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Building accessible healthcare in rural India: Reform Playbook

Introduction



We can define access to healthcare as the availability of healthcare services of a certain quality at a specific cost and convenience. Though policies and regulations over the last few decades have strengthened urban India’s health system, access to healthcare in the rural parts of our country is alarmingly poor.



  • India ranks considerably lower than some of its peers in the Health access and quality Index (HAQ index) growing only 16.5 points over 26 years and continues to score below the global average of 54 points.

  • With just over a million qualified doctors to treat a population of 1.36 billion, medical personal are unable to keep up with the growing health needs of the population.

  • Healthcare related costs push nearly 39 million hospitalized patients towards the poverty line, thus creating an environment of fear and helplessness among rural patients.


This paper takes a deep look into the major pain points affecting the rural public health system in India in terms of availability, quality as well as affordability. We have also touched upon awareness briefly, which more often than not acts as the primary barrier to demanding healthcare.


1. Quality of healthcare


WHO defines Quality of Care in the following way: "all people have access to health services that are provided in a way that responds to their preferences, are coordinated around their needs and are safe, effective, timely, efficient and of an acceptable quality”


India sees more deaths due to poor quality of care than its peers.


The worst performing states constitute about 49.54% of our total population, 78.18% of which is rural. By focusing on the rural population, we could potentially alleviate grievances of nearly half of the nation's population.


Fig. Composite overlapping score based on NITI Aayog and the Health Access Quality Index (Gates Foundation) to identify the most concerning states in India


Reasons for poor quality of care


Chief reasons for poor quality are:

  • Low competence - Qualifications or knowledge as per medical vignettes studies

  • Low effort - Time spent with patients, more questions asked, more exams performed, adherence to case specific checklists of recommended care

Both these parameters fare better in private set ups vs public, which is the majority provider of healthcare in rural areas

  • In rural India, 67% of healthcare providers reported no medical qualifications at all. This directly correlates with the rate of unnecessary or harmful treatment at 41.7%

  • In India, on an average doctors spent just 40 minutes actively seeing patients which points towards grossly underutilized capacity

  • Time spent in the public sector is 30%-50% lower than in the private sector


Quality assurance vs quality control


Quality assurance refers to a proactive effort from the providers to ensure quality. Quality control, in contrast, involves external surveys, tests or investigations to identify defects in the system, which is then rectified reactively.


Quality assurance in the public sector is inhibited by the absence of need for accountability to their customers. This can be better understood from the know-do gap curve below.



The resolution to this problem is, counter-intuitively, through ensuring a robust quality control mechanism at an individual primary healthcare provider’s level.

Following are the steps involved in ensuring quality assurance:

  • Measurement of data at an individual level to ensure accountability

  • Constant analysis to identify specific geographies and concerns

  • Design of solutions based on concerns and implementation across geographies

  • Monitoring of data to check implementation and course correct, if necessary



1.1. Measurement of quality


Definition of quality has variants, differing by bodies such as WHO, NQAS, BMGF, etc depending on their particular area of interest.


We find some gaps in their approaches especially in periodicity of reporting, accountability and transparency & ease of understanding.


1.1.1. Our proposed framework


We propose a system that allows for administrative personnel to assess at any point in time state of the public healthcare machinery and deploy resources effectively. It can be utilized by multiple stakeholders, and its structure allows for customization that can help improve the system over time.

The proposed framework can be utilized by stakeholders, and its structure allows for customization that can be improved over time.


HCQ = f(Dimension1, Dimension2, Dimension3,...... Dimensionn)


HCQ= f(Availability, Conformity, Timeliness, Efficiency, Effectiveness...)


The following explains the working of this framework:

  • We disaggregate healthcare into intuitive, measurable and actionable dimensions to act as indicators (e.g. timeliness of treatment).

  • Dimensions are based on a fixed set of standard metrics to evaluate quality, defined by Indian Public Healthcare Standards (e.g. Infrastructure requirements, drug lists, healthcare personnel etc.)

  • These dimensions are converted into a score and displayed via an interactive dashboard

  • The scores help trigger attention to gap areas and invite investigation, which would in turn call for right action to be taken

Some core principles

  • The framework can be deployed across the entire hierarchy of the public healthcare system - serves as a homogeneous score with broad applicability.

