In response to the question posed by INC Lok Sabha MP from Rajasthan, Ummeda Ram Beniwal, on the lack of healthcare facilities and resources, affecting patients in India, the Central Government has cited the Rural Health Statistics 2022, which suggests that massive health infrastructure gaps need to be covered in rural areas. The Minister of State for Health and Family Affairs, Anupriya Patel referred to the Rural Health Statistics 2022 data in her reply to the query put forth by Beniwal on August 9 concerning the lack of health infrastructure in the country. The data given reveals that as of July 1, 2022, rural areas face a shortfall of 48060 Sub-Centres as against the requirement of 1,93,310 such centres, with the present number of Sub-Centres being at 1,57,935.

Similarly, rural India has a shortage of 9,742 Primary Health Centres (PHCs) against its required strength of 31,640 PHCs, with 24,935 PHCs presently in use. The number of Community Health Centres (CHCs) currently in use stands at 5480 against the required strength of 7894 such centres, with a shortfall of 2852 CHCs in total.

The parliamentary answer by the MoS Anupriya Patel explained that “All India Shortfall is derived by adding State-wise figures of shortfall ignoring the existing surplus in some of the states.” However, state-wise data regarding the shortage was not included in the response. Importantly, the figures provided here does not include shortage of such centres in urban areas, thus revealing the magnitude of the issue.

Patel further informed the Lok Sabha about the Union Government’s efforts at improving health infrastructure and human resource shortage, noting that the Health Ministry provides “technical and financial support including support for recruitment of health human resource (Specialists Doctors and other health workers), to the States/UTs to strengthen the public healthcare system, based on the proposals received in the form of Programme Implementation Plans (PIPs) under National Health Mission.”

She also said that under the Fifteenth Finance Commission (FC-XV) and PM-Ayushman Bharat Health Infrastructure Mission (PM-ABHIM) various initiatives have been undertaken, with “a total of 12,606 units of building-less sub-health centre, 881 units of building-less Primary Health Centre and 125 units of building-less Community Health Centre” being provisioned for the FY 2021-22 to 2023-24.

The response further stated that “Under PM-ABHIM, provisions have been made for construction/strengthening of 730 Integrated Public Health Labs (IPHLs), 3382 Block Public Health Units (BPHU), 602 Critical Care Blocks (CCBs) and 7,808 units of building-less sub-health centre-Ayushman Arogya Mandir during the scheme period FY 2021-22 to 2025-26.”

Notably, some states, including Mizoram, Nagaland, and Meghalaya have pushed back over renaming of Ayushman centres as ‘mandirs’ questioning the imposition of dominant religious nomenclature.

The parliamentary response on the subject dated August 9 can be found here:

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What can MHWs do in rural areas? Gender inequities in developing societies mean that men play a dominant, decision-making role in reproductive health. MHWs can make a difference by educating men about maternal health issues and guiding their decisions, said the study. They can also complement the efforts of female health workers in delivering health services in remote areas and at late hours.
 
However, this may prove to be difficult in India. There are no MHWs in 48% of health sub-centres in Indian villages; and overall, there is a 65% shortage of MHWs in public health centres, according to the Rural Health Statistics 2016.
 

Source: Rural Health Statistics 2016
 
It is clear India has to improve its maternal-health services. The government scheme to reduce maternal mortality rate, Janani Suraksha Yojana (JSY), has helped push up institutional deliveries by 15% over the decade ending 2014, according to this 2016 report by Brookings India, a think tank. But as IndiaSpend reported in February 2017, JSY is often not delivering quality care to the country’s poorest women.
 
This lack of access could explain why India accounted for close to a fifth of 303,000 maternal deaths and 26% of the neonatal deaths globally, as IndiaSpend reported in September 2016. MHWs can help improve the coverage of maternal and newborn child health services delivered by the formal health care system, and improve home-based management of these services.
 
