While health-preservation and awareness are almost non-existent all over the country, availability of medical treatment is aggressive and dismal in urban areas and scanty and unscientific in the villages. With 70 percent population living in rural areas and prevailing low level of medical care facilities, mortality rates due to diseases are high. A majority of rural people face deplorable medical facilities in the public hospitals as well as private clinics. Government has limited capability to fulfill the basic health needs of the rural folk like e g nutrition, sanitation, prevention of sickness, promotion of wellness, vaccination and administration of primary medical care. The PHCs lack infrastructure, a credible referral system, and manpower policy. Blaming or bonding the doctors for not serving in rural areas, but not providing them even basic amenities like accommodation, electricity and water, and security about their own lives, cannot improve the situation. While primary health centers (PHCs) hardly function, rural medical practitioners (RMPs), who provide 80% of outpatient care, are uneducated to illiterate.
Scarce trained manpower
With one doctor for every 11,000 people, India falls far below the World Health Organization standards of one doctor per 1,000 patients. The problem is particularly stark in villages. It is hard to change patient behavior and get them to come to PHC instead of the village quack. Village quacks charge for injections of low efficacy and possible harm. Unethical practices such as unnecessary investigations and surgeries and kickbacks for referrals are known. Regulatory bodies such as the medical councils are unwilling to fulfill their responsibilities, the legal system is ill-equipped to handle the burden of medical litigation, and aggrieved patients and their relatives cannot afford the costs. A.J. Philip of the Tribune had called Public healthcare in Punjab a sham, after visiting and studying a number of PHCs in the state, a few years ago. Things have further gone down the hill, since then. Major problems at the level of primary healthcare found were: i) absenteeism of the staff ii) shortage of qualified doctors iii) non-availability of proper infrastructure, including equipment, consumables ,medicines; iv) poor motivation of the public to visit PHCs.
Public health care system needs to be strengthened
Bhore committee (1946) had recommended Integration of preventive and curative services and development of Primary Health Care on priority. Later the Alma Ata declaration of ‘Health for all by 2000’ signed in 1978 was yet another declaration, which the government endorsed. The 93rd amendment in the constitution accepting Education as a fundamental right has strengthened the case of ‘right to healthcare’, if not right to health. The National health policy 2017 mentions the growing incidences of catastrophic expenditure due to health care costs, especially in the rural areas. The need to strengthen public health facilities is paramount.
Rural healthcare has been on the sickbed for long; the government’s efforts have perpetually fallen short. When seriously ill, the villagers either rush to the witchcraft and hermits, placing themselves in the grip of lechers or forced to flock to cities, overcrowding institutions such as AIIMS or PGI.
Common health problems in rural areas
Health issues confronted by rural people are many and diverse – from severe malaria to uncontrolled diabetes, multidrug resistant TB, from badly infected wounds to cancers, besides drug addiction, smoking and drinking alcohol. Postpartum maternal illness is a common problem and contributes to maternal mortality. Most women suffer from protein-iron-calcium deficiency with resultant anemia in over 50% women, dehydration in 60-70% people, malnourishment in 45% among under five children, lack of immunization in 58% children. Besides, 69% of the rural population has no access to potable water and 99.5% no basic sanitation and suffer from plenty of infectious diseases. While the foregoing may be due to underlying poverty, abject poverty does not confer any immunity against non-communicable diseases like diabetes or heart disease. It is also estimated that mental ailments affect about 20% of villagers.
While corporate hospitals offer latest equipment, highly-qualified doctors and patient-friendly services to the rich clients, Sick or injured villagers are left in the lurch, with nowhere to go even for first aid.
Healthcare in Punjab
While Punjab’s public health delivery system operates at three levels viz. Primary, secondary and tertiary level, private practitioners provide clinic based practice, in low risk cases. Public health facilities increased up to the mid-1980s in the state mainly due to increased allocation of funds and pro-rural policy of state government. Subsequently the health budget and attention towards rural care dipped in the public sector and the gap was filled by RMPs. The fact that the poor have to pay for treatment from their own pockets reveals the breakdown of the rural public health care system. The techno-centric nature of treatment in high profile hospitals of cities, traps patients in a web of technology-centered medical system that is confusing, intimidating and expensive to unaffordable. Physician-patient fee for service model or health insurance model brings unethical practices and push the costs sky- high. A simple headache will warrant a MRI/CT scan. These models do not suit our rural folks.A Social perspective Model that envisages PHC as a social enterprise to advance the well-being of citizens is the right choice. It also means the greatest good for the greatest numbers.
Punjab government’s recent resolve to strengthen public health services and try PPP model for OPD treatment on a pilot basis is laudable, especially when medical care at PHC’s at present is inadequate. However, fleecing of patients needs to be prevented. It should reduce the cost of treatment for the poor, if not make the tests and medicines absolutely free to them. Other step is to promote healthy life styles so that the need for medical treatment is curtailed. In this direction, the project Tandrust Punjab has been conceived well, it can restore health among Punjabis, if implemented honestly. Multi department involvement in bringing health to the people is the right strategy.