  • Uniformity of metrics allows for benchmarking & relative measurement

  • Data is collected at all levels – bottom up from an individual all the way to the state

  • Metric Definition: Must have a review committee to assess the rationale and the utility of the metric; too many pseudo metrics can break the system.



1.1.1.1. Dimensions and indicators


There are typically 5 dimensions we look at. Each quality metric falls into one or more of these dimensions. It appears in the form of a score within the dimension.


Dimensions

  • Availability - Intends to measure the availability of any resource; Assessed as a 1-0 (available/not-available) estimate or a percentage-of-required estimate.

  • Timeliness –Intends to measure timely service; Measured using delay in service deployed.

  • Conformity –intended to measure the conformance to established standards & uniformity of services. Strict conformance shall be measured by a 1-0 (conforms/non-conforming) estimate.

  • Effectiveness – Measuring the outcomes of all actions that Availability/Conformity/Timeliness led to is essential to assess the adequacy of the actions

  • Efficiency – Assesses the efficiency in operations across the healthcare system.


The most immediate focus is on availability and timely delivery, further moving on to standardized effective and efficient healthcare as the system matures.


1.1.1.2. Sample calculations


As an example, let us look at availability and conformity of beds at a PHC level under the Indian Public Health Standards. It suggests that the entity have 6 beds.




Let’s say 5 days of delay is ~70% timely for the sake of this computation. Now, this 70% can be improved because one bed has been added within 5 days. Thus 70% + (1/5)*70 can be used to scale the score giving a new score of 84%.


If this entity consisted of only these three metrics, the entity (PHC) level score is:


The entire score has been penalized due to lack of strict conformity to the standard of having 6 beds. These calculations are then averaged across dimensions and then for each entity, moving upward in the hierarchy.


1.1.1.3. Dashboard and usage


Snapshot of the dashboard


How to use the dashboard?

  • Low scores draw attention to alarming dimensions, enabling immediate identification and redressal at multiple levels – specific areas, districts, states, etc.

  • Time series representation on the dashboard to visualize drops any patterns in entities/ regions/ districts to pay attention to

  • Within each state/ district, identify worst performing entities across dimensions.

  • Auxiliary information such as the following can help link outcomes to plausible hypotheses that can be later investigated:

    • Demographic profile: Gender, Ages etc

    • State/District mechanisms at play: State, district spending, Number of healthcare campaigns etc

    • Effects of trends - availability of internet, smartphones, awareness


1.1.2. Implementation and governance


  • For governance we suggest an escalation/ accountability hierarchy synonymous where each nodal officer owns the said nodel level KPI performance with an incentive mechanism in place, and penalty for continuous degradation.

  • This hierarchy can be integrated into the performance dashboard to preclude any negligence on the end of the nodal officers.

  • Ensure integrity of data reported, any tampering renders the entire effort futile. This would require using security mechanisms along with Aadhar authentication for any data entry which can be driven by a simple 2 step SMS authentication.

  • Escalation hierarchy: Country Head -> State Heads -> District Head -> Entity heads -> Metric Owners


2. Availability of healthcare


Adopting the World Health Organization's definition of Availability for rural India, Availability can be defined as:


The sufficient supply and appropriate stock of health care workers, with the required skill levels (Including Image and trust-worthy ness) who are given adequate infrastructure to cater to the health needs of the population of an area within a standard range of the population. These workers also need to improve safety standards, improve administrative processes and take up a social responsibility to help educate India’s rural population on healthcare.


Conversations with a small section of the stakeholders including doctors, nurses and ward boys serving at PHCs helped us identify the main pain points affecting availability – A shortage in human resources, infrastructure and medicines.


2.1. Issues


Shortage of human resources

  • With less than 40% of PHCs having the necessary two doctors, there is increased pressure on the referral-based three-tier healthcare system.

  • With only 5 of the 35 states studied meeting the requirement of specialist doctors at community health centres, patients are forced to look elsewhere for their treatment.



Shortage of infrastructure


Policies and laws enacted by the administration have improved the situation of health infrastructure in our country. 40% of our sub-centres exceed the requirements of covering 3000-5000 citizens, 60% of our community health centres exceed the requirement of one CHC for a population of 80000 – 120000.


With a shortfall of about 20% in sub-centres, 22% Primary Health Centers and 32% Community Health Centers in rural areas across the country, we need to further improve access to public healthcare infrastructure.



