Mahatma Gandhi, the father of the nation, believed that the village should be the center of all activity in India. He saw the village as the backbone of the country and believed that the true measure of India's progress lay in the well-being of its rural population. As we mark the 75th anniversary of his death on January 30th, it is a tragic reality that we have failed to live up to his vision for the village and rural India. This is particularly evident in the state of Healthcare in Rural India.

Today as the world stresses on economic growth, globalization and privatization, a silent section of the society seems to slip through all safety nets. In India, one is talking about at least 26 percent of the population who fit into this category. The percentage varies from state to state. In most of the northern states poverty seems to be increasing and if you further disaggregate from urban to rural, you will find that 40 percent of the rural population in 10 states in India are below the poverty line. If one further disaggregates the figures into schedule caste, schedule tribes, the marginalized, the percentages just keep on rising.

In India, health care has emerged as one of the largest sector with maximum expenditure incurred.

An astounding 60 percent of this is out of pocket expense. India has one of the highest proportions of private health spending, only to only few countries in the world with a recent history of major internal unrest, such as Cambodia and Myanmar. Such is the lack of trust in the public health system that not only do 80 percent of the wealthy seek treatment in the private sector, but a similar percentage of the poor also goes to private practitioners, even though the treatment may be of low quality and provided by untrained practitioners.

Some unfortunate statistics reflect this state of affairs:
1.One quarter of hospitalised Indians slip below the poverty line because of hospital expenses alone. This number has been estimated to be sixty million people every year but has risen exponentially during the last year because of the Covid pandemic.

2. Hospitalised Indians spend more than half of their annual expenditures on healthcare.
More than 40 percent of those hospitalised borrow money or sell assets to cover expenses.

3.The poorest 20 percent Indians have more than twice the rate of mortality, malnutrition and fertility of the richest 20 percent.

Gandhi's vision for rural India was that of a self sufficient and self-reliant village where the people were the masters of their own destiny. He believed that the village should be the center of all economic and social activity, with the people having control over their own resources. He said, "The true measure of any society can be found in how it treats its most vulnerable members". Recent reports on rural healthcare in India, though paint a bleak picture for most of the vulnerable members, a large majority of whom live in the rural areas. The Rural Health Statistics 2021-22 released recently show that health sub centres (SCs), primary health centres (PHCs) and community health centres (CHCs) functioned with a staff strength that was less than even the preceding year, 2020-21. According to the RHS 2021-22, the number of auxiliary nurse midwives (ANMs) at SCs in the country in March 2022 was 2,07.587. This number was 2,14,820 in March 2021. Similarly, the number of doctors working at PHCs decreased to 30,640 in 2021-22 as against 31,716 in the previous year. This is important because in 2021-22, India had already battled the first wave of COVID-19 and it was common knowledge that because the worst had not happened yet, preparations were a must.

The shortfall in rural health resources was going to have an impact and was also, therefore, not difficult to gauge. The RHS report also highlights the acute shortage of specialist doctors in the country, with a shortfall of nearly 80 percent of the required specialists at Community Health Centers (CHCs). CHCs are 30-bed block-level health facilities that are supposed to provide basic care related to surgery, gynecology, pediatrics, and general medicine. There are 6,064 CHCs across India, and the Health Ministry has been unsuccessful in meeting the requirement for specialist doctors in most of these centers. The report points out that there is a shortfall of specialist doctors, including surgeons (83.2 percent), obstetricians and gynecologists (74.2 percent), physicians (79.1 percent), and pediatricians (81.6 percent).

Apart from specialist doctors, there is also a shortage of female health workers and auxiliary nursing midwives, with up to 14.4 percent of these posts lying vacant in PHCs and SCs.
The National Health Profile 2021, released by the Central Bureau of Health Intelligence, reveals that the rural areas of the country are facing a severe shortage of healthcare facilities and personnel. According to the report, there is only one government doctor for every 10,189 people in

rural areas, while the ratio in urban areas is one doctor for every 1,844 people. The report also highlights that the rural areas have a shortage of nurses, paramedics, and other healthcare workers. This shortage of healthcare personnel in rural areas is further compounded by a lack of infrastructure. The report states that there are only 24,988 primary health centers in rural areas, which is far below the government's target of one primary health center for every 30,000 people. Additionally, many of these primary health centers lack basic facilities such as electricity, water and sanitation.

