Kurukshetra November 2018 - Rural Health (Part 3) (Download PDF)


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Challenges & Need of Hour: Lack of awareness of health issues: Bcoz of high illiteracy, poor educational level & insufficient exposure to external world tribal could not identify what is good or what is bad for them.

  • Raising awareness of health issues is 1st step towards improving health outcomes.

  • 👌 ICMR-National Institute of Research in Tribal Health located at Jabalpur demonstrated designing of theatre based communication strategy using school students as agent of change to generate awareness & control of malaria in Baigachak area of Dindori, MP. ]

Map of Malaria in Baigachak area of Dindori

Map of Malaria in Baigachak Area of Dindori

Map of Malaria in Baigachak area of Dindori

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Rural Health - Kurukshetra November 2018 (In English)

Dr. Manishika explained Kurukshetra November 2018: Rural Health

Health facilities in remote tribal areas:

  • There is scarcity of health care facilities in terms of infrastructure, inadequate or no drug & diagnostics & personnel in tribal areas.

  • Mobile medical camps to improve outreach in remote tribal populations would play major role.

Lack of emergency transportation:

Pregnant women or sick persons from remote tribal hamlets are unable to make it to health facilities in time for institutional deliveries or emergency medical care for want of easily available & affordable transportation.

Discriminatory behavior by health care providers:

There are deep-rooted cultural chasms b/w tribal groups & largely non-tribal health care providers, resulting in insensitive, dismissive & discriminatory behavior on part of health care personnel.

Financial Constraints:

As most of rural tribal populations live below poverty line, lack of funds influences how much & what type of health care they receive & determine whether households are able to maintain their living standards when one of their members falls ill.

Financing Rural Health Care

  • Framework of GoI’s fiscal responsibility legislation & that of States restricts vigorous pressing for public expenditure on health services financed by respective govt. deficits & public borrowings.

  • Delivery of health services in India is yet to improve itself particularly in rural areas, as it lacks quality health facilities & human resources, financial limitations, absence of health awareness.

Rural Health Infrastructure

India’s rural health care delivery is characterized by 3 tier system.

  • At lowest level are Sub-Centres (SCs) w/each covering population b/w 3,000 (in hilly/difficult areas) & 5,000 (in plain areas).

  • 2nd tier is Primary Health Centres (PHCs) covering population of 20,000 to 30,000.

  • 3rd tier is Community Health Centres (CHCs) w/population of 80,000 to 1,20,000.

National Health Policy 2017

  • One of main issues before NHP 2017 was to achieve universal access to good quality health care services w/o anyone having to face financial hardship in process.

  • 📝 Accessible public healthcare system & inter alia, envisaged following:

  • Raising public health expenditure to 2.5 % of GDP

  • Positive & proactive engagement w/pvt. sector to achieve national goals.

  • Financial & other incentives for encouraging pvt. sector participation.

  • Investment in health, organization & financing of healthcare services.

  • Prevention of diseases & promotion of good health thru cross-sectoral action.

  • Ensuring access to technologies, developing human resources, encouraging medical pluralism, building knowledge base required for better health, financial protection strategies & regulation & progressive assurance for health.

  • Reorienting & strengthening Public Health Institutions across country, so as to provide universal access to free drugs, diagnostics & other essential healthcare.

  • Achieving significant reduction in out of pocket expenditure due to healthcare costs

  • Ensuring voluntary service in rural & under-served areas on pro-bono basis by recognized healthcare professionals under ‘giving back to society’ initiative.

Budget 2018 - 19 & ‘Ayushman Bharat’ Program

Keeping in view recommendations of National Health Policy, 2017 Budget earmarked Rs. 1200 cr. to finance 1.5 lakh Health & Wellness Centres to revolutionize India’s health system by bringing health care system closer to homes of needy.


Recent estimate indicates that public expenditure on health care in India is only 1.4 % of country’s GDP whereas world average is 6%.

Health Concerns of Adolescent Girls

  • Adolescents aged 10 - 19 years, constituting large cohort of young people represents great demographic dividend w/potential to contribute to India’s economic growth & development.

  • Abt 21 % of Indian population is adolescent & forms major demographic & economic force facing challenges like poverty, lack of access to health care services, unsafe environment etc.

  • Promoting good health & nutrition can go long way in easing transition of young girls to womanhood & promoting healthy & productive lifestyle amongst young girls & their families.

Health Challenges

  • Main health issues faced by adolescents include mental health problems, early pregnancy & childbirth, HIV/STI & other infectious diseases, violence, unintentional injuries, malnutrition & substance abuse.

  • Adolescent girls often lack social support & community social norms can create barriers to their economic & social advancement.

  • Many girls are married as children & assume adult roles of motherhood.

  • Knowledge & attitude regarding health & hygiene, exclusive breast feeding & menstrual hygiene & practices among adolescents were either very poor or incorrect.

Government Schemes

  • 👌 Kishori Shakti Yojana (KSY) was launched in 2000 to improve health & nutrition status of adolescent girls & to promote their around development mainly knowledge & awareness of health, nutrition, personal hygiene, family welfare & mgmt. & to upgrade home-based & vocational skills.