Shortage of medicines and treatment drugs


The median availability of the 30 essential medicines in 6 of the biggest states in India varied between 0% to 30%.


These essential medicines are procured centrally to benefit the public health system, but this procurement is unable to meet the demand. This shortage is mainly due to poor inventory management (further strained by the shortage of pharmacists), low spending, lack of knowledge and an inefficient procurement and distribution system.



Data analysis of shortfall in infrastructure and manpower in various states in Rural India Based on the Rural Health Statistics 2019-2020



The major issues we identify through the analysis were

  1. A shortage of nearly 76% specialists across CHCs and a shortage of 65% male health workers across SC’s and PHCs are major pain points that need to be addressed.

  2. 33% CHCs do not have physical building infrastructure to cater to the population.

  3. Life-saving treatment drugs and medicines are not easily available across most parts of rural India.

The administration and other social organisations have come together and tested a few solutions that have proved to work in small hamlets in addressing these issues. The need is to scale these solutions to help improve the public health system. These are examples of a few organizations trying to solve availability issues in their regions.


2.1.1. Addressing the issue of shortfall of manpower at the CHC level – The Vellore model



Christian Medical College, Vellore (CMC, Vellore) has developed and integrated a model of healthcare in Vellore district, where students undergo mandatory 2 year periods serving the community as a part of clinical teams in medicine, surgery, obstetrics and pediatrics. They also function as independent primary care doctors in rural communities. Thus solving the shortage of specialists at CHCs in the district.


2.1.2. Addressing the shortage of manpower at the SC and PHC level – Jan Swasthya Sahyog and Basic Health Service


Jan Swasthya Sahyog (JSS) aims to provide education and employment opportunities to the local communities of rural Bilaspur. JSS offers nursing courses to the adivasis of Bilaspur which helps overcome the shortage of well trained, qualified and motivated health workers in Central India.

Basic Health Service (BHS) works with the most vulnerable communities by providing a responsive and empathetic primary health “circle of care”, that is rooted in the community. BHS offers preventive, promotive and curative care while using a combination of innovations in human resources. Their flagship Amrit clinics have skilled nurses who are the primary care providers and managers. There is a downward integration with community volunteers and an upward integration with a family physician. Nurses and male workers are more available to work in remote, rural areas thus solving for the shortage of manpower.


2.1.3. Addressing the shortfall of infrastructure at the CHC – Possible Health and PPP model


Due to the lack of government budgets and low investment from private players in the health sector, the creation and improvement of hospitals is unable to keep up with the required numbers.



Possible Health, in their efforts to improve health care in Nepal’s western lowlands, started to run the government Bayalapata hospital in Accham district. Possible runs the hospital through a partnership that includes government funding and funding from global philanthropies. Possible also runs the district's public health system with the Nepali Ministry of Health and Population. Through their US-based fundraising team and the care team consisting of locals from the Accham district, they can care for more than 250,000 people.


2.1.4 Addressing the Shortfall of medicines – Generic drug substitutions

Improving access to essential medicines needs to include improved public provisioning, regulation of drug prices and an evidence-based drug approval process. The use of generic medicines could reduce the shortage of medicines and treatment drugs, as nearly 1/5th of the generics are produced in India and majorly exported to other countries. There have been successful implementations of generic drug prescriptions (United States and United Kingdom) and generic drug substitution (Sweden and Finland) where biases against generic drugs and medicines have reduced while improving the availability of essential.


3. Affordability


What is affordability?


Healthcare affordability describes whether a person or an organization has sufficient income to pay for the healthcare costs incurred. These costs could include direct healthcare service costs or insurance premiums.

The main components of affordability of healthcare in rural India include

  • Medical devices

  • Critical healthcare equipment

  • Medicines

Medicines can account for 90% of healthcare spending by poor people.


Affordability of healthcare in rural India is a problem in terms of Out-Of-Pocket expenditure.

  • More than half of India’s rural population uses private healthcare, which can cost the poorest 20% of Indians more than 15 times their average monthly expenditure

  • 70-80% of the cost borne by rural India is an out of pocket expenditure (OOPE), landing them closer to poverty.

  • Between 2004 and 2014, the average medical expenditure per hospitalization for rural patients jumped by over 160%.

