By Anchal Kashyap

Himachal Pradesh is a hilly state in northern India and because of its physiography, it creates a barrier to health service diffusion and accessibility. Despite performing admirably, the state nevertheless has healthcare difficulties such as a lack of medical personnel and inadequate infrastructure. This article compares the state’s rural health infrastructure to those of other hilly states and attempts to understand the reasons for the region’s current healthcare issues.

Himachal Pradesh is a hilly state in northern India and because of its physiography, it creates a barrier to health service diffusion and accessibility. As a result, health facilities in rural Himachal Pradesh are unevenly dispersed, making state governments’ efforts to address the state’s inter-district variation a difficult task. The Census of India, 2011, classified Himachal Pradesh’s health institutions into a variety of categories, including community health centres, primary health centres, primary health sub centres, maternity, and child welfare centres, T.B. clinics, allopathic and alternative medicine hospitals, dispensaries, mobile health clinics, family welfare centres, and other healthcare institutions.

Because transportation in rural Himachal Pradesh is inadequate, the rural areas being serviced by the health centres is an essential criterion in evaluating health facilities in the region. Better rural healthcare facilities would suggest that the state’s general health will improve.

Rural healthcare system in India

The Sub-Centre is the first point of interaction between the community and the primary health care system. Basic medications for minor ailments are provided to the Sub-Centres in order to meet the vital health needs of individuals. The Primary Health Centres (PHCs) are the next level of interaction, and also include a Medical Officer. The PHCs were designed to provide comprehensive, curative and preventive health care with a focus on health promotion and prevention. The last tier in the system is the Community Health Centres (CHCs). The State Government maintains CHCs, which are staffed by four medical specialists.

Healthcare infrastructure: a comparative analysis

The official stats of Himachal Pradesh states that the Number of Medical Institutions per ’000 Sq. Kms in Himachal has increased from 68.27 to 74.08 from 2005 to 2019 respectively. Despite there being inter-district differences, with Shimla acquiring the first position in health facilities in rural Himachal, the other districts perform fairly well. 

Several reports conclude that the state, when compared to the norms of hill states in India, displays a satisfactory level of general availability of existing health care. However, these health services – in terms of hospitals, community health centres, primary health centres, health sub-centres, and physical and human health resources in the form of beds, doctors, and nurses – are not evenly distributed across the state. In rural Himachal Pradesh, the Shimla district takes first place in terms of health facilities. The availability of high-quality healthcare facilities in this district is linked to a number of other characteristics, including it having the state’s third greatest population concentration, the state’s only class I town, and a high road density. Shimla is able to achieve first place in terms of health facilities due to the combination of all the above facilities.

Contrasting picture

According to the National Health Profile of the state, the availability of beds in Himachal Pradesh was substantially higher than in the other hill states of India as a whole (5 beds per 10,000 person). However, the state in reality experiences a shortage of doctors in the public sector hospitals, particularly specialists. The shortage of specialists is at an alarming level and the doctors at the PHCs handle most of the burden. The state data on the availability of the nurses also reveal that there is a serious shortage of nurses in the state. A study conducted on nurses revealed that out of 120 nurses only 30.8 percent were satisfied with the quantum of work. This also makes public healthcare ineffective as nurses are a vital human resource of any hospital.

On the one hand, the state is short on medical practitioners., while in a few districts, about 50% of health worker positions are vacant in public health centres (PHCs), community health centres (CHCs), civil hospitals (CHs), and health sub-centres. While vacancies are less prevalent in urban regions, rural health institutions are said to be in poor condition due to a lack of employees. Due to physician scarcity, many health facilities have effectively become referral centres, with no emergency patients being treated. Patients with minor illnesses are also referred to the sub-divisional hospital. In some districts, one doctor has to attend to 150-200 patients per day.  The picture depicts the misery of doctors. Even after announcing the development of new infrastructure and various incentives for the doctors, the shortage of health staff remains the same. Studies also reveal that even though rural healthcare costs more than urban healthcare, the share of urban spending has maintained around 40% of overall expenditure, despite the fact that urban areas account for only 10% of the state’s population.

Reasons for medical staff shortages in Himachal Pradesh

One of the main reasons for the shortage of staff in remote areas is that the doctors in ‘Aspirational’ districts, feel isolated because they do not have their families with them. Further, there are no good schools for education, eateries, and other entertainment exercises for families. Some of the parameters which are considered backward on various are education, health, child, women’s care, and agriculture. Secondly, doctors and health workers in the remote regions are housed in substandard housing with inadequate facilities. The government of Himachal makes it mandatory for newly recruited doctors to work in rural areas for two years. However, incentives and support systems for workers stationed in tough and difficult-to-reach facilities, such as semi-furnished housing, have not been arranged.

Thirdly, despite the existence of a policy for encouraging health care providers based on performance, it has not been implemented in full spirit and on a timely basis due to a lack of differential financing based on performance, which must be included into the grant release. Finally, there have been cases where the state government is not transparent in its posting of doctors, resulting in a rise in the patient-to-doctor ratio in hospitals.

Conclusion 

Himachal has superior human development metrics when compared to  on average than other states with similar rural populations. Along with Kerala and Delhi, it has been one of India’s best states in terms of HDI. Himachal Pradesh stands in stark contrast to Kerala, with which it contends for the top spot in the country in terms of Human Development. Himachal Pradesh is one of the few Indian states where there is no shortage of Sub Centres, Primary Health Centres, or Community Health Centres based on population. Despite its robust physical infrastructure, however, the Himachal health system is suffering from significant manpower shortages. Himachal Pradesh’s health and nutrition concerns are exacerbated by significant human resource restrictions in the public sector, which might have terrible consequences on the for citizens’ health. It is necessary to identify districts that require more attention in terms of health and nutrition initiatives. In remote places, additionally, however, improved facilities and incentives for specialists and other workers should be offered. 

Anchal Kashyap, second year PhD student at Jindal School of Government and Public Policy

Image credits – Wikipedia commons