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Dr R Kumar
President, Society for Promotion of Ethical and Affordable Healthcare
WHILE health preservation and awareness are almost non-existent all over the country, medical treatment is scanty and unscientific in villages. With 70 per cent of the population living in rural areas and the level of medical facilities low, the mortality rates due to diseases are high. Most villagers get deplorable facilities in public hospitals as well as private clinics. The government has limited capability to fulfil the basic health needs of the rural folk, including nutrition, sanitation, prevention of sickness, promotion of wellness, vaccination and the administration of primary medical care.
The primary health centres (PHCs) lack infrastructure, a credible referral system, and a manpower policy. Blaming or bonding the doctors for not serving in rural areas, but not providing them even basic amenities such as accommodation, electricity and water, and security, cannot improve the situation. While PHCs hardly function, rural medical practitioners, who provide 80 per cent of the outpatient care, are largely uneducated.
With one doctor for every 11,000 people, India falls far below the World Health Organisation standard of 1:1,000. The problem is particularly stark in villages. It is hard to change patients’ behaviour and get them to visit the PHC instead of the village quack. These quacks charge for injections that have low efficacy and are potentially harmful. Unethical practices such as unnecessary surgeries and kickbacks for referrals are well known. Regulatory bodies such as medical councils are unwilling to fulfil their responsibilities; the legal system is ill-equipped to handle the burden of medical litigation; and the aggrieved patients and their relatives cannot afford the high costs.
Major problems at the level of primary healthcare are: absenteeism of the staff; shortage of qualified doctors; non-availability of proper infrastructure, including equipment, medicines etc.; and low motivation of the public to visit the PHCs.
The Bhore Committee (1946) had recommended integration of preventive and curative services and development of primary healthcare on priority. The Alma Ata Declaration of ‘Health for all by 2000’, signed in 1978, was endorsed by the government. The Constitution’s 93rd Amendment, accepting education as a fundamental right, has strengthened the case for ‘right to healthcare’, if not the ‘right to health’. The National Health Policy-2017 mentions the growing incidences of catastrophic expenditure due to healthcare costs, especially in the rural areas. The need to strengthen public health facilities is paramount.
Rural healthcare continues to be on the sickbed. The government’s efforts have been inadequate. When seriously ill, the villagers either rush to sorcerers and hermits or throng the cities, overcrowding institutions such as AIIMS or PGI.
Health issues confronted by rural people are many and diverse — from severe malaria to uncontrolled diabetes and multidrug-resistant TB, from badly infected wounds to cancer, besides drug addiction, smoking and alcoholism. Post-partum maternal illness is a common problem that contributes to maternal mortality. Most women suffer from protein-iron-calcium deficiency with resultant anaemia in over 50 per cent of them, dehydration in 60-70 per cent of the people, malnourishment in 45 per cent cases among under-five children, and lack of immunisation in 58 per cent of the children. Besides, 69 per cent of the rural population has no access to potable water and 99.5 per cent is deprived of basic sanitation and suffers from infectious diseases. It is also estimated that mental ailments affect about 20 per cent of the villagers.
While corporate hospitals offer latest equipment, highly qualified doctors and patient-friendly services to the rich clients, sick or injured villagers are left in the lurch, with nowhere to go even for first aid.
The Punjab Government’s recent resolve to strengthen public health services and try out the PPP model for OPD treatment on a pilot basis is laudable, especially when medical care at PHCs is inadequate. However, fleecing of patients needs to be prevented. The move should reduce the cost of treatment for the poor, if not make the tests and medicines free for them. Another step is to promote a healthy lifestyle so that the need for medical treatment is reduced. In this direction, the Tandarust Punjab project has been conceived well. Multi-department involvement in bringing healthcare to the people is the right strategy.
While Punjab’s public health delivery system operates at three levels —primary, secondary and tertiary — private practitioners provide clinic-based practice in low-risk cases. Public health facilities increased up to the mid-1980s in the state mainly due to an increased allocation of funds and a pro-rural policy of the state government. Subsequently, the health budget and attention towards rural care dipped in the public sector and the gap was filled by RMPs.
The fact that the poor have to pay for treatment from their own pocket underlines the collapse of the rural public healthcare system. The treatment in high-profile hospitals of the cities traps the patients in a web of tech-centric medical system that is confusing, intimidating and expensive. The physician-patient fee for service model or the health insurance model bring unethical practices and push the costs sky high. For a normal headache, MRI/CT scan is prescribed. These models do not suit our rural folk. A social perspective model that envisages the PHC as a social enterprise for the well-being of citizens is the right choice. It also means the greatest good for the greatest numbers.