3.1. Gaps in the system


We break down healthcare services to government and private services. The problems within each segment are then further analyzed to arrive at breakpoints and provide solutions.



3.1.1. Healthcare from Government Services


While most healthcare expenditure of people below the poverty line are covered under various government schemes, there are multiple stark loopholes like:


3.1.1.1. Coverage Gaps


  • 13% of the rural population got covered under government schemes like Rashtriya Swasthya Bima Yojana or similar plans; 86% were without health-expenditure support

  • Above Poverty Line (APL) population is left out: A significant portion of the rural populace falls under this category.

  • Government schemes like Yeshasvini and Arogyasri offer surgeries that benefit a small section of the society. Thus, a larger section is forced to pay for medical care for ailments requiring only medication and not surgery.

  • Non-hospital drugs, out-patient expenditure not covered

  • Travel costs not covered: 48% of overnight trips made by millions of rural Indians (compared to 25% in urban areas) are for medical purposes. Since more than half of India’s rural population uses private healthcare – mostly located in urban areas – travel costs are a significant problem.


3.1.1.2. Implementation Problems


Despite the existence of various government schemes, there are certain implementation gaps hindering their utilization-

  • Lack of awareness of the schemes

  • Inability to avail benefits due to lack of relevant documents/Identity proofs

  • Federalist approach to healthcare policies: In India, individual states maintain control over their healthcare spending and resource allocation. While this model empowers states to prioritize the health of their citizens, unwillingness to collaborate among states has resulted in inconsistencies in the national healthcare system


3.1.2. Healthcare from private sources


Healthcare services from private sources can be availed either through OOP expenses or insurance.


3.1.2.1. Breakpoints in OOP


  • Consultation charges high due to lack of limit in profit percentage

  • Service/ device charge high due to excessive cost to hospitals at the back of problematic supply chain: Some private hospitals charge INR 25-50,000 (EUR 287-575) for ventilators each day. Other costs like room rent, equipment, monitoring, also add up.

  • Travel expenditure: Travel expense is significantly higher for rural population than urban, given the lack of infrastructure

  • Medicine cost high


3.1.2.2. Breakpoints in Insurance


We have prioritized some of the common problem areas + more important contributors within each segment for solutioning.

  • Travel expenditure: Government expenditure on health can be scaled up. New schemes should be developed to factor in the healthcare travel expense gap between rural and urban India.

  • Medicine cost: Some system where generalist medicines cost is lowered by promoting regional production and specialist medicines covered under relevant scheme

  • Medical devices: Importers, in order to avoid customs duty, argue that intermediate costs like R&D and clinical evaluation are not part of the landed price. However, they also attract hospitals with high MRPs and higher trade margins. This tactical marketing warfare is highly unethical and has cost the consumers dearly apart from adversely impacting domestic manufacturers.

  • Monitoring system: Implement a comprehensive multi-level and multi-tool system of monitoring and evaluating rural development programmes in different parts of the country.


4. Awareness related to healthcare


What is Awareness?


Health care awareness is a measure of whether individuals, groups of individuals, and/or organizations have adequate knowledge regarding the healthcare system located within the region, state, and/or nation.


4.1. India lacks in the following aspects of awareness:


A. Preventive Measures

  • Only ~20.3% of people are aware of common causes of prevalent illness and their prevention

  • In current times of COVID19, one can see a lot of people breaking rules despite the government running campaigns on preventive care for the virus

B. Treatment Measures

  • Very low understanding and awareness of the various treatment methods

  • Not having much knowledge of the symptoms and how to identify the more dangerous symptoms regarding a certain condition

  • Low awareness of the medicine available

C. Healthcare Insurance

  • In one study conducted in a rural area, only 11% were aware about health insurance and only 6% had any health insurance policy (vs urban setting where 43.4% were aware of health insurance)


4.2. Solutions:


A: Campaigns for Healthcare Accountability:

  • Conduct Health campaign to review health services for accountability in rural areas of India.

  • Invite opinions, experiences, information, and feedback from the public on current Government health facilities.

B. Health Camps/ Interventions

  • Various self-help groups in rural India

  • Women’s self-help groups to be utilised for promoting awareness of symptoms and COVID-19-appropriate behaviour.

