Exploring Gaps in the Existing Healthcare System
in Rural Tamil Nadu
Chiai Uraguchi, Maki Ueyama, Sunayana Sen
Background
Healthcare System in India
The first National Health Policy that aimed to achieve ‘Health for All’ by 2000 was introduced in 1983. Improvements, through focus on better infrastructure for primary healthcare and healthcare delivery systems, resulted in reductions in infant mortality and death rates, longer life expectancy, and higher rates of childhood vaccinations. However, not every segment of the population was benefiting equally, and, according to a human development health report by UNDP, India ranked 128 out of 177 countries (Human Development Index 2007/2008). Other South Asian countries, such as Vietnam, Indonesia, and the Philippines, ranked higher than India.
Since the Community Development Program 1 was launched in 1951 in India, the country has gradually enhanced the healthcare infrastructure. The National Healthcare system in India is delivered by public and private players. As of 2005, 142,655 sub-centers, 23,109 primary health centers (PHCs) and 3222 community health centers (CHCs) provide services to 742.49 million rural people (72.2% of India’s population live in rural areas). Over 5479 sub-divisional and district hospitals play a role in the public sector (Bulletin on Rural Health Statistics in India, 2005). The population coverage norms are 3000/5000 per sub-centre, 20,000/30,000 per PHC and 80,000/120,000 per CHC respectively, depending on the location of the center (i.e. in a hilly, tribal, or other difficult area to be accessed) (Central Bureau of Health Intelligence, 2005). On the other hand, the private sector plays a significant role in the delivery of healthcare, catering to 46% of hospital inpatients and 81% of outpatients (WHO Financing and Delivery of Healthcare Services in India, 2005). While both players are indispensable to the nation’s healthcare delivery, the latter predominates in the health sector.
Healthcare delivery in the public sector is targeted towards sections of the population that cannot afford appropriate healthcare. A Facility Survey in 1999 by the Government of India indicated that 75% of the government-run Community Health Centers lacked in adequate equipment – and only 33% of the Primary Health Centers provided quality delivery care – if they provided any care at all (Bulletin of Rural Health Statistics in India, 2006). These inadequate public health facilities have led to the non-utilization of such facilities.
A lack of managerial and technical ability in the Public Healthcare system is a major part of primary challenges here. Unequal distribution of facilities is also found between rural and urban health service areas in India: Although 75% of the population still lives in villages, 59% of all practitioners and 84% of hospital beds are in urban areas (Duggal, 2000). There are about 4621 hospitals and 18.5 beds per 100,000 population in rural areas. The number of hospitals and beds per 100,000 population in urban areas are 10,406 hospitals and 232.36 beds. This presents a stark contrast existing in the health infrastructure development between urban and rural India (Varman and Kappirath (2008). In terms of managerial ability, many public health sectors apply the “first-come, first-served” policy.
In 2003, of the 8.8% of the GDP that was spent on health, the public expenditure on health was 25% and private expenditure was 75% (WHO Country Health System Profile, India, 2007). In spite of efforts to provide free public services, health-expenditure surveys consistently show high levels of private out-of-pocket spending on healthcare (Berman, 1997).
Today, the capacities for human resources in healthcare are significantly scarce in India – even within low income countries, approximately 1,125,000 practitioners of various levels of qualification – and from different schools of medicine – are registered in the country. Of them, only 125,000 (which constitutes only 11% of the total number) serve the government-public sector, while the rest are all working in the private sector. This excludes an innumerable number of unqualified and unregistered medical practitioners that also operate throughout the country (R. Duggal, 2000). There is a disparity of human resources between rural and urban areas. Only 0.6 doctors per 10,000 population in rural India currently are working; on the other hand, 3.4 doctors per 10,000 population are in urban areas (Ashok Kumar, 2007). Rural/urban disparities are equally pronounced in the outcome of health services.
Consequently, despite the fact that large portions of the population seek medical services from the private sector (NHP 2002), due to high medical fees, private healthcare is not equally accessible to everyone in India. This has made it increasingly difficult for the poor to avail of private care and caused them to refrain from seeking any healthcare at all (Levesque et al, 2006). Therefore, poorer households access less preventive and curative healthcare from the private sector than richer households. Due to the lack of ability to pay the fees, the poor are much less likely to be hospitalized. Indians who are hospitalized tend to spend 58% of their total annual expenditures on healthcare (David H. Peters, Abdo S Yazbeck, Rashmi R.Sharma, Lant H. Pritchett, Adam Wagstaff, 2002). More than 40% of hospitalized people in India manage to cover expenses by borrowing money or selling assets to cover expenses. Consequently, many hospitalized people are likely to fall into poverty. There is a great financial risk that hinders the poor from accessing private healthcare.
