With not enough dedicated health professionals willing to work in rural areas, the last-mile connectivity has not been achieved in the health system of the country. Add to that the public systems' poor responsiveness to community needs and the major challenges faced by primary health care only get compounded.
This was one of the major focuses of a recent report on universal health coverage (UHC) prepared by a high level expert group (HLEG) under the Planning Commission. The report, while spelling out the problems with healthcare management in the country, recommends ways of overcoming the barriers to an effective UHC.
To produce a cadre of rural health care practitioners for recruitment and placement at sub-health centres (SHCs), the report recommends the introduction of a new 3-year Bachelor of Rural Health Care degree programme.
Meanwhile, to meet the short term needs, the report recommends the deployment of health providers from recognised systems of medicine such as Ayurveda, dentists and nurses upon their completion of bridge courses. These courses are expected to equip them with appropriate competencies to follow standard management guidelines and provide the national health package (NHP).
At present, there is one Accredited Social Health Activist (ASHA) or community health worker (CHW) for a population of 1,000 in rural and tribal areas. The HLEG recommends doubling the number of ASHAs to two per 1,000 population with at least one female who is to be offered the opportunity to train as an auxiliary nurse midwife (ANM) in future.
A similarly trained CHW for every 1000 population among low-income vulnerable urban communities should also be appointed, according to the report. The CHWs should provide preventive and basic curative care, promote healthy lifestyles, serve on health and sanitation committees, and enable people to claim their health entitlements, says the report. They should be paid a fixed compensation supplemented by performance-based incentives. The government estimates that close to 1.9 million CHWs will be needed to meet the requirements of the proposed UHC system.
Since 2005, only 12 states have got new nursing schools. This is insufficient to meet the requirements of UHC due to the inequitable distribution of these schools. Some 149 districts in 14 high focus states do not have any nursing school or nursing college as of 2009. The HLEG proposes setting up of new nursing schools and new nursing colleges over the next decade focusing mainly on underserved states. Many SHCs face shortages of ANMs. For instance, most SHCs in Bihar and Uttar Pradesh do not have ANMs even though the mandate is to have two ANMs per SHC. It is estimated that around 230 additional schools for ANMs would need to be established specifically in underserved the States of Assam, Bihar, Gujarat, Jammu and Kashmir, Jharkhand, Meghalaya, Mizoram, Sikkim, Rajasthan, Tripura, Uttar Pradesh and West Bengal.
The highly uneven distribution of medical colleges has resulted in the skewed production and unequal availability of doctors across the country.
There is, for instance, only one medical college for a population of 11.5 million in Bihar and 9.5 million in Uttar Pradesh, compared to Kerala and Karnataka who have one medical college for a population of 1.5 million. The HLEG recommends selectively setting up around 187 new medical colleges over the next decade in currently underserved districts with a population of more than 1.5 million.
Acknowledging that district hospitals have a critical role to play in health care delivery under the UHC system, the report says that the delivery and health professional training should be well attuned to the needs of the particular district, while conforming to national standards of health care provision. An adequately equipped and suitably staffed district hospital, backed by contracting-in of regulated private hospitals, should aim to meet the health care needs of at least 95 per cent of the population within that district, so that only a small number would need referral to higher level tertiary care centres, says the report. This would require the upgrading of district hospitals as a high priority over the next five years.
The HLEG on UHC was constituted by the Planning Commission in October 2010, with the mandate of developing a framework for providing easily accessible and affordable health care to all Indians.