To research the role MHWs could play, the study recruited and trained men to complement the work of female health workers. An IndiaSpend analysis of the findings of the study and other data reveals three reasons why MHWs were effective in improving the quality of maternal and newborn child health services:
 
1. Female health workers struggle with mobility, security issues
 
In rural India, sub-centres are the ‘first port of call’ for accessing health care. Ideally, sub-centres in remote and hilly areas should be manned by at least two auxiliary nurse midwives (ANMs), one male multipurpose worker, one pharmacist and one AYUSH doctor or community health officer. There was an increase of 5% in sub-centres from 2005-15, IndiaSpend reported in February 2016.
 
Each ANM is assisted by four to five Accredited Social Health Activist (ASHA) workers who are responsible for delivering health services to the village population but they face some obvious challenges at work given prevailing gender norms.
 

• Night deliveries: The study interviewed women who spoke about the risks associated with night deliveries when villages are far from health facilities and there is a lack of ready transportation. In such cases, female health workers (FHWs) are often unable to help pregnant women reach a hospital. MHWs, on the other hand, can facilitate pregnant women’s access to health services, especially during night, as observed during the study.
• Communication gap with husbands: The reach of FHWs to men in local communities is limited due to gendered norms and other factors, according to the study. MHWs can bridge the communication gap with husbands and educate them about various aspects of reproductive health.

An estimated 22% of sub-centres are short of ANMs and in 30% of India’s districts, sub-centres with ANMs serve double the patients they are meant to, IndiaSpend reported in September 2016. MHWs can help the system deal with these shortages.
 
2. MHWs can convince men about the need for better maternal care
 
The subordinate position of women in Indian society has been acknowledged as a fundamental constraint to women’s access to reproductive health services. Women tend to have less access to household resources.
 
Nearly 80% of women in India said they had to seek permission from a family member to visit a health centre. Of these, 80% said they needed permission from their husbands, 79.89% from a senior male family member, and 79.94% from a senior female family member, according to the 2012 Indian Human Development Survey (IHDS) survey, IndiaSpend reported in February 2017.
 
However, regional variations exist. As many as 94% of women reported needing permission to visit a health centre in Jharkhand, the highest in any state, while only 4.76% of women in Mizoram said they needed to ask family members, the lowest.
 
Given this social structure, MHWs can convince husbands–who have poor knowledge on the do’s and don’ts during pregnancy, childbirth and the postpartum period–about the importance of providing antenatal care and health services during pregnancies.
 
India’s RMNCH+A (Reproductive, Maternal, Newborn, Child and Adolescent) health strategy–formulated in 2013–recognised the central role of men in women’s reproductive health and includes guidelines for training of health workers to provide husbands of pregnant women with the relevant information.
 
Interventions to promote the involvement of men during pregnancy, childbirth and after birth have been strongly recommended by the World Health Organization in its 2015 report on recommendations on health promotion interventions for maternal and newborn health.
 
3. Complementing the work of female health workers
 
Coverage of maternal health services in west Odisha’s Keonjhar district, where the study was focussed, improved due to increased MHW engagement. The male health workers arranged transport and accompanied pregnant women to distant health facilities in emergencies and, according to the ASHA workers interviewed in the study, also sometimes climbed hills to reach distressed households in different settlements.
 
At the time of deliveries, the gendered division of labour was apparent, researchers found. MHWs handled tasks outside of the delivery room–keeping track of the family’s personal items, obtaining medicines, and in cases where a blood transfusion was necessary, obtaining donated blood.
 
One ASHA worker who was interviewed during the study said: “He [MHA] cannot enter in the delivery room. He brings the medicine which is required and all things he [the health professional] tells; he [MHA] tells the husbands (sic). I can convince the mothers but not the husbands.”
 
Male health workers have made a difference in other developing nations
 
Health initiatives that are shouldered by both male and female health workers have worked well in other countries. There is a significant need to scale up men’s participation in maternal health and provide them with the sufficient information to help them make decisions and support their partner’s decisions concerning family health, wrote Olena Ivanova, a maternal health expert at the International Centre for Reproductive Health, Belgium, in this blog in February 2015.
 
“More rigorous evaluations of male involvement initiatives, attention to vulnerable and disadvantaged families, acknowledgement of heterogeneity of fathers’ groups, revision of policies and laws and closer collaboration between different sectors are needed in order to strive for better maternal and newborn health outcomes and well-being,” she added.
 
