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Patient Rural Care :

Camp Sidhi 9-Dec-2002


Rural Health Care: :

Towards a Healthy Rural India Rural Health care is one of biggest challenges facing the Health Ministry of India. With more than 70 percent population living in rural areas and low level of health facilities, mortality rates due to diseases are on a high. Reality of Healthcare in Rural India Healthcare is the right of every individual but lack of quality infrastructure, dearth of qualified medical functionaries, and non- access to basic medicines and medical facilities thwarts its reach to 60% of population in India. A majority of 700 million people lives in rural areas where the condition of medical facilities is deplorable. Considering the picture of grim facts there is a dire need of new practices and procedures to ensure that quality and timely healthcare reaches the deprived corners of the Indian villages. Though a lot of policies and programs are being run by the Government but the success and effectiveness of these programs is questionable due to gaps in the implementation. In rural India, where the number of Primary health care centres (PHCs) is limited, 8% of the centres do not have doctors or medical staff, 39% do not have lab technicians and 18% PHCs do not even have a pharmacist. India also accounts for the largest number of maternity deaths. A majority of these are in rural areas where maternal health care is poor. Even in private sector, health care is often confined to family planning and antenatal care and do not extend to more critical services like labour and delivery, where proper medical care can save life in the case of complications.


The Problems :

Due to non accessibility to public health care and low quality of health care services, a majority of people in India turn to the local private health sector as their first choice of care. If we look at the health landscape of India 92 percent of health care visits are to private providers of which 70 percent is urban population. However, private health care is expensive, often unregulated and variable in quality. Besides being unreliable for the illiterate, it is also unaffordable by low income rural folks. To control the spread of diseases and reduce the growing rates of mortality due to lack of adequate health facilities, special attention needs to be given to the health care in rural areas. The key challenges in the healthcare sector are low quality of care, poor accountability, lack of awareness, and limited access to facilities. Various organizations are coming together for improvements in health care and technology plays a crucial role to facilitate this. Information and communications Technology provides hosts of solutions for successful implementation of these changes.


Technology for Rural Health Care :

