Nikhil Kalita

APA
Review of Literature Addressing the Access to Healthcare in Rural India

I. INTRODUCTION
India has a complex healthcare system that has been covering more and more of its 1.4
billion people in the past decades. However, there are many challenges that persist, as achieving
access to adequate and affordable healthcare is still very difficult for most of India’s rural
inhabitants. These rural areas include almost 950 million people or an eighth of the world’s
population and 68% of India’s population. In this paper, the current status of access to adequate
and affordable healthcare for rural communities will be examined through the review and
analysis of various existing studies. The literature exploration will focus on India’s rural
healthcare infrastructure and workforce, affordability and expenditure, health attitudes and
behaviors, and other key indicators and outcomes of health. These themes capture the
contributing factors and results of inequitable access to healthcare in rural India.

II. FINDINGS
A. Rural Healthcare Infrastructure and Workforce
India has a unique public healthcare system that is split up into sub-centers (SC), primary
health centers (PHC), and community health centers (CHC) responsible for providing its services
to all rural communities. Most research on India’s healthcare infrastructure analyzes data from
the Government of India Ministry of Health and Social Welfare’s Rural Health Statistics reports.
These reports consist of thousands of entries of data explicating the availability of healthcare
infrastructure by type of facility, location, patients served, and more (MHFW, 2020).
In a statistical analysis of these reports, Lyngdoh (2015) highlighted the disparity in rural
access to healthcare and the need for more health services by using a composite index of
infrastructure for the northeastern states of India. Kumar (2020) also suggested that there is
unsatisfactory rural access to healthcare after sifting through the Rural Health Statistics reports.
He found that there is an average of only 3.2 hospital beds per 10,000 population and rural
inhabitants had to travel more than 60 miles to reach these facilities (Kumar, 2020).
Other researchers used the Ministry of Health’s data, like Goel (2016), who validated the
need for more health workforce retention. He compared the 100 skilled health workers per
100,000 population in India to the international norm of 228 per 100,000 (Goel, 2016). Goel
reviewed different strategies for the retention of healthcare workers and suggested various
interventions that would greatly benefit rural communities.
Rao’s research (2016) used alternative sources of data like the National Sample Survey to
develop estimates on the composition and distribution of the health workforce in India. Rao
(2016) concluded that there was a cumulative low number of qualified health workers while
there was a large presence of unqualified health workers specifically in rural communities.
Specifically, there were 11.4 times more qualified allopathic doctors and 5.5 times more qualified
nurses and midwives in urban areas than rural (Rao, 2016).
B. Rural Health Attitudes and Behaviors
Although India’s health infrastructure is inadequate, there has been a substantial increase
in rural health facilities to combat this issue through the National rural health mission (NRHM)
(Kumar, 2020). One challenge that still remains is convincing doctors to work in these rural
areas. Sharma (2015) reasons that this challenge is occurring partly due to the attitudes that
medical students and doctors have towards rural living and working conditions. Sharma (2015)
expounds on the Indian Government’s policies and incentives to attract more health specialists to
rural areas. Such incentives include “compulsory role postings, linking rural postings to
admission into postgraduate courses, and offering monetary incentives” (Sharma, 2015).
The health behaviors of Indian rural communities may also be restricting their access to
healthcare. Through the sociocultural perspective of medicine, Jacob (2018) explores the
health-seeking behaviors among tribal communities which make up 9% of India’s population. He
argues that tribal beliefs lead them to neglect constitutional symptoms as unimportant (Jacob,
2018). He cites that many deadly diseases are believed to be caused by evil spirits and the curse
of gods rather than clinical determinants for these tribal communities (Jacob, 2018).
C. Rural Healthcare Affordability and Expenditure
During the research comparing the spending habits and wealth of different groups of
people, the government was found to only allocate 2-3% of the total GDP for healthcare in 2020
(Doke, 2021). In a report done to update India’s status on the Millenial Development Goals
(MDGs), the percentage of people below the poverty line in 2011-2012 was estimated at 25.7%
in rural areas and 13.7% in urban areas (SSD, 2017). This highlights the rural-urban economic
gap that affects the equity of affordable healthcare distribution and utilization.
 A majority of the studies done on India’s rural healthcare affordability and expenditure
aimed to analyze and develop interventions to combat issues regarding the subject matter. For
example, Devarakonda (2016) strived to promote the hub and spoke model (HSM) to increase
the healthcare market’s reach and profits while reducing costs for all related entities. He justifies
that there is a need for HSM because the average Indian makes $3 a day which translates to a
nominal per capita income of $1,000 a year, while patients typically have to pay 64% of health
care expenses from their own pockets (Devarakonda, 2016; Kaur, 2020). Kaur (2020) also
suggests that there is a need for better financing mechanisms in the form of insurance schemes as
only 28.6% of total health expenditure is financed by the government which is responsible for
supplying all rural healthcare services. This disproportionately impacts the rural communities as
a fourth of their population lives under the poverty line (SSD, 2017).
Experts like Katyal (2015), analyzed the results and implications of such insurance
schemes as the Rajiv Aarogyrasi scheme (RAS) in the state, Andhra Pradesh (AP). RAS
provided free access to over 900 secondary and tertiary procedures to cover a majority of AP’s
population (Katyal, 2015). With the implementation of RAS, Katyal (2015) found that rural
inhabitants utilized more healthcare services from 2002 to 2014.
D. Key Indicators of Health in Rural India
To better contextualize India’s status in health care, key indicators of health must be
examined. Some of these include the mortality rates of infants, children under-5, mothers during
live-births, tuberculosis, HIV-related illnesses, malaria, and the rates of immunizations. These
indicators are monitored by the World Health Organization (WHO) and the United Nations
Children’s Fund (UNICEF). These multinational UN organizations require countries, like India,
to develop progress reports on their statuses on MDG goals (SSD, 2017).
India was reported to have one of the worst infant, under-five, and maternal mortality
rates in Asia, one-fourth of the world’s burden of TB, and a significant amount of the global
burden of HIV-related illnesses (SSD, 2017). The only health indicators that do not top lists of
worst health outcomes are that of India’s malaria mortality and immunizations (SSD, 2017).
These comprehensive reports suggested that the mortality rates are much higher in rural
areas (SSD, 2017). Though many studies have linked rural health outcomes to structural issues,
some studies have tied the increased child mortality in rural areas to decreased sanitation and
health literacy in rural communities (Andres, 2017). Andres (2017) found direct health benefits
when certain rural communities were exposed to proper sanitation practices in his team’s
randomized control trials.

