By Dr Dileep Mavalankar
After nearly 77 years of Independence, people in an average village in India do not have any formally trained health providers employed by the government. It is a shame that the standards laid down in the 1980s for the provision of rural health services are still being followed.
In the 1980s, the Indian government set a target of one auxiliary nurse midwife (ANM) for a population of 5,000 (five average villages) and a primary health centre with one MBBS doctor to serve a population of 30,000 (30 average villages). Many states are following this even today.
In the mid-1990s under the National Rural Health Mission, the government provisioned a part-time health volunteer called an accredited social health activist (Asha). An Asha worker typically has had school education till eight-10 standards with few weeks of scattered training. She is not a health professional by any stretch of the imagination. Her main role was to mobilise the community for better health behaviour, and paid incentives based on performance over two to three hours of work every day in her village. It was a great move forward after many years of discontinuing village health volunteers, a practice following the Chinese model of barefoot doctors instituted in the 1970s by then Union health minister Raj Narain.
Think of a villager with a health problem. It may be even a simple problem, but the villager has no one to consult as the Asha worker cannot provide any health service, except for some basic maternal and child health care. The villager has to go to the nearby sub-health centre and see an ANM or the primary health centre where an MBBS doctor could provide care. This means travel time and expenses. At these centres too, the patient may or may not find a nurse or a doctor to diagnose and treat the ailment as many posts are vacant or the health provider may be unavailable immediately. Villages have poor access to basic care. But we are in a frenzy to open new medical colleges and also expand the number of All India Institutes of Medical Sciences-like institutions, where doctors are trained at high cost and largely prefer to practise in the private sector and in big cities.
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Is it not fair that after 77 years of Independence, the nation assures every villager the availability of a nurse at least eight hours a day for basic health services? A doctor is trained for five years. But a nurse is trained for three years and can provide basic health services at the village level. India has over 550,000 villages of which around 150,000 are already covered by ANMs, 31,000 have primary health centres, and some are covered by other health facilities including by non-governmental organisations. So the remaining 350,000 villages need to be covered by either an ANM (trained for two years) or preferably a fully qualified nurse (3-4 years of training). It might seem a major endeavour. However, given India’s large number of nursing schools and colleges, it is not a big challenge.
India has an annual capacity to train 325,000 nurses. If we offer reasonable remuneration, the position of village-level nurses will be filled in no time — at the most three to four years. Indian nurses are going abroad and serving the developed nations in the West and the Gulf countries on a very large scale. But we haven’t decided that each villager in India should have access to a fully trained nurse. We have decided to induct bullet trains, which will cost Rs 1 trillion for just one line between Ahmedabad and Mumbai. And we have landed a spacecraft on the south pole of the Moon, which is unparalleled in the history of space exploration. But why is there so much apathy to providing basic health care to the rural population? Are they not citizens of India?
The cost of such a scheme will not be very high. If we assume an annual cost of about Rs7 lakh per nurse per year, including salary, drugs and supplies, and supervision, the total cost for 400,000 nurses will be Rs 28,000 crore annually. This is not a very high cost for a nation aspiring to become a developed country or Viksit Bharat. In many developed countries, the governments provide a qualified MBBS with two-three years of general practice to cater to a population of 2,000-3,000. So one nurse per village will not bring us anywhere near a developed country status, but definitely improve access to primary care for the rural population.
We shouldn’t see nursing only as an expense, but an investment which will improve the health of people and thus improve national productivity and add to the GDP. Secondly, a nurse will diagnose many diseases early and hence prevent complications as well as hospitalisation and expensive treatments that are now being carried out under the Pradhan Mantri Jan Arogya Yojana or in the government and private sectors. Thus investment in primary care through the deployment of nurses in villages will save cost of secondary and tertiary care. It will save a large sum for people as they will not have to travel to primary health centres and district hospitals for basic care. The last benefit of such a scheme will be employment for women on a large scale in rural areas. It will also provide a role model in each village in terms of how educated and well-trained women health workers can improve the health of the nation. They should be seen as an investment in nation-building. I urge the finance and health ministers as well as the Prime Minister to include this proposal in this year’s Budget.
(The author is former director of the Indian Institute of Public Health, Gandhinagar. Views expressed are personal and not necessarily those of financialexpress.com.)