Evidence from Rwanda, among the few countries to pair male and female health workers, indicates that the approach could work in settings where it is not safe or socially acceptable for women to travel alone. And educating pregnant women and their male partners leads to better maternal health behaviour than educating women alone, according to this 2006 study in urban Nepal.
 
However, it is important to tread cautiously, said the study.
 
To reinforce these successes, as the study showed, MHWs should operate in ways that do not contribute to widening gender inequalities in favour of men.
 
(Saha is an MA Gender and Development student at Institute of Development Studies, University of Sussex.)

Courtesy: India Spend
 

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Overall, there was a 6% rise in dependence on public healthcare for out-patients and 7% for in-patients over the decade ending 2014, said the Brookings report, which analysed National Sample Survey Office (NSSO) data over this period.
 
An in-patient is formally admitted for at least one night to a hospital, while an out-patient visits a hospital, clinic, or associated facility for diagnosis or treatment.
 
For out-patient care, 74.9% of ailing patients (who sought care) exclusively accessed a private facility in 2014, compared to 79.7% in 2004. The biggest decrease was seen among rural women, as we said. While 78.2% of them sought private care in 2004, 70.4% did in 2014.
 

Source: Brookings India, based on National Sample Survey Office data
 
In-patients depend less on the private sector than do out-patients, the data reveal.
 
The percentage of in-patients seeking public care increased from 42.3% in 2004 to 45.4% in 2014;  the percentage of rural women accessing public care rose from 45.1% in 2004 to 56.1% in 2014.
 

Source: Brookings India, based on National Sample Survey Office data
 
“The number of people seeking private healthcare, however, might be an underestimation, as NSSO surveyors are instructed to mark all those who went to both government and private facilities as “only going to government facilities,” said the Brookings report.
 
Indians spend eight times more in a private hospital than a government hospital, according to this analysis of National Health Accounts (NHA) 2013-14 data by The Hindu.
 
Quality of care biggest constraint for not accessing public hospitals
 
Despite the decline in exclusive dependence on private care, 29 of every 1,000 Indians pointed to the unsatisfactory quality of healthcare, the most commonly cited reason for not accessing a public hospital.
 
Long waiting periods at government health services appears to be an increasing bottleneck in seeking public care. In 2004, 6.8 of every 1,000 cited this as a reason for not using a public hospital; it rose to 18.6 in 2014.
 
Of 930,000 doctors in India, 11.4% (106,000) work for the government. This means there is one government doctor for every 11,528 people, according to the National Health Profile 2015, IndiaSpend reported in November 2016.
 
Public-health centers across India’s rural areas–25,308 in 29 states and seven union territories–are short of more than 3,000 doctors, the scarcity rising 200% (or tripling) over 10 years, IndiaSpend reported in February 2016.

Source: Brookings India
 
More people required medical care over a decade
 
The number of people not using medical services fell from 15.1 in every 1,000 in 2004 to 12.4 in 2014, which implies an 18% increase in Indians seeking some form of healthcare.
 
There was an increase, however, in the proportion of people not seeking services, as they felt their ailment wasn’t serious enough, and more women than men report not using healthcare due to the same reason–the gender gap has widened over the decade.
 
More Indian men are likely to be admitted to hospital during the last moments of life than women–62.5% to 37.5%, IndiaSpend reported in November 2016. For every 1,000 men whose death is certified by medical professionals, the corresponding figure for women is 600.

Source: Brookings India
 
The number of people not using healthcare due to financial reasons reduced from four of every 1,000 in 2004 to 0.7 in 2014, said the Brookings report, possibly a result of rising incomes or use of publicly funded health-insurance schemes implemented over the last 10 years by the central and state governments.
 
About 12% of the urban and 13% of the rural population got health insurance through the Rashtriya Swasthya Bima Yojana (National Health Insurance Scheme) or similar plans, IndiaSpend reported in July 2015.
 
(Saha is an MA Gender and Development student at Institute of Development Studies, University of Sussex.)

