Rural Health an Sanitation - An overview

India is the world’s largest democracy with a population of 1.2 billion. It has around 6,30,000 villages which are homes to around 70 percent of the Indian population. Rather the concept of urban India is a new one. From ancient times Indians adapted a village life style of living. There was limited trade and villages were self sufficient. Harmony, unity and diversity the three pillars of Indian culture are primarily adapted for the village life style.

Today also more than 50 % of the people in India depend on farming (agriculture and allied activities) for their livelihood. Ours is an agrarian economy. Though the share of agriculture has fallen from a peak of more than 70 percent to the current levels still it is significantly higher than what is there in developed countries (<5 %).

Rural India has faced many problems in the past and till today problems in rural India have just multiplied. Poverty, unemployment, low health and sanitation levels, poor infrastructure, etc are just some of the problems that rural areas in India face. The government has never given rural India its share/position that it deserves. Till today the rural and urban income inequalities are quite high. According to the figures of 2004-05 the rural per capita income was Rs. 16,237 an urban per capita income was Rs. 44,223, which is a around 3 times the rural income. This is despite the fact that majority of Indian population lives in the rural areas.

Lack of employment opportunities leads to unemployment. There is chronic disguised unemployment in the agrarian sector. Rural areas don’t have proper roads, buildings, water facilities. Till today ladies in Rajasthan have to walk miles just to fetch drinking water. There are no colleges for higher education. Though primary schools are there in almost every village now and enrolment ratio is also high but the quality of education provided is not of a good standard. The ambitious project to open Industrial Training Institutes in rural areas to promote self employment has not garnered the desired result again due to the lack of proper infrastructure.

Health and Sanitation Problem

Since independence India has worked tremendously towards improving the basic parameters of life like life expectancy rate, infant mortality rate, literacy, number of doctors per thousand of population. The government has tried or at least made an effort to penetrate deeper and deeper so that basic health facilities can be provided to the people. The life expectancy of India has climbed from mere 42 in 1960’s to 64.1 in 2009 according to the WHO report. Also the infant mortality rate has fallen from 160 to 50 during the same time period. This is a signal of the reforms and effort taken by the government on the medical front.

The above stated figures clearly tell the reforms that have taken place but there is another side of the coin. Statistics say that more than 75 % of the health infrastructure, medical man power and other resources are concentrated in urban areas where mere 30 % of the population lives. Rural population is always in a fight with contagious and water borne diseases like diarrhoea, cholera, typhoid, malaria, dengue, and various diseases related to child birth. Also there has been a rise in less common diseases like cancer and AIDS/HIV mainly due to lack of education and awareness among the rural population.

The rural population live and work in the most hazardous conditions, have unsafe and unhygienic birth places, unsanitary and degraded environment. The majority of rural population are farmers or daily labourers, small artisans, etc. The article aims to review the steps taken to improve health and sanitation management in India.

The major problem in rural India is that majority of the population is illiterate and there are a lot of tribal groups who believe that they health ailments are caused by spirits. Till today the practice of taking help of magicians and religious practise is prevalent in some rural sections. Malnutrition is also one of the major problems that rural India faces. More than 70 % of the rural children are malnourished because of hunger. Early marriage of women, frequent pregnancies and miscarriages deteriorate the health of women.

Infrastructure in rural areas

There is a severe lack of qualified doctors practising in rural India. Majority of the doctors don’t have proper training. There are about 7,00,000 doctors in India presently and almost 80 % of them practice in the urban areas. There are just 10 beds per 1,00,000 population in rural areas as compared to 180 in urban areas.

Rural infrastructure basically comprises of a 3 tier structure :

The first is the sub – centre and it is the first point of contact between the primary health care and the community. Each sub – centre is manned by one auxiliary nurse midwife and one multipurpose male worker. A lady health worker is in charge of 6 sub centres. Each of these centres is provided by basic drugs and provide services in relation to child birth, family welfare, nutrition, etc. There are 1,45,272 sub centres in India as on March 2007.

Next come the primary health centres (PHCs) which is a point of contact between the medical office and the local population. A PHC acts as a referral to 6 sub centres and is manned by the medical officer and 14 para medical staff. There are around 24,000 PHCs in India as per data of September 2005.

Then there is Community Health Centres which are maintained by State Governments. CHCs are equipped with 4 medical specialists and 21 para medical staff. It acts as a referral centre for 4 PHCs and are supposed to be equipped with latest medical equipment. There are around 3,500 CHCs in India which is almost 50 % less than what is required.

Problem with rural infrastructure

Though the government’s plan for rural infrastructure is very fine and if implemented properly then this can bring tremendous improvement in health and sanitation conditions in rural areas, but in reality most of the plans remain on paper. Implementation is a big issue. The major problems with rural infrastructure which is a hindrance to good health and sanitation conditions in these areas are :-

1.      Lack of Equipment – Rural health infrastructure is one of the poorest in India. Sub centres, PHCs and CHCs all lack basic infrastructure. So much so that in some of the backwards villages there are no beds and water facilities. These so called hospitals are of no good to the people.

2.      Lack of personnel – India at present have just 6 doctors per 10,000 of population which is one of the lowest amongst the developing countries. The proportion in rural areas is even worse because generally qualified doctors don’t prefer to work in rural areas due to low paying capacity of people in rural areas. Indian Government has never been able to attract skilled doctors due to lack of infrastructure. This is a serious issue. There is also a lack of male para medical staff. To counter this problem the government is thinking to come out with a regulation that all the doctors at least need to work for 2 years in a rural area.

3.      Absenteeism – Almost 40% of the rural medical staff remains absent on a daily basis. There is no regulation to check absenteeism. Doctors on high ranks operate private clinics and remain absent from their government jobs. This ensures double income for them.