Several organizations are working alongside the government and NGOs to help relieve the burden on the public health system using mobile technology. India has over 900 million mobile phone users and this fact can be leveraged to employ better practices in even the remote areas. Leading global organizations of healthcare industry are using our mobile technology to enhance the quality of care and bridge the gaps in healthcare services. India has a universal health care system run by the constituent states and territories of India. The Constitution charges every state with "raising the level of nutrition and the standard of living of its people and the improvement of public health as among its primary duties". The National Health Policy was endorsed by the Parliament of India in 1983 and updated in 2002. Parallel to the public health sector, and indeed more popular than it, is the private medical sector in India. Both urban and rural Indian households tend to use the private medical sector more frequently than the public sector, as reflected in surveys. India has a life expectancy of 64/67 years (m/f), and an infant mortality rate of 46 per 1000 live births. Healthcare Policy Healthcare policies in India are largely based on lobbying, political ideologies, belief system and economy; and not merely based on evidence. Recent involvement of AYUSH in healthcare is perfect example. AYUSH provides low cost healthcare expenditure to government. However, none of the AYUSH teaching syllabus empowers practitioners to deliver national healthcare programs. So, this mismatch has created lot of low quality healthcare delivery. State owned and funded healthcare does not give regionalized approach and people's satisfaction is very low. Even in healthcare policy 2015 draft, there is minimum emphasis given to decentralization. It does not give a clear picture about panchayat's role, accountability and responsibilities. However, there is lot of under current among public healthcare professionals and leaders to decentralize the healthcare delivery and enrich people's participation.[6] Criticism Indian Health care system is just a nominal health care system; there are not enough hospitals, doctors, medical staff, medicines or ambulance services available in the system. Quality of care and accessibility is very poor. Most people depend on private hospitals for health care except very poor people, who depend on government hospitals because they can't afford private out of pocket health care. This system can't be called a health care system from a Western perceptive. Not an organised or functional system but a collection of government hospitals in different parts of the country to serve a huge population. India ranks last in healthcare compared to OECD or BRICS countries. The 12th five year plan document on health has received a lot of criticism for its limited understanding of universal health care and failure to increase public expenditure on health. While the HLEG report recommends an increase in public expenditure on health from 1.58 per cent of GDP currently to 2.1 per cent of GDP by the end of 12th five year plan it is far lower than the global median of 5 per cent. The lack of extensive and adequately funded public health services pushes large numbers of people to incur heavy out of pocket expenditures on services purchased from the private sector. Out of pocket expenditures arise even in public sector hospitals, since lack of medicines means that patients have to buy them. This results in a very high financial burden on families in case of severe illness. Though, the 12th plan document express concern over high out-of-pocket (OOP) expenditure, it does not give any target or time frame for reducing this expense. OOP can be reduced only by increasing public expenditure on health and by setting up widespread public health service providers.[10] But the planning commission is planning to do this by regulating private health care providers. It takes solace from the HLEG report which admits that, "the transformation of India’s health system to become an effective platform for UHC is an evolutionary process that will span several years". Quality In major urban areas, healthcare is of adequate quality, approaching and occasionally meeting Western standards. However, access to quality medical care is limited or unavailable in most rural areas, although rural medical practitioners are highly sought after by residents of rural areas as they are more financially affordable and geographically accessible than practitioners working in the formal public health care sector. Malnutrition in India According to a 2005 report, 60% of India’s children below the age of three were malnourished, which was greater than the statistics of sub-Saharan African region of 28%.[14] It is considered that one in every three malnourished children in the world lives in India. The estimates vary within the country. It is estimated that, Madhya pradesh is having the highest rate of 55% and Kerala the lowest with 27%. Although India’s economy grew 50% from 2001–2006, its child-malnutrition rate only dropped 1%, lagging behind countries of similar growth rate. Malnutrition can be described as the unhealthy condition that results from not eating enough healthy food. Child malnutrition A well nourished child is one whose weight and height measurements compare very well within the standard normal distribution of heights and weights of healthy children of same age and sex. Malnutrition impedes the social and cognitive development of a child. These irreversible damages result in lower productivity. Just as with serious malnutrition, growth delays also hinder a child’s intellectual development. Sick children with chronic malnutrition, especially when accompanied by anaemia, often suffer from a lower learning capacity during the crucial first years of attending school. Also it reduces the immune defence mechanism, which heightens the risk of infections. Due to their lower social status, girls are far more at risk of malnutrition than boys their age. Partly as a result of this cultural bias, up to one third of all adult women in India are underweight. Inadequate care of these women already underdeveloped, especially during pregnancy, leads them in turn to deliver underweight babies who are vulnerable to further malnutrition and disease. Different forms of malnutrition Protein-energy malnutrition (PEM), also known as protein-calorie malnutrition Iron deficiency: nutritional anaemia which can lead to lessened productivity, sometimes becoming terminal Vitamin A deficiency, which can lead to blindness or a weakened immune system Iodine deficiency, which can lead to serious mental or physical complaints Foliate deficiency itself can lead to insufficient birth weight or congenital anomalies such as spina bifida. [19] High infant mortality rate Despite health improvements over the last thirty years, lives continue to be lost to early childhood diseases, inadequate newborn care and childbirth-related causes. More than two million children die every year from preventable infections. Approximately 1.72 million children die each year before turning one. The under five mortality and infant mortality rates have been declining, from 202 and 190 deaths per thousand live births respectively in 1970 to 64 and 50 deaths per thousand live births in 2009. However, this decline is slowing. Reduced funding for immunization leaves only 43.5% of the young fully immunized.