III. DISCUSSION
A. Data Collection Limitations
Most of the studies and articles reviewed in this paper analyzed data from expansive
government reports on healthcare and health outcomes. Although these reports proved to be very
useful for analyses and fostering improvement, many changes can be made to enhance its
utilization. For example, there can be more focus on comparing the access to healthcare and
health outcomes between rural and urban communities. There was no data that uncovered the
causes of health outcomes that were more prevalent in rural areas. Instead, external researchers
were forced to make subjective estimates on rural health inequity. Like Lyngdoh (2015), who
stated that there were limitations and unavailability of data for the construction of his healthcare
infrastructure index. Moreover, studies on health behavior often mentioned the lack of research
done on rural health behaviors and utilization (Katyal, 2015). Although these large reports
impressively collected data of more than 1 billion Indians and their health outcomes, more
specific data collection can allow for the development and implementation of tailored
interventions to increase access to adequate health care for rural communities.
B. Fragmentation of Rural Health Services
India demonstrates a unique, unquantifiable demand for health services as millions of
rural communities are scattered across the diverse country. To address this vast need, rural India
relies on its public healthcare system because private providers are primarily in urban areas. As
previously mentioned, the public healthcare system has three types of centers with norms set by
the Indian Public Health Standards (IPHS) (Chokshi, 2016). However, a majority of studies
criticized the public healthcare infrastructure as these centers never lived up to their proposed
goals. Various programs have different roles when managing the SCs, PHCs, and CHCs
(Chokshi, 2016). There is no common oversight or checks and balances system other than the
requirement to meet the IPHS without federal supervision (Chokshi, 2016). Every time these
issues come to light, the NRHM mitigates infrastructure shortages reactively rather than being
proactive. And due to these problems, rural patients are referred to private facilities far from their
homes and too expensive for their pocket, further worsening the rural-urban economic and health
inequities (Kumar, 2020; Gupta, 2020).
 Additionally, India had insurance schemes covering only a few populations like RAS in
AP (Katyal, 2015). In response to these fragmented infrastructural and insurance systems, India
launched the tax-financed National Health Protection Scheme (or PM-JAY), similar to other
national health insurances, providing access to private secondary and tertiary healthcare services
for all lower-income individuals (Gupta, 2020). This plan provides immense opportunities for
rural patients even if their primary health centers are inadequate. With more equitable initiatives
like this, India can significantly increase access to healthcare for those in rural areas.
C. Progress in Healthcare Access and Outcomes
Fortunately, many articles indicated that India’s current status of rural healthcare has
actually been improving since the inception of the NRHM in 2005. Chokshi (2016) stated that
the NRHM has become a “major financing and health sector reform strategy to strengthen the
state health systems”. WHO and UNICEF’s national targets have also accelerated the Indian
Government’s focus on achieving adequate and affordable access to healthcare for all. The 2017
progress report from the Integrated Global Action Plan for Prevention and Control of Pneumonia
and Diarrhea (GAPPD), stated that India had the greatest positive change in meeting intervention
targets compared to every other country in 2017 (IVAC, 2017). India’s recent efforts in
increasing access to healthcare for rural communities must have contributed significantly to the
improvement in these key indicators of health. This brings hope to the fact that these initiatives,
and the hard work of those involved, will not go to waste.