  • 👌 Nutrition Program for Adolescent Girls (NPAG) was launched in 2002 - 03 for adolescent girls in 51 selected districts to address under nutrition of girls.

  • 👌 Govt. has combined existing 2 schemes into pilot scheme w/comprehensive coverage & launched as Rajiv Gandhi Scheme for Empowerment of Adolescent Girls – SABLA.

  • 👌 Scheme aims to support empowerment & development of adolescent girls aged 11 - 18 years by making them self-reliant, improving their health & nutritional states, promoting health awareness, hygiene, nutrition, Adolescent Reproductive & Sexual Health (ARSH), family & child care, life skills education & vocational training along w/mainstreaming Out Of School Adolescent Girls (OOSGS) into formal & non-formal education.

Adolescent Health

  • 📝 Adolescence is classified into:

    • Early Adolescence: Period b/w ages of 10 - 14 years. At this stage, there is start of physical changes in body.

    • Late adolescence: Period b/w ages of 15 - 19 years.

  • Some authors divide adolescence into 3 age groups:

    • Early adolescence (10 - 13 years)

    • Middle adolescence (14 - 16 years)

    • Late adolescence (17 - 19 years)

  • There are abt 253 million adolescents (10 - 16 years) living in our country out of which, more than 60 % live in rural areas.

📝 Problems in Adolescent Age Group

  • Teenage pregnancy:

    • Abt 47 % of Indian women are married before age of 18 years.

    • Unmet need for family planning in 15 - 19 years age group is 27%

    • Abt 1/5th of pregnant girls (below 20 years of age) have no antenatal checkups.

    • Perinatal deaths & infant mortality are higher in girls aged less than 20 years.

    • Incidence of low birth weight babies is higher among adolescent mothers.

  • Malnutrition

  • Violence/risk-taking behavior

  • Substance abuse

  • Sexually transmitted infections including HIV/AIDS

📝 Development of Adolescent Health Programs

  • Life-course approach: Interventions started from early childhood thru their late adolescence for this generation & next.

  • Ecological model: Need for diff. levels of 2 way interventions acting on both immediate environment of family & wider environment created by policies, social determinants.

  • Human rights-based approach: This approach supports good public health. It ensures implementation of evidence-based interventions for adolescent health up to target.

  • Heterogeneity: Program should take consideration of similarities & differences b/w & w/I Region of country & b/w adolescents themselves.

  • Equity: It builds on concepts of heterogeneity & human rights. This principle helps to ensure that state gives sufficient consideration to vulnerable adolescents.

Rashtriya Kishor Swasthya Karyakram (RKSK)

📝 RKSK identifies 6 strategic priority areas for adolescents:

  • Improve nutrition: Reduce prevalence of malnutrition, Reduce prevalence of iron-deficiency anaemia.

  • Improve sexual & reproductive health: Reduce teenage pregnancies, Improve birth preparedness, provide early parenting support for adolescent parents, Improve knowledge & behavior, in relation to SRH.

  • Enhance mental health

  • Prevent injuries & violence

  • Prevent substance misuse

  • Address NCDs

📝 Interventions under RKSK:

  • Adolescent Friendly Health Clinics (AFHCs): In India, 7298 AFHCs have been established & abt 60 lakh adolescents avail services in year.

  • Weekly Iron Folic Acid Supplementation (WIFS): Program aims to cover total of 11.6 cr. beneficiaries both in-school & out-of-school.

  • Menstrual Hygiene Scheme: Rs. 44.76 cr. are allocated thru National Health Mission to 18 states for decentralized procurement of Sanitary Napkins during FY 2017 - 18.

  • Peer Education (PE) Program: Aby 1.93 lakh Pes are selected & are being trained.

📝 SAATHIYA Resource Kit & ‘Saathiya Salah’ Mobile App for adolescents

  • It is part of Rashtriya Kishor Swasthya Karyakram (RKSK) program.

  • Key interventions under RKSK program are introduction of Peer Educators (Saathiyas).

  • Peer Educators:

    • Act as catalyst for generating demand for adolescent health services.

    • Impart age-appropriate knowledge on key adolescent health issues.

  • Mobile app is linked to toll-free Saathiya Helpline (1800 - 233 - 1250) which will act as e-counselor.

Mobile Connectivity for Rural Health

Mobile, the Great Enabler

  • Agent that has brought change even in remotest areas is mobile phone. It has acted as enabler & force multiplier for healthcare workers & general people alike.

  • In many places ASHA workers as well as Anganwadi workers have created WhatsApp groups & communicate w/their group of women spreading awareness abt new govt. schemes, date of regular check for pregnant women & for neo-natal care & well as information abt immunization.

Game Changing Initiatives

  • 👌 App called mSakhi, initiated in 5 dist. w/population of 15 million people, was downloaded by 12000 health workers.

  • Initial reports suggests app helped them to be in constant touch w/their supervisors, track & report health related data of community they are working w/ & help new parents in teaching them how to save their newborn from various illnesses.

  • 👌 On nationwide scale, GoI launched national health portal in 6 languages including