This article was firs published on India Spend
 
 

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The primary health centre at Melkote, in Mandya district, Karnataka, has only one doctor–to serve 20,000 people across 33 villages. The number of medical colleges and seats have almost doubled in India over the past decade. But the doctor-patient ratio in even the most prosperous states, home to the majority of India’s private medical colleges, is still way off the WHO requirement of 1:1,000
 
Anyone who falls critically ill in Melkote on a Sunday has only one option–to take the ambulance parked at the PHC to the closest hospital 23 km away, in Pandavapura talukasubdivision.
 
For a decade now, Dr Harsha D has been treating every sick person in this rural pocket, commuting 120 km between the centre and his home in Mysuru. “I wish there was another hospital in the vicinity and more doctors too,” he said.
 
Melkote is not some remote, poor village in an ailing state. It sits in Mandya district, just 100 km south-west of the state capital, Bengaluru. This is an agriculturally prosperous district with a literacy rate of 70.4%. Its per capita income of Rs 114,270 is well above national average of Rs 93,293. And 70% of its villages boast of a human development index above the state average of 0.4392.
 

 
Melkote itself boasts of lush fields and agro units, and the incomes of its residents are rising. But it still doesn’t have 24×7 access to basic healthcare. Its troubles are representative of one of India’s biggest failures–that a country with an 8% growth in gross domestic product (GDP) still cannot provide the essential healthcare to its citizens.
 
Here is a bigger irony: Karnataka ranks number three among states that produce the most number of doctors every year in India. But Mandya’s doctor-patient ratio of 1:20,000 is closer to that of backward states such as Chhattisgarh and Jharkhand. The World Health Organization (WHO) standard is 1:1,000.
 
An analysis by IndiaSpend revealed that, between 2007 and 2014, the southern states added more doctors to the national talent pool than other regions. Tamil Nadu added 23,754 doctors, Karnataka 25,432, Kerala 9,406 and Andhra Pradesh 15,233. This is a third of the total number of doctors added by all states across the country during the period.
 

Source: National Health Profile, 2015, Ministry of Health & Family Welfare
 
But none of these states have doctor-patient ratios that are anywhere close to the ideal. Karnataka, for instance, ranks number 10 among the worst performers on this parameter and Andhra Pradesh, number 5.
 
Shortage of doctors; disparity between states
 
Despite government investment, India could add only 2.07 lakh doctors between 2007 and 2015. The requirement is for another 3 lakh. IndiaSpend had earlier reported how India is faced with shortage of 5 lakh doctors.
 
Data analysis showed that it would take India another decade to come up to the WHO standard.
 
Of the 9.3 lakh doctors in the country, only 1.06 lakh work for the government. This means there is one government doctor for every 11,528 people, according to the National Health Profile 2015 report.
 
Even if we add private doctors to the tally, the doctor-patient ratio only moves up to 1: 1,319, still lower than the WHO limit, 75% lower than Argentina, and 70% lower than the US, according to data from World Bank.
 
There are states that fare worse than the average–in Bihar, Chhattisgarh and Maharashtra, one doctor serves more than 25,000 people.
 

Source: National Health Profile, 2015, Ministry of Health & Family Welfare
 
Bihar, which has the worst doctor-patient ratio, could add only 3,179 doctors in seven years. It would take it another 140 years to make it to the WHO standard.
 
Medical college seats double, but all concentrated in south, west
 
The number of doctors available can be directly linked to the number of its medical colleges in the country. Data collected over the past 10 years show an impressive growth in number of colleges and seats, with almost 18 more colleges added each year and the number of seats doubling.
 
As of October 2016, there were 422 medical colleges with 57,000 medical seats across the country. However, 60% of them are concentrated in six states and one union territory–Maharashtra, Karnataka, Andhra Pradesh, Tamil Nadu, Kerala, Gujarat and Pondicherry–covering 50% of the medical seats in India, according to ministry of health & family welfare data.
 
In contrast, in states such as Bihar, Uttar Pradesh and Assam where there is greater need for medical help, the number of colleges is less.
 