IV. CONCLUSION
In this literature review, the research and studies of experts elucidated numerous barriers
that rural Indian communities face when accessing healthcare services. These issues included an
unsatisfactory rural healthcare infrastructure, a major deficiency in the quality of rural healthcare
provided, negative rural health attitudes and behaviors, and a lack of affordable healthcare
services. All of these problems likely contributed to India’s abysmal negative health outcomes.
Regardless, India has made incremental improvements in its public healthcare systems. These
refinements to overcome outreach and financial hurdles are increasingly helping provide
adequate, affordable, and equitable healthcare to its diverse and massive rural populations.
Although there is a lot of work to be done, India can potentially be a model for accessible rural
healthcare using a hybrid federal and regional, public and private system.
V. REFERENCES

1. Andrés, L., Briceño, B., Chase, C., & Echenique, J. A. (2017, June 1). Sanitation and
externalities: Evidence from Early Childhood Health in rural India. Journal of Water,
Sanitation and Hygiene for Development. Retrieved December 10, 2021, from
https://iwaponline.com/washdev/article/7/2/272/30238/Sanitation-and-externalities-evide
nce-from-early.

2. Chokshi, M., Patil, B., Khanna, R., Neogi, S. B., Sharma, J., Paul, V. K., & Zodpey, S.
(2016, December 7). Health Systems in India. Nature News. Retrieved December 9,
2021, from https://www.nature.com/articles/jp2016184.

3. Devarakonda, S. (2016). Hub and spoke model: Making Rural Healthcare in India
affordable, available and accessible. Rural and remote health. Retrieved December 9,
2021, from https://pubmed.ncbi.nlm.nih.gov/26836754/.

