This document proposes a rural healthcare system for India that addresses the lack of access and high costs that currently prevent many rural Indians from receiving adequate medical care. It involves: 1) Providing health insurance of Rs. 50,000 annually for each family, with the government paying for those below the poverty line. 2) Staffing existing primary health centers with recently graduated doctors and nurses who receive training and incentives to work rurally, including housing for their families in nearby cities. 3) Equipping these centers with basic services, medicines, and transportation to referral centers like medical colleges, with costs covered by insurance. 4) Using the existing infrastructure of medical colleges and ambulances for secondary and tertiary

1. Sparktherise.com
RURAL DEVELOPMENT AND SOCIAL
ENTERPRENEURSHIP
For improvement in
healthcare delivery
systems in India
Dr Alok Vardhan Mathur, MS,
Associate Professor,
Dept of surgery,
Shri Guru Ram Rai Insitute of Medical and Health Sciences,
Patel Nagar
Dehradun
dralokvardhanmathur@yahoo.com

2. Nature and scale of the problem
• About a third of all people below the poverty line
have landed there because of unforeseen medical
expenses
• State run medical facilities are not trusted by the
rural population , hence they rely on the private
medical sector for their medical care, sometimes
exposing them to exploitation by quacks.
• Government funds , when they arrive, are largely
being channeled off by the organized mafia, as
evidenced by the recent murders in connection
with NRHM funds.

3. Nature and scale of the problem
• The condition of medical facities available in India
is today largely dependent on the private sector.
Though the metros today have some government
presence in terms of hospitals and facilities
offered, but even there the facilities offered are
such that most people even from lower middle
classes prefer to use private sector.
• Facilities in rural villages are nonexistent to say
the least.

4. The reasons for such a decline
• Lack of government funding and low budgetary
allocation
• The absence of political will.
• Unwillingness on the part of doctors to go to rural
villages- due to absence of basic facilities like
electricity, water, education for children and
monetary considerations.
• The failure of the government setup means that
the sytem is often directing patients to the
private establishment

5. Some opportunities that the current
medical set up has
• Infrastructure resource
• Finance resource
• Manpower resource
• Transport resources

6. Infrastructure resource
• Medical education is today being catered to by as as many
as 150 private medical colleges.
• A large number of them are situated in relatively far flung
areas and grade B and grade C towns.
• These colleges need to have an average of 500 beds under
medical council of India guidelines.
• However since these hospitals have facilities at near
market rates, and because the management of these
colleges is dependant more on the income from admissions
in these colleges rather than the hospital revenue, most
such medical colleges have low bed utilization from the
affiliated hospitals.
• This is the infrastructure resource that needs to be tapped

7. Finance resource
• Insurance sector has become the mainstay of funding of medical
care in the west.
• However Indian government has not used the insurance sector to
fund medical facilities other than CGHS and ESI and a few similar
organizations.
• Today a few states have begun to purchase medical insurance for
people below the poverty line to the tune of about Rs 30,000 per
annum.
• Even the United States depends on the Insurance sector to fund
government spending in the medical sector, so, developing nations
will need to utilize it more efficiently.
• The rural Indian will need to know more about medical insurance
and either the state or the individual himself will need to purchase
the insurance. Funding of medical care will need to be from this
financial resource for the porposed scheme.

8. Manpower resource
• A large number of medical graduates are been produced in India
today, but only a small handful of them are able to make it to post
graduate programs.
• Many of them are setting up small private practices in grade B cities
because they do find attractive employment opportunities, or
because they feel that the employment offered does not match
society’s image of a doctor’s lifestyle. This is the manpower
resource we can tap.
• Similarly there is a large pool of nurses, technicians etc being
produced similarly, and they end up gaining employment in foreign
countries, again because of poor salaries in India.
• This manpower resource will need to to be offeredmotivation to
offer quality primary health care in more peripheral areas instead
of flocking to central areas.

9. Transport
• A number of states now have begun to offer
ambulance facilities which are run by private agencies
on contract basis for the government.These services
transport patients to the nearest health care providers,
goernment or private, free of cost.The quality and
reliability of these resources has been good.
• They provide a fast means of transport for patients in
urgent need of medical care.
• They can be used as they are, but with additional
inputs to b e able to transport patients over longer
distances ,to secondary and tertiary care.

