered under Ayushman Bharat Insurance Schemes. A special fund of Rs. 100 Cr. administered through banking infrastructure as interest subvention to pilot transiting the small nursing homes to upgrade their facilities for empaneled under Ayushman Bharat Insurance will support bringing quality tertiary care closer to communities.
Rural India relies on faith healers and ubiquitously present what is often called as Jholachhap Doctors – untrained, delivering a quick-fix cocktail of steroids and saline. A program that links the accredited health service facility to local unemployed rural STEM graduate to deliver 3D health services (doctors, diagnostics, drugs) as ‘Medical Entrepreneurs’. Local youths can be trained on basic skills and linked to Jan Aushudhi Kendra, and facilitate doctor -patient conversation on ‘Doctor-on-Call’/ telemedicine platforms put in many states, this could be supported under SKILL INDIA.
The big learning from the COVID response has been the opportunity to integrate Panchayat Raj Institutions and Women Collectives with the health care system; PRI-SHG-Frontline Workers (ANM-ASHA-ANM) can establish a mechanism at the habitation level for identifying, and tracking and referring ‘high-risk’ cases and access to tertiary care. This can be formalised as part of the Village Health Plan and become the social spine for delivering the National Health Mission mandate powered by the emerging digital spine being put in place as part of the National Digital Health Mission.
* Rural Health Statistics 2021-22, GoI, Ministry of Health and Family Welfare, pg 121. (Accessed online on 19/1/23)
* Rural Health Statistics 2021-22, GoI, Ministry of Health and Family Welfare, pg 138 Table 23. (Accessed online on 19/1/23)
(This article has been authored by Shyamal Santra, Public Health & Nutrition Expert at Transforming Rural India Foundation.)
Disclaimer: These are the personal opinions of the author.
NDTV – Dettol have been working towards a clean and healthy India since 2014 via the Banega Swachh India initiative, which is helmed by Campaign Ambassador Amitabh Bachchan. The campaign aims to highlight the inter-dependency of humans and the environment, and of humans on one another with the focus on One Health, One Planet, One Future – Leaving No One Behind. It stresses on the need to take care of, and consider, everyone’s health in India – especially vulnerable communities – the LGBTQ population, indigenous people, India’s different tribes, ethnic and linguistic minorities, people with disabilities, migrants, geographically remote populations, gender and sexual minorities. In wake of the current COVID-19 pandemic, the need for WASH (Water, Sanitation and Hygiene) is reaffirmed as handwashing is one of the ways to prevent Coronavirus infection and other diseases. The campaign will continue to raise awareness on the same along with focussing on the importance of nutrition and healthcare for women and children, fight malnutrition, mental wellbeing, self care, science and health, adolescent health & gender awareness. Along with the health of people, the campaign has realised the need to also take care of the health of the eco-system. Our environment is fragile due to human activity, which is not only over-exploiting available resources, but also generating immense pollution as a result of using and extracting those resources. The imbalance has also led to immense biodiversity loss that has caused one of the biggest threats to human survival – climate change. It has now been described as a “code red for humanity.” The campaign will continue to cover issues like air pollution, waste management, plastic ban, manual scavenging and sanitation workers and menstrual hygiene. Banega Swasth India will also be taking forward the dream of Swasth Bharat, the campaign feels that only a Swachh or clean India where toilets are used and open defecation free (ODF) status achieved as part of the Swachh Bharat Abhiyan launched by Prime Minister Narendra Modi in 2014, can eradicate diseases like diahorrea and the country can become a Swasth or healthy India.