Rural health gap: is there a role for informal providers?

Abstract

There is a glaring disparity between the rural and urban health environments in India. This could be in terms of infrastructure, health personnel, funds allocated and other attributes, and translates into a situation where there is a palpable decrease in the quality, access and health care available to the rural poor. RURALHEALTH SCENE: The following facts and figures related to critical indicators such as doctor population ratio, beds per population, access to medicines, distance to a health set up and vacancies substantiate the grim situation. The doctor-population ratio of rural population to doctors is six times lower than in urban areas .The ratio of rural beds vis -à-vis the population is 15 times lower than in urban areas. More than about 66 percent of the rural population in India lacks access to preventive medicines. Next is the question of equity and it is estimated that 31 percent of the rural population in India has to travel over 30 km to get needed medical treatment. More than 50 percent of the posts for specialists in PHCs or CHCs are vacant. Even the health indicators like Infant Mortality Rate, Crude Death Rate, Neo natal mortality rate and Peri natal mortality rate are higher in rural areas. WHO WILL BRIDGE THE GAP : Having understood that there is a health gap in rural areas and that the existing three tier health model is not able to meet the requirements of access and equity , the question to be answered is how or who can bridge the gap. This could be through several policy alternatives - by raising a new RURAL HEALTH FORCE, bringing in NGOs/ PRIVATE SECTOR, creating REFERRAL SERVICES to the existing set up or by engaging with INFORMAL PROVIDERS (IP). The merits and demerits of each alterative should be analyzed in the light of experiences had both in India and in international scenario. EXPERIENCE: Indian policy makers have tried various models to bridge the rural health gap. They vary from the earliest Licentiate Medical Practitioners (LMP) doctors to the most recent Rural Medical Practitioners (RMP) doctors in Chhattisgarh, which is creation of a new rural health force. In-between there were efforts to bring in the already trained MBBS and Post Graduate doctors to serve in the rural areas, which did not meet with great success. We can also learn from international experience like the barefoot doctors in China which formed the blueprint of China s rural health system. Each policy alternative has merits and demerits and are analysed based on key attributes including access to patient, quality of care, cost to patient, cost of policy implementation and risk profile of the solution. STATUS QUO: Rates ok in terms of access to patient and quality of care. There is no increase in cost to patient and no cost of policy implementation. However the risk of further widening the rural health gap is very high and an opportunity to make best use of available local resources in terms of informal providers is foregone. REFERRAL SERVICE BY IPs: Quality of care is just ok and cost of policy implementation is minimal. However, the demerits include poor access to patient and increased cost to patient. While the access, rural people had, to basic curative care persists, access to a formal doctor is still a problem. This also translates into increased transportation costs and more out of pocket expenditure. STRONGER INTEGRATION OF IPs: This rates best in providing access to patient and quality of care. However the cost of training and supervision means the cost of implementation of this policy model is a constraint. Plus cost to patient will see an increase. RURAL HEALTH FORCE: Rates good in providing access to patient and is very good in terms of quality of care. The demerits include cost of the policy implementation - encouraging the doctors to stick to rural areas and to see that the rural services are effectively rendered, which means additional administrative and regulatory or supervisory costs. Cost to patient will also see an increase. NGO / PRIVATE SECTOR: With respect to quality of service and access to the patients there appear to be no pitfalls in this alternative if contracted out to right agencies. However cost to patient will see an increase and cost of policy implementation is low and would be more regulatory. The demerits that may crop up may be related to execution of regulation. CONCLUSION: There is a need to implement a clearly defined policy with a set of guidelines that will aid in ensuring the sustainability of rural health. The integration approach seems to be good in terms of making use of informal providers and village level citizens and bring them back to be a part of the Rural Health delivery system. The other highly rated policy solution of creating a rural health force is also good but the cost of policy implementation is very high .The NGO approach has most of the merits and is rated high on care and quality parameters but scaling up to include each and every person in rural society is herculean. Finally it may be said that a ONE SIZE FITS ALL approach may not work and a judicious mix of approaches may have to be used. A clearly defined national rural health policy will help in attracting private sector. Above all, rural healthcare needs to be declared as a priority area by both central government and the state governments.