Private colleges outnumber govt ones
 
Most of the colleges added over the last decade, however, were private. Today, private colleges (224) outnumber government medical colleges (198).
 
But medical education entrepreneurs seem to be steering clear of the northeast–there are none in Assam, Manipur, Meghalaya, Tripura and Nagaland. Sikkim has one.
 

Source: Rajya Sabha answers: 2016 and 2006
 
“Medical education is a thriving business. But private investment in medical education is concentrated in the southern states, and in Maharashtra. It’s not lucrative in backward states,” said Deoras Kiranshankar of the Indian Medical Association. “Second, private medical colleges are bringing in rich students who show little willingness to work in rural areas. Many of them go abroad.”
 
The government needs to intervene, he said, opening more affordable medical institutions. Kiranshankar cited Chhattisgarh, with five government medical colleges and only one private college, as the ideal that other states needed to emulate.
 
India continues to spend little on health
 
India’s poorer states have health indicators that are worse than those of many nations poorer than them. This is not surprising because health expenditure as a share of India’s GDP has not improved in the last two decades–it was 1.1% of the GDP in 1995 and it only rose to 1.4% in 2014.
 
The Twelfth Five Year Plan and the draft health policy in 2015 have committed to an increase in public expenditure on health–to 2.5% of the GDP.
 
Among the BRICS (Brazil, Russia, India, China and South Africa) nations, India spends the least on health.
 
The result is that that 89.2% of the health expenditure in India is private (out-of-pocket), according to this 2014 World Bank report. It was 91.4% in 1995. Out-of-pocket expenditure is the share of expenses that patients pay to the healthcare provider, without a third party insurance or government-subsidised treatment.
 
In 2011-12, the share of out-of-pocket expenditure on health care as a proportion of total household monthly per capita expenditure was 6.9% in rural areas and 5.5% in urban areas, according to the National Health Policy-2015 report of the ministry of health and family welfare.
 
This has led to an increasing number of households shouldered with health costs: 18% of all households in 2011-12 from 15% in 2004-05.
 
In India, to finance hospitalisation costs, “rural households are primarily dependent on household income/savings (68%) and less on borrowings (25%), whereas urban households rely more on income/saving (75%) and lesser (18%) on borrowings”, noted Thayyil Jayakrishnan, department of community medicine, Government Medical College, Kozhikode, in his research paper.
 
The Indian healthcare industry, which remained strong even during the recession of 2008–when it was valued at Rs 3 lakh crore–is projected to grow to Rs 18 lakh crore by 2020, according to industry body India Brand Equity Foundation.
 
Why rural India still travels to town for medical help
 
Melkote’s inadequate medical infrastructure is visible across Indian villages. Two-thirds of the country lives in villages, but most doctors are concentrated in urban areas which already have good medical infrastructure. In PHCs across India, only 27,355 allopathic doctors were posted in rural areas; 79,060 were working in towns and cities, data from two years ago show.
 
Union health minister J P Nadda has acknowledged this divide. Answering a question in the Rajya Sabha on doctors’ reluctance to serve in rural areas, he said that the feeling of professional isolation and a disparity in the living conditions between towns and villages were the primary reasons.
 
He maintained that the number of doctors posted in PHCs in rural areas has risen from 22,608 in 2007 to 27,355 in 2014, marking a slow improvement.
 
PHCs in rural areas are short of more than 3,000 doctors, the scarcity rising 200% (or tripling) over 10 years, IndiaSpend reported in February 2016.
 
But, government efforts lack in scale, resources, training and financial outlay: Around 25% of the sanctioned posts for doctors in PHCs and 66% of specialist posts in Community Health Centres are lying vacant, according to a rural health statistics report.
 

Source: Rural Health Statistics, 2014-15, Ministry of Health & Family Welfare
 
“The government is to blame. Without creating necessary infrastructure, without medicines, without medical equipment and lab facilities, how can a doctor function if posted in a distant village? Housing and schools for doctors’ families should be there,” said Kiranshankar.
 
(Mallikarjunan is a Bengaluru-based independent reporter and a member of 101Reporters.com, a pan-India network of grassroots reporters.)

Courtesy: India Spend
 

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