Exploring Gaps in the Existing Healthcare System
in Rural Tamil Nadu

Chiai Uraguchi, Sunayana Sen, Maki Ueyama

Introduction

Chiai Uraguchi is a candidate for a Master of Public Administration at the Cornell Institute for Public Affairs. She acquired a Master’s degree in Environment, Development and Policy from the University of Sussex and a Bachelor of Arts degree in Environment and Information from the Musashi Institute of Technology in Japan. She has worked in the Philippines on several projects, including one that explored the ‘Role of scavenging in urban livelihoods in the Philippines’ and a ‘Case study of livelihoods in the INAYAWAN dump site in Cebu and a strategy for the poor.’ She was also the project manager for a project aimed at ‘Income Generation for Disadvantaged Women’.

Sunayana Sen has a Bachelor’s degree in Psychology from Sophia College, Mumbai. She completed her Master’s in Human Rights, from the University of Calcutta in 2008 and volunteered for several non-profit organizations. She worked on several projects related to child health and the human rights of rural populations before she joined ICTPH as a Research Analyst, Epidemiology.

Maki Ueyama obtained her Ph.D. in Policy Analysis and Management from Cornell University (Ithaca, USA). Her main research interests are in the fields of health and healthcare in developing countries. She has a Master’s degree in Policy Analysis and Management and in Public Administration, both from Cornell University. She has a Bachelor’s degree in Economics from Keio University (Tokyo, Japan).

Executive summary

In 1978, the International Conference on Primary Healthcare, meeting in Alma-Ata, made a historical declaration that expressed the urgent need for action by all governments, all health and development workers, to protect and promote the health of all the people of the world.

After more than two decades, India has achieved tremendous improvements in human development factors: e.g., Life Expectancy at Birth (LEB) is 65 and Infant Mortality Rate (IMR) has become 32.31 deaths/1,000 live births. Compared to year 2003, the rate improved drastically from 60 deaths in 2003 to 32.31 deaths per 1,000 population.

Public sectors are actively involved in the healthcare system and contribute to society.

However, the healthcare sector as a whole is still facing many challenges. According to UNDP, India ranked 128 out of 177 countries (Human Development Index 2007/2008). There are obviously more gaps to fill or unmet needs in the current healthcare system.

There is an understanding that South India performs relatively well in terms of healthcare: e.g., 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. With respect to national mortality rate, Jharkhand in East India and Uttar Pradesh in Northern India have the highest rates (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. However, some studies show that local people – especially in rural areas – face difficulty in accessing healthcare services due to long distances, the lack of facilities the government (public) sector provides, and unaffordable medical fees that the private hospitals charge.

This study – Healthcare Needs Assessment – was designed and conducted by the epidemiology team at the IKP Center for Technologies in Public Health. The study aims to explore whether there are gaps in the existing healthcare system in Thanjavur in rural Tamil Nadu, in the Southern part of India – and what kind of interventions are required to fill the gaps, if any. It has been conducted by utilizing qualitative study methods – key informant interviews and focus group discussions.

Through the qualitative studies, the following factors were mainly focused on for analysis: quality of service, accessibility, availability, and affordability – both in the private and public healthcare sectors.

The overall picture that the study gives is that, while most villagers manage to access necessary healthcare, there is still more room for the public sector to improve in order to offer better healthcare service. The result of this study showed that the most serious issue is the huge shortage in manpower in the public sector that provides healthcare to the poorer segments of the population.

Lack of management, especially emergency care and short length of duty for doctors in the government – led Primary Health Centres, leads to low quality treatment and hasty and careless diagnosis. Due to a lack of explanation about diseases, physical problems, and medicines from doctors, patients are likely to lack knowledge about medicines and rely on heavy dosage medicines to seek quick recovery. It could be necessary for medical providers to explain usage of medicines and procedure of treatment in order to build awareness among patients.

Both public and private hospitals are located within accessible distances. However, there are no hospitals in the village offering any X-ray, ECG scan, ultrasounds, and so on. So most villagers have to visit nearby towns to avail of these facilities. The need for hospital beds, scans and ambulances, addressed by women, are strongly related to pregnancy and child birth. Accessibility would be even less of a concern for villagers if there were clinics or hospitals in the village that offered the aforementioned facilities.

The cliché of unaffordable charges in the private sector does not seem to be entirely true in this geography since some people mentioned that some private doctors now charge lower fees and provide injections and tablets at an affordable price although there are some people who still have to borrow money in order to access the private sector. Despite it being an illegal medical practice, unqualified doctors (‘quacks’) seem to exist and often meet villagers’ needs with 24-hour access and affordable medicines.

Introduction

India contributes the largest number of births per year (27 million) in the world (Ronsmans C, Graham WJ, 2006). With its high maternal mortality of about 300 to 500 per 100,000 births, a total of 75,000 to 150,000 maternal deaths occur every year in India (Maternal mortality in India: 1997 to 2003 and National Family Health Survey (NFHS-2), 1998- 1999). This makes up about 20% of the global share, hence India’s progress in reducing maternal deaths is crucial to the global achievement of Millennium Development Goal 5, which aims at improving maternal health (UN, 2009). Despite its achievement of rapid economic growth, India ranked 128 out of 177 countries in the Human Development Health Report by UNDP (Human Development Index 2007-2008).

A Healthcare Needs Assessment Study was undertaken to explore gaps in the current healthcare system and existing health facilities in the Thanjavur district of Tamil Nadu, India, and subsequently design interventions needed to fill in the gaps. The study was designed to cover the following aspects which were then going to be used for the analysis: quality of healthcare, availability, accessibility, and affordability of healthcare services. The data was collected by conducting key informant interviews with several people holding positions of authority in the village, and two male and two female focus group discussions with villagers in each village. The study is a small part of the Healthcare Needs Assessment study in that it covers only one village, Alakudi, located in the Thanjavur district of Tamil Nadu, India.

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