4.      Lack of information – Rural population is generally deprived of information on chronic diseases and when they realize about these diseases it is already too late. Population explosion for example is a serious problem in rural areas due to lack of information on family planning. Likewise due to non protective sex habits rural population suffers from STDs like AIDS.

5.      Lack of government initiative – The government has launched many schemes from time to time but implementation of these schemes is a major issue. No check is there to ensure that the scheme is being properly implemented or not. Corruption is a serious deterrent.

6.      Lack of private sector participation – There is no incentive for the private sector to step in the rural health care market. The government never thought of this route probably thinking that the private sector will come to its exploitive activities and the motto of welfare of population will be defeated. In thinking this the government didn’t take into account the inefficiencies and red tapism that is eating up the mission to improve rural health and sanitation problems.

7.      Lack of public toilets – People in rural areas are generally poor and can’t afford to have well built toilets in their homes. So most of the rural population goes to a nearby field or a barren land where they can defecate. This is a serious health hazard because defecating openly can give rise to many diseases. There is no provision for public toilets in most of the Indian villages and the villages that have this facility have toilets which are so unhygienic making them unfit for use.

An Assessment of Government Initiatives

Indian government has taken a lot of initiatives since independence to tackle the problem to dwindling health and sanitation problem in rural areas. Times to time many schemes were introduced. These schemes no doubt have improved the plight of rural population but the change isn’t what the visionary leaders wanted or what they visualized. Below is provided a brief analysis of various schemes that were launched by the government :-

1.      Rural Water Supply and Sanitation Programme

Drinking water supply and sanitation are state subjects and are backed by central government. Under this scheme the government provides funding for installing hand pumps and piped water supply. India has one of the largest rural drinking water supply networks in the world. Today almost 98% of the population has access to portable drinking water which is a big achievement. However, sanitation continues to be an issue with just over 25 % of population having access to basic sanitation. Total Sanitation Campaign was launched by the government in order to address this problem. TSC focuses on family sanitation and hygiene. It also focuses on school sanitation. India has been declared free of some water borne diseases by the WHO. This is a big achievement as the government has been taking action since early 1980s to eradicate these diseases.

Sanitation is a big issue. The practice of defecating in open is a grave health hazard. However people don’t have any choice as they don’t have access to proper toilets and technology. People in rural areas have to walk a long distance just to find a place to defecate. Around 65% of the Indian population still defecate in public. The programme followed an approach to provide free of cost, construction of toilets for SCs, STs and landless labourers. Later on the sanitation problem was shifted to another scheme called the total sanitation scheme.

On the whole Rural Water Supply and Sanitation Programme has been a very successful program in terms of implementation of plans. However, its success is only on the account of portable water supply. In case of sanitation this scheme didn’t do much and thus another scheme was launched to counter sanitation problems.

2.      National Rural Health Mission (NHRM)

NHRM was launched in April 2005. NHRM provides support to states for strengthening health care system in rural areas through provision of physical infrastructure, human resources, equipment, and emergency transport, drugs, etc. NHRM covers all health sectors but excludes cancer, HIV/AIDS & mental health. NHRM besides providing support for infrastructure development also provides a community worker called ASHA in every village.

There are around 8 lakh ASHAs working presently. Also NHRM has appointed around 12,000 doctors, 30,000 doctors & 15,000 paramedic staff. The state is held responsible for filling up the vacancies.

NHRM is the main funding body for rural health infrastructure. It gives united funds to all government facilities. Rs. 20 lakhs is provided to each District Hospital and CHC for up gradation of facilities.

NHRM is the pioneer in cause of rural health and sanitation. Though still a lot of work is to be done but this scheme has taken the whole government initiative to an entirely new level. Discussed below are the achievements of this scheme:-

ACHIEVEMENTS OF NHRM

·         Since its inception in 2005 NHRM has hired more than 8 lakh personnel which includes doctors, nurses, ASHAs and other personnel.

·          Under NHRM more than 10,000 sub centres, PHCs and CHCs are being constructed and renovated.

·         NHRM has been constantly working to provide medical facilities like ambulances in rural areas.

·         Under NHRM almost every village in India have a VILLAGE HEALTH & SANITATION COMMITTEE.

·         Around 5% of the PHCs and sub centres are operating 24x7 which is an achievement in itself.

·         NHRM has given impetus to the state & central government. It has forced the governments to shell out more for rural health ad sanitation. Due to NHRM the percent expenditure of GDP on health has increased from 1.19% in 2004-05 to 1.53% in 2009-10.

·         There has been a significant increase in the budget allocation to NHRM. In 2005 a total of Rs. 6,500 crores was allocated to the scheme which has risen to more than Rs. 30,000 crores in 2010-11. This clearly speaks of the achievements of NHRM. On an average more than 90% of the fund allocations are used.

·         There has been a significant decline in the infant mortality rate in rural areas since the inception of NHRM vis-a-vis the urban areas. The rural IMR improved from 58 in 2005 to 53 in 2008.

·         There has been a decline in the maternal mortality rate.

·         Total fertility rate has reduced from 2.9 in 2005 to 2.6 in 2008. This is due to the family planning initiatives taken under NHRM.

·         There has been around 50 % reduction in deaths related to malaria and dengue.

·         Toilets are being built in rural areas. Government is giving grants to village panchayats to install submersibles in these villages to ensure proper water supply.

Apart from the achievements mentioned above NHRM has achieved most of its targets on or before time. The major threat to this scheme is the acute shortage of personnel and lack of awareness amongst the people. Besides corruption at local level is also a problem.

Conclusion

Different government schemes and a sincere effort by the government to uplift the rural section has definitely reaped results. Success has been enormous but still a long way is there to go. Non willingness of doctors to work in rural areas, corruption and neglect are still the problems that rural India faces which needs to be tackled.