The report states that there are only 24,988 primary health centers in rural areas, which is far below the government's target of one primary health center for every 30,000 people. Additionally, many of these primary health centers lack basic facilities such as electricity, water and sanitation.

Laggard states continue to be in the red. For instance, as per norms an SC should be present for every 5,000 people. But in Uttar Pradesh, Bihar and Jharkhand, more than 7,000 people depend on one SC. In 10 states, 5,000-7,000 people depend on one such centre. Similarly, for every 30,000 people there should be one PHC but in Uttar Pradesh, Bihar, Jharkhand and West Bengal, more than 50,000 people depend on one PHC. In another five states, 30-50,000 people get services from one PHC. The higher level of health facility, a CHC, is needed for every one lakh people.But in Karnataka, Andhra Pradesh, Telangana, Maharashtra, Madhya Pradesh, Bihar and Uttar Pradesh, 2-5 lakh people depend on one CHC. However, what these statistics don’t reveal are some ground realities. While a certain number of health personnel are shown posted at a health facility, it does not take into account absenteeism which was officially reported in the Economic Survey 2018-19.

The rural population of our country deserves the same access to healthcare as their urban counterparts and it is our duty to make sure they get it

“Moreover, what this data [number of personnel present at health centres] do not reveal is that even if the personnel are present, their level of participation in providing health services, may not be at desirable levels due to lack of supplies, inadequate infrastructure facilities, poor monitoring of the staff and so on”, the Economic Survey 2018-19 said.

The report highlights the stark disparities between urban and rural healthcare, with rural areas lacking basic infrastructure, trained personnel, and essential medicines, also highlights the lack of government funding and political will to address these issues. The report states that nearly 70 percent of healthcare facilities in rural India are run by the government, but they are often understaffed and underfunded. This results in poor quality care and high rates of maternal and infant mortality. However, the reality is that the Indian government has failed to prioritize the needs of the rural population, particularly when it comes to healthcare. This is evident in the lack of funding and political will to address the issues highlighted in the report.

These shortcomings in rural healthcare have dire consequences for the health of rural populations. The report states that the maternal mortality rate in rural areas is higher than in urban areas, and that infant mortality is also higher in rural areas. Additionally, the report highlights that the prevalence of communicable diseases such as tuberculosis and malaria is higher in rural areas.

Gandhi, in his writings, emphasized the need for decentralized healthcare system, with the village as the focal point. He believed that the village should be self-sufficient in terms of healthcare and that the village community should take responsibility for the health of its members. As we mark the 75th death anniversary of Mahatma Gandhi, let us remember his vision for rural India and renew our commitment to ensuring that the villages of our country are truly the center of all activity. The rural population of our country deserves the same access to healthcare as their urban counterparts and it is our duty to make sure they get it.

Let us remember the Mahatma’s message and work towards a more just and equitable society for all. Let us ensure that the village, the foundation of our economy and society, is not ignored in terms of healthcare and other basic needs. Let us work towards a India where the rights and duties of all citizens are respected and fulfilled

In conclusion, Mahatma Gandhi's vision of rural India as the backbone of the nation remains as relevant today as it was 75 years ago. However, the state of rural healthcare in India today is a far cry from his vision. It's high time we take a step back and re-evaluate our priorities and make amends to ensure that the rural population is not left behind in terms of healthcare. Only then can we truly honour the legacy of Mahatma Gandhi.

Dr. Shuchin Bajaj, Founder & Director, Ujala Cygnus Healthcare
Dr. Shuchin is a doctor and social entrepreneur. He was inspired by his roots as the son of refugee parents to give up his work in Delhi's biggest private hospital and open hospitals, clinics and digital health services aimed at providing high quality low cost health care to communities that don't have access.