[16] A study conducted by the Future Health Systems Consortium in Murshidabad, West Bengal indicates that barriers to immunization coverage are adverse geographic location, absent or inadequately trained health workers and low perceived need for immunization. Infrastructure like hospitals, roads, water and sanitation are lacking in rural areas. Shortages of healthcare providers, poor intra-partum and newborn care, diarrheal diseases and acute respiratory infections also contribute to the high infant mortality rate. Diseases Diseases such as dengue fever, hepatitis, tuberculosis, malaria and pneumonia continue to plague India due to increased resistance to drugs. In 2011, India developed a totally drug-resistant form of tuberculosis.[26] HIV/AIDS in India is ranked 3rd highest among countries with the amount of HIV-infected patients. National AIDS Control Organisation, a Government of India 'Apex Body' is making efforts for managing the HIV/AIDS epidemic in India. Diarrheal diseases are the primary causes of early childhood mortality. These diseases can be attributed to poor sanitation and inadequate safe drinking water in India. India also has the world's highest incidence of Rabies. However in 2012 India was polio-free for the first time in its history. This was achieved because of the Pulse Polio Programme started in 1995-96 by the government of India. Indians are also at particularly high risk for atherosclerosis and coronary artery disease. This may be attributed to a genetic predisposition to metabolic syndrome and adverse changes in coronary artery vasodilatation. NGOs such as the Indian Heart Association and the Medwin Foundation have been created to raise awareness of this public health issue. Poor sanitation As more than 122 million households have no toilets, and 33% lack access to latrines, over 50% of the population (638 million) defecate in the open.(2008 estimate) This is relatively higher than Bangladesh and Brazil (7%) and China (4%). Although 211 million people gained access to improved sanitation from 1990–2008, only 31% use the facilities provided. Only 11% of Indian rural families dispose of stools safely whereas 80% of the population leave their stools in the open or throw them in the garbage. Open air defecation leads to the spread of disease and malnutrition through parasitic and bacterial infections. Safe drinking water Several million more suffer from multiple episodes of diarrhoea and still others fall ill on account of Hepatitis A, enteric fever, intestinal worms and eye and skin infections caused by poor hygiene and unsafe drinking water. Access to protected sources of drinking water has improved from 68% of the population in 1990 to 88% in 2008. However, only 26% of the slum population has access to safe drinking water, and 25% of the total population has drinking water on their premises. This problem is exacerbated by falling levels of groundwater caused mainly by increasing extraction for irrigation. Insufficient maintenance of the environment around water sources, groundwater pollution, excessive arsenic and fluoride in drinking water pose a major threat to India's health. Female health issues Maternal deaths are similarly high. The reasons for this high mortality are that few women have access to skilled birth attendants and fewer still to quality emergency obstetric care. In addition, only 15 per cent of mothers receive complete antenatal care and only 58 per cent receive iron or foliate tablets or syrup. Women's health in India involves numerous issues. Some of them include the following: • Malnutrition : The main cause of female malnutrition in India is the tradition requiring women to eat last, even during pregnancy and when they are lactating. • Breast Cancer : One of the most severe and increasing problems among women in India, resulting in higher mortality rates. • Stroke • Polycystic ovarian disease (PCOD) : PCOD increases the infertility rate in females. This condition causes many small cysts to form in the ovaries, which can negatively affect a woman's ability to conceive. • Maternal Mortality : Indian maternal mortality rates in rural areas are one of the highest in the world. Rural health Rural India contains over 68% of India's total population, and half of all residents of rural areas live below the poverty line, struggling for better and easy access to health care and services. Health issues confronted by rural people are many and diverse – from severe malaria to uncontrolled diabetes, from a badly infected wound to cancer. Postpartum maternal illness is a serious problem in resource-poor settings and contributes to maternal mortality, particularly in rural India. A study conducted in 2009 found that 43.9% of mothers reported they experienced postpartum illnesses six weeks after delivery. Public and private sector According to National Family Health Survey-3, the private medical sector remains the primary source of health care for 70% of households in urban areas and 63% of households in rural areas. Reliance on public and private health care sector varies significantly between states. Several reasons are cited for relying on private rather than public sector; the main reason at the national level is poor quality of care in the public sector, with more than 57% of households pointing to this as the reason for a preference for private health care. Other major reasons are distance of the public sector facility, long wait times, and inconvenient hours of operation. The study conducted by IMS Institute for Healthcare Informatics in 2013, across 12 states in over 14,000 households indicated a steady increase in the usage of private healthcare facilities over the last 25 years for both Out Patient and In Patient services, across rural and urban areas. National Health Mission (former National Rural Health Mission) The National Rural Health Mission (NRHM) was launched in April 2005 by the Government of India. The goal of the NRHM was to provide effective healthcare to rural people with a focus on 18 states which have poor public health indicators and/or weak infrastructure. Lack of political, economic and administrative decentralization of health care is being chronically ignored by NHM.