This blog marks the beginning of a series delving into the complex, multi-faceted, and rapidly evolving rural healthcare system of India. I hope it can be a good reference and begin conversations with my peers and clients. India and other developing countries have already created solutions that the United States can leverage to address rural healthcare and underserved health populations.
In India’s vast healthcare landscape, the rural healthcare system is a critical piece, serving essential care to a geographically dispersed and socio-culturally diverse population of over 830 million. Rooted in the principle (and constitutional mandate) of “right to health for all” India’s healthcare approach recognizes the pivotal role communities play in shaping health outcomes.
The Key Elements:
1) Maximize Outreach - Tiered Care Delivery
There are certainly cultural differences between our countries, but we both share variations in topography, population density, and a need to address access to healthcare. In India, healthcare delivery centers are strategically located based on these factors, divided into Sub-centers, Primary Healthcare Centers (PHCs), and Community Healthcare Centers (CHCs). These form the Primary Healthcare System, the first line of care infrastructure.
Sub-centers provide basic services like maternal health, child health, family welfare, nutrition, and immunization. They also implement communicable disease programs and conduct community outreach to promote behavioral change. PHCs focus on preventive, promotive, curative services, and outreach activities. CHCs serve populations of 120,000 in plain areas and 80,000 in hilly, tribal, or difficult terrain and serve as 24/7 First Referral Units (FRU). Any referral from one tier to another is supported by a government-funded free ambulance service.
These three tiers together cater to all basic and essential care services for the communities, making healthcare more accessible and preventing unnecessary burden on higher-level facilities in the healthcare delivery system. Close proximity enables community members to easily identify and access the appropriate facility when needed. Familiarity with staff reduces communication barrier, increases trust and encourages uptake of government initiatives.
2) Ensure Continue of Care - Network of Frontline Champions
A dynamic workforce of Accredited Social Health Activists (ASHAs), Auxiliary Nurse Midwives (ANMs), and Anganwadi Workers (AWWs) form the backbone of rural healthcare.
There are over 1 million ASHAs of which 98% are recruited from the communities they serve. They participate in health surveillance, conduct surveys, facilitate access to care for women and children, and promote maternal/child health awareness forming a crucial link in the rural healthcare system. ANMs at Sub-centers provide essential maternal and child health services. AWWs, belonging to the same community, operate the Aanganwadi Centers (rural childcare centre for children below 6 years of age) that focus on early childhood development and education.
Their local connection allows ASHAs and AWWs to navigate barriers and improve health outcomes. Equipped with smartphones, they facilitate real-time tracking of health and nutrition indicators which helps in data-driven decision making at local, state and national level.
These champions provide additional support to Village Administration to meet additional health needs when required. For example, ASHAs played a critical role in COVID response through case identification, tracking, and promoting vaccinations. Their extraordinary contribution during the pandemic earned them global recognition at the 75th General Assembly of the World Health Organization in May, 2022.
3) Increase Ownership - Collaboration & Community Engagement
The success of rural healthcare system in India hinges on strong collaboration with Village Health Sanitation and Nutrition Committees (VHSNC). Integrated with local self-governance structure, they comprise of elected representatives from the community. VHSNCs participate in drafting of Village Development Plan by helping prioritize needs and building accountability system.
The National Health Mission (NHM) further helps in advancing community collaboration by skill building of local governance bodies and providing guidelines for Village Health Plans. VHSNCs help in delivery of national and state level health initiatives, and also gives access to government health and wellness schemes. Examples include “Ayushman Bharat” and “Pradhan Mantri Matru Vandana Yojana” which provide financial protection to reduce out-of-pocket expenses when seeking care and additional incentives for maternal and child healthcare.
India’s collaboration model transforms communities from passive recipients to active participants in shaping their healthcare. This structure of social audit fosters a shared responsibility for health outcomes.
Conclusion
Despite challenges like shortage of human resource, infrastructural limitations, and lack of adequate funding, the Indian rural healthcare system presents a compelling narrative of resilience, innovation, and community-driven care. It is designed to understand the socio-cultural fabric of its villages, optimize grassroots engagements, and leverage strengths and resources from within the communities. Its remarkable strength in delivering essential healthcare services resulted in significant improvements in infant and maternal mortality, immunization coverage, institutional deliveries and overall health and sanitation behavior among rural communities.
As nations navigate the complexities of healthcare delivery, India's experience offers invaluable lessons for building robust, inclusive and equitable healthcare systems that recognizes the intrinsic value of communities in promoting collective well-being.
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