Exploring Gaps in the Existing Healthcare System
in Rural Tamil Nadu

Chiai Uraguchi, Maki Ueyama, Sunayana Sen

Literature Review

The importance of health needs assessment has been emphasized by several studies done in the Indian subcontinent; the results of which prove to be extremely useful in identifying needs that are not addressed by existing healthcare facilities – and the important factors (social, cultural, economic) that are ignored by existing healthcare systems, thus pointing out areas which need improvement (e.g.: Varatharajan, 1999, Kannan, et al. 1991, Navaneetham and Dharmalingam 2002, Kavitha and Audinarayana (1997), Ravichandran and Mishra (2001). Most existing studies in South India focus on reproductive and child heath, thus not much is known about general healthcare services (e.g.: Navaneetham and Dharmalingam (2002), Kavitha and Audinarayana (1997), Rajaretnam and Deshpande (1994), Ram (1994), Ravichandran and Mishra (2001).

A study about the prevalence of reproductive tract infections was conducted since little is known about rates among the youngest married women in South India. A community-based cross-sectional study of prevalence of reproductive tract infections was conducted among an age group – 16 to 22 – of young married women. Qualitative and quantitative data on treatment-seeking behavior were collected. Multivariate analysis found that 2/3 of symptomatic women had no access to any treatment because of lack of privacy, distance from home, and cost (Jasmin Helen Prasad, Sulochana Abraham, Kathleen M. Kurz, Valentina George, M.K. Lalitha, Renu John, M.N.R. Jayapaul, Nandini Shetty, Abraham Joseph). The study clearly shows that some factors – such as quality of healthcare, accessibility in terms of distance, and affordability – hinder patients’ access to healthcare facilities.

A study was conducted to explore unmet needs for reproductive health via a cross-section of 70 women from rural Tamil Nadu. TK Sundari Ravichandran and US Mishra concluded the need for an integrated women’s health program within a strengthened health system. Poor facilities, inadequate supplies, insufficient working hours, lack of proper monitoring and evaluation mechanisms – and a mismatch between training and work allocated to health workers – were the key gaps identified (TK Sundari Ravichandran and US Mishra, 2001). Ram K. (1994) used an ethnographic approach to explore maternity practices among lower-caste Mukkuvar women in Kanyakumari, Tamil Nadu, and identified: prolonged stays during delivery disrupted daily activities; caste disparites between the provider and the user created a power hierarchy; harsh treatment by the hospital staff during delivery; and unnecessary medical interventions. These were cited as reasons for the women in the village not seeking medical care during pregnancy and having reservations against institutional deliveries.

Despite improvements in the healthcare status and increasing accessibility to healthcare services in the prior decades, Tamil Nadu still has challenges to adequately treat intricate health cases. Tamil Nadu has not done so well in respect of the late neonatal mortality rate; and done poorly with respect of the early neonatal mortality rate (Venkatesh Athreya, Sheela Rani Chunkath, 1998). More than 70% of those with chest symptoms make one or more efforts to seek care – and private practitioners are consulted more often than government healthcare providers. A research with chest symptomatics in a community-based study in Tamil Nadu showed that private healthcare facilities provided ‘good care’ and easy accessibility – and were the main reasons why patients preferred private healthcare (G. Sudha, C. Nirupa, M. Rajasakthivel, S. Sivasubramanian, V. Sundaram, S.Bhatt, K. Subramaniam, Thiruvalluvan, R.Mathew, G.Renu and T.Santha, 2003). The studies above showcased that there could be certain unmet areas in each of the private and public sides.

A qualitative study was conducted to identify basic healthcare available to the poorer segmentation of the population in Tamil Nadu. The study focused on quality issues from the perspective of users in 17 villages and 1 town across rural, semi-urban and urban districts in Tamil Nadu. The focus group discussions in the study described public facilities as being less clean, utilizing poorer equipment, and stocking less effective, slower acting drugs. In cases where drugs were necessary to treat a particular ailment and were expensive (such as snakebites or dog bites), PHCs simply did not have any stock of medicines which were in high demand. Moreover, it was emphasized that issues around the non-availability of physicians, poor staff attitudes, and demands for unofficial payments were common in Tamil Nadu. (Pia Malaney, 2000)

Lymphatic filariasis is recognized as the second leading cause of permanent disability in Tamil Nadu. A study was designed that aimed to identify the economic impact affected by the costs of constant treatment and the possibility for patients to lose working time. The ranges of treatment costs in private hospitals are from Rs.500 to Rs. 2,000. Such high costs – coupled with loss of working income during recuperation – causes financial crises for poor households in rural areas (K.D.Ramaiah, Helen Guyatt, K. Ramu, P. Vanamail, S.P.Pani and P.K Das, 1999). According to the study, expenditure for healthcare is likely to burden people – especially daily wage workers – and leads to poverty.

More often than not, improvement in healthcare requires building better healthcare services and a system of both users and providers. Awareness is one of the factors users can play significant roles in, to contribute to improving individual health. In focusing on maternal knowledge of malnutrition and child health, the study highlighted that the lack of awareness about health issues in general is the major issue – rather than healthcare availability and healthcare-seeking attitudes. Therefore, the study emphasized that building robust health education regarding maternal health among villagers is of primary importance (K. Saito, J. R. Korzenik, J. F. Jekel, and S. Bhattacharji Yale J, 1997).

Although a limited number of studies have been conducted in the past, quality of service, treatment and medicines, availability of doctors and nurses, sufficient facilities, accessibility and affordability have been all highlighted as gaps in the healthcare system time and again.

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