C. Increase education within the School Systems

  • Implementing seminars, workshops, and various informational sessions to educate young boys and girls


Meet The Thought Leaders


Shatakshi Sharma is a public policy advisor, has been a management consultant with BCG and is Co- Founder of Global Governance Initiative with national facilitation of award- Economic Times The Most Promising Women Leader Award, 2021 and Linkedin Top Voice, 2021. Prior to graduate school at ISB, she was Strategic Advisor with the Government of India where she drove good governance initiatives. She was also felicitated with a National Young Achiever Award for Nation Building. She is a part time blogger on her famous series-MBA in 2 minutes.


Naman Shrivastava is the Co-Founder of Global Governance Initiative. He has previously worked as a Strategy Consultant in the Government of India and is working at the United Nations - Office of Internal Oversight Services. Naman is also a recipient of the prestigious Harry Ratliffe Memorial Prize - awarded by the Fletcher Alumni of Color Executive Board. He has been part of speaking engagements at International forums such as the World Economic Forum, UN South-South Cooperation etc. His experience has been at the intersection of Management Consulting, Political Consulting, and Social entrepreneurship



Shreya Ravichandran was a consultant at McKinsey and Company, with a background in economics from Shri Ram College of Commerce. She loves problem-solving on social issues to make an impact on people's lives. She is currently working at The Antara Foundation as the Chief of staff to the founder, working on maternal and child health in rural India. She is also an avid musician and spends her free time experimenting different styles.



Meet The Authors (GGI Fellows)


Chris Pinto is currently a Quantitative Analyst at Nomura; in this role he provides analytical expertise by utilizing both financial know-how and technology primarily in assessing capital adequacy. Prior to this, he has extensive experience in delivering technology solutions for the firm. Chris is a 2017 Computer Science Graduate from NMIMS university. He has been awarded both Student Ambassador for exemplary overall performance and Academic Merit. A firm believer in continuous learning, he holds a GARP FRM certification, and is also a candidate in the CFA program. With a penchant for seemingly simple yet complex problems, Chris believes in the power of employing a cross-disciplinary approach for bigger, more convoluted issues faced by society at large.


Abhijith Giridhar has spent more than 3 years working to improve education and early childhood development in India. He spends his time helping non-profits scale by leveraging technology. Abhijith has worked towards impacting the lives of children and their communities through a focused classroom program at Teach For India.

His experiential learning initiative, "Games for Ed" integrates playful learning with classroom teaching at government schools in Pune. Currently, as a product manager at Upepo, he is building a community of playful learning enthusiasts in India. In addition, he travels across urban and rural India to build sustainable playscapes for children. Lastly, Abhijith is an incoming MBA student at Asia School of Business, Kuala Lumpur.


Simran Chauhan is a Business Operations Associate at ZS, working closely in the healthcare sector. She did her BTech in Chemical Engineering from NIT Rourkela and has an admit from ISB for their PGP. She has previously volunteered for the United Nations and various other NGOs to help solve problems at the grassroot level. She also enjoys creating art and reading books.


Aseem Kumar is currently pursuing an MBA from the Indian School of Business (Class of 2022). He was a Young India Fellow (Class of 2017) and a graduate from IIT-BHU (2013). He cares about transformation and has experienced how very simple ideas come up after sifting through detailed information! Previously, he has led marketing in a West Bengal district for Ambuja Cement and later worked as the COO's Chief of Staff and Executive Assistant, and Project Leader at NRB Bearings, where he led numerous projects ranging from supply chain optimization to operations to diversity. He has recently had a bit of startup experience for an eCommerce tech firm where he designed and led account-based marketing (ABM) efforts.



Apeksha Gadia is an Assistant Manager at PwC in Deals team. She is a co-founder of Train to Teach a social impact venture focused in the field of education. She is a chartered accountant and CFA L2 candidate. Apart from work she enjoys reading and learning about new ideas and volunteering with various NGOs.



Aavaiz Raza is a recent graduate from the University of Toronto, specializing in Management. He is enthusiastic about management consulting, product management, and venture capital. Throughout his journey at the University of Toronto, he assisted many professors as a Teaching Assistant for various finance, technology, and operation courses. Aside from this, he has completed multiple consulting fellowships and been mentored by MBB consultants. He is also interested in research and has recently completed an internship at Harvard University.


If you are interested to apply to GGI Impact Fellowship, you can access our application link here.

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