4. Doke, P. P., Palkar, S. H., Gothankar, J. S., Patil, A. V., Chutke, A. P., Pore, P. D.,
Deshpande, A. V., Bhuyan, K. K., Karnataki, M. V., & Shrotri, A. N. (2021, October 18).
Association between adverse pregnancy outcomes and preceding risk factors: A
cross-sectional study from Nashik District, India. BMC pregnancy and childbirth.
Retrieved December 9, 2021, from
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8522067/#CR1.

5. Goel, S., Angeli, F., Bhatnagar, N., Singla, N., Grover, M., & Maarse, H. (2016).
Retaining health workforce in rural and underserved areas of India: What works and
what doesn’t? A critical interpretative synthesis. Researchgate: Review Article. Retrieved
December 9, 2021, from
https://www.researchgate.net/profile/Sonu-Goel/publication/312943464_Retaining_healt
h_workforce_in_rural_and_underserved_areas_of_India_What_works_and_what_doesn
%27t_A_critical_interpretative_synthesis/links/5a66e42f4585158bca54d576/Retaining-h
ealth-workforce-in-rural-and-underserved-areas-of-India-What-works-and-what-doesnt-A
-critical-interpretative-synthesis.pdf.
6. Gupta, I., & Patel, N. (2020, June 5). India. International Health Care System Profiles -
India. Retrieved December 10, 2021, from
https://www.commonwealthfund.org/international-health-policy-center/countries/india.

7. Islary, J. (2018, April 18). Health and health seeking behaviour among tribal
communities in India: A socio-cultural perspective. SSRN. Retrieved December 9, 2021,
from https://papers.ssrn.com/sol3/papers.cfm?abstract_id=3151399.

8. International Vaccine Access Center (IVAC). (2017). Pneumonia & diarrhea progress
report - jhsph.edu. Pneumonia and Diarrhea Progress Report 2017. Retrieved November
13, 2021, from
https://www.jhsph.edu/research/centers-and-institutes/ivac/resources/IVAC-2017-Pneumo
nia-Diarrhea-Progress-Report.pdf.

9. Katyal, A., Singh, P. V., Bregkvist, S., Samarth, A., & Rao, M. (2015, March). Private
sector participation in delivering tertiary health care: a dichotomy of access and
affordability across two Indian states. Academic.oup.com. Retrieved December 9, 2021,
from https://academic.oup.com/heapol/article/30/suppl_1/i23/729794?login=true.

10. Kaur, B. (2020, February). Disasters and exemplified vulnerabilities in a cramped public
health infrastructure in India. International Journal of Disaster Risk Management.
Retrieved December 9, 2021, from
https://www.ceeol.com/search/article-detail?id=946672.

11. Kumar, A., Nayar, K. R., & Koya, S. F. (2020, May 5). Covid-19: Challenges and its
consequences for Rural Health Care in India. Public Health in Practice. Retrieved
December 9, 2021, from
https://www.sciencedirect.com/science/article/pii/S2666535220300082#bib6.

12. Lyngdoh, L. (2015, December). Inter-state variations in rural healthcare infrastructure ...
Nehu Journal 2015. Retrieved December 9, 2021, from
https://nehu.ac.in/public/downloads/Journals/Journal_VolXIII_No2_Jul-Dec2015_A3.pdf
.
13. MHFW, . (2020). Rural Health Statistics, 2019-20. People's Archive of Rural India.
Retrieved December 10, 2021, from
https://ruralindiaonline.org/en/library/resource/rural-health-statistics-2019-20/.

14. Sharma, D. C. (2015, December 12). India still struggles with rural doctor shortages.
The Lancet. Retrieved December 9, 2021, from
https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(15)01231-3/fulltext?rss
%253Dyes.

15. SSD, . (2017). Millennium Development Goals- Final Country Report of India. Social
Statistics Division. Retrieved December 9, 2021, from
http://www.mospi.nic.in/sites/default/files/publication_reports/MDG_Final_Country_rep
ort_of_India_27nov17.pdf.