Healthcare indicator and system in Tamil Nadu
Within India, healthcare services in the country vary substantially between states, regions and societies. These differences in healthcare provision translate to differences in various health indicators, including: Life Expectancy at Birth (LEB) and Infant Mortality Rate (IMR). The state of Tamil Nadu, located in the South of India, is one of the foremost states in terms of overall development. The state has the highest number (10.56%) of business enterprises in India (Provisional Results of Economic Census 2005). Tamil Nadu has also done very well in terms of human development among the better performing states in terms of health indicators (R.J Chellian, K.R. Shanmugam, 2002). Tamil Nadu had among the lowest percentage of the hospitalized falling into poverty from medical costs in 1995–96 – less than the national average. Following is the comparison of various health indicators in Tamil Nadu compared with the national averages.
Table 1: Life Expectancy Rate at Birth
In Tamil Nadu, a male at birth is expected to live for almost 69 years while a female is expected to live for almost 72 years; whereas the national averages for life expectancy at birth in India for males and females are approximately 64 years and 67 years respectively.
Table 2: Childhood Mortality Rate 2005 to 2006
With respect to national mortality rate, East India: Jharkhand and Central India: Uttra Pradesh has the highest rate (48.6 and 47.6) and Kerala has the lowest rate of 11.5. Tamil Nadu has a relatively low mortality rate, as compared to other states. This is indicative of the decrease in the death rate and the improvement of the quality and availability of health services in the state.
Table 3: Percent distribution of women who had a live birth in the five years preceding the survey by antenatal care (ANC) provider during pregnancy for the most recent live birth 2005-06
The percentage of women seeking antenatal care in Tamil Nadu is an encouraging 99% whereas the All-India average is only 77%. In Tamil Nadu, women who access doctors to receive antenatal care are relatively higher in number than the average percentage in India. Only 1.1% women in Tamil Nadu do not access antenatal care; on the other hand, India as a whole averaged more than one fifth of women answering ‘no one’ to receive any information about antenatal care.
Table 4: Percentage of Institutional Deliveries
The disparity between the state percentage and the All-India percentage of institutional deliveries is even starker – Tamil Nadu has a phenomenal record of 90% institutional deliveries whereas the All-India figures are a dismal 41%. While these may reflect the greater level of health awareness among the people in Tamil Nadu, both increased awareness and greater healthcare use can be attributed to the relatively advanced health infrastructure in the state in comparison to other states.
Within the state of Tamil Nadu, there are inter-district disparities as far as healthcare is concerned: Among the 30 identified districts in Tamil Nadu, the district of Thanjavur ranked 9th in health infrastructure development. Thanjavur district also performs well nationally with the ranking of 41 among the 593 districts studied in the country (IIPS, 2006). Although the study failed to cover information from all the districts, due to unavailability of data, it covered most of the districts and hence was successful in providing an idea of where Thanjavur stands with respect to health services and infrastructure.
Notably, Tamil Nadu has successfully established a high quality of healthcare management by decentralizing healthcare services. For instance, each PHC covers from 5 to 10 sub-centers and each is staffed by community health workers called ‘Village Health Nurse’ (VHN). Each VHN has a service area comprised of approximately 5000 population in (up to) 7 or 8 villages and receives two years of healthcare training to become eligible for service. According to multi-state studies, Tamil Nadu’s VHNs have better knowledge levels and more effective contact with service communities than their counterparts in other states. Most of the VHNs live in their service villages, and emergency cases are brought to them night or day. Because of their close contact with the community, and the extensive records they keep, VHNs are familiar with the needs and problems in their communities. Their services and the PHCs are widely seen as intended mainly for women and children. VHNs are responsible for house-to-house contacts and for schools. They provide preventive healthcare by providing vaccinations and pre-delivery care for expectant mothers. Their services have generally included immunizations, nutrition and other health education, antenatal care, childbirth services and referrals, and family planning (Lakshmi Ramachandar, Pertti J Pelto, 2002). Despite limited amounts of information and unavailability of data, it successfully illustrates where Thanjavur stands with respect to health standards, services and infrastructure.
1 Community Development Program: In 1951, Government of India viewed rural development as pivotal to achieving economic growth and social development. The objective of the program was to achieve “Samagra Gramin Vikas“, addressing all the issues of basic needs of the people and implementing a number of programs in rural areas. (Continue reading)
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