10. The proposal- Finance
• Either the sate or the individual himself contributes to
medical insurance for each member in the family to the
tune of approximately Rs 50,000.
• The annual premium for such insurance would be
approximately Rs 1000 for most Indians whose age is
less than 50 years.
• State insurance companies like United India or
Nationalinsurance could provide such insurance on a
all India level.
• The government could pay the premium for
individuals below the poverty line.

11. The proposal - manpower
• The existing infrastructure of primary health centers, extended health
centers etc could be utilized and fresh medical and nursing graduates
could be posted in these centers after a three month training course in
family medicine.
• The challenge would be to ensure that they feel motivated enough to stay
there.
• The proposal would be, either to build colonies at state capitals or district
headquarters levels where the families could stay without a feeling of
dissatisfaction or frustration.
• For this they would have to be offered the benefits of
– a handsome salary,
– availability of power and water
– facilities for their family to stay in bigger cities like state capitalsor district
headquarters level, where their dependants’ needs like children’s education,
and the need for an urban lifestyle exposure would be addressed.

12. The proposal - manpower
• The team of doctors at the peripheral level will need to include one
male and one female doctor. Together they would provide for
primary health care for most problems.
• They will in addition need a nurse and a lab technician and a Xray
technician.
• Most government Primary health centers already have these
personnel
• This team will provide basic medicines, pediatric and obstetric
facilities.
• In addition they will provide basic lab investigations and radiology
facilities. The cost of the medication and investigations will be
borne by the insurance of the individual where not provided by the
existing Primary health centers.
• They will supplement the existing system and not attempt to
replace it.

13. The proposal- medicines
• Primary health care medication will have to be procured at
a central level to ensure its quality.
• India is able to offer cheap, good quality generic medicines
to many countries globally. Since there is little in terms of
margins or commisions, that such quality and value for
money products offer to government purchasers, these
products are infrequently used by the existing sytem.
• One big reason why the general public distrusts the
government setup is that the medicines available are
substandard.
• The cost of such medicines, investigations and treatment
would be borne by the insurance.

14. The proposal-secondary & tertiary
care
• Patients with problems that cannot be managed at the peripheral levels
will be transported to the identified regional centers. The transport would
be by means of the preexisting ambulance network provided for by the
government in some states.
• In areas where such a facility does not exist, it would need to be created.
• The referral centers will be the 150 or so medical colleges which are
currently available throughout the country. So most states today have
about 5 to 10 medical colleges.
• These colleges have unutilized bed capacities and pre existing manpower
and medical infrastructure.
• The proposal would be to foot the bill of the hospitalization through the
insurance.
• The medication or part of it for such hospitalization would be provided
for by the insurance scheme so that the expense on medicines could be
reduced.

15. • Initial the scheme would cater to primary,
secondary and part of tertiary health care.
Problems not managed at these medical
colleges would be transferred to the regional
AIIMS, six of which have been established
throughout the country, Cost of treatment in
these tertiary centers is and would continue
to be the responsibity of the government.

16. the biggest hurdles will remain:
• The unwillingness of the state machinery to divert funds at
alternative schemes thereby accepting their failure
• The inability of good medical manpower to work in the remote
areas- this could be effectively addressed if the needs of their
families are addressed at district headquarter and state capital
levels and a family medicine is encouraged as a ttractive rewarding
area of specialization. Brain drain will reverse when the financial
aspect is effectively addressed in the country itself. Real estate
developers could be asked to offer housing to the manpower
employed for health care delivery at district head quarter level
• Current governments do not have the time or the inclination to talk
about health care and government expenditure on health care is
way below the expected level considering that India will soon be
the world’s third largest economy. How can the government be
made to increase expenditure on this front in the presence of other
problems will be a challenge.

17. Acknowledgements
• This project proposal is for my patients whose
lives were drastically changed, or wasted, for
want of medical care ,which the state should
have delivered, but did not, for want of a
proper system, and which I delivered, but was
inadequate or late, for want of money or
information.

18. This is a common sight in India- because we have a
system where rules are flouted because palms have
been greased, the result proved disastrous for this 25
year old farmer in UP, who, in a fraction of a second lost
his hand to electrocution from an overhead low
hanging high tension wire

19. This horror story was actually a young mother
burned by her in laws and deprived further
treatment for want of money, came to me when
her child would not come to her, out of fear- a
life destroyed by a lame system

20. This patient had cancer of the penis-He was advised
surgery, but it took him two weeks to organize finances
– just about 5000 Rs- by the time he came back, his
organ was teeming with maggots-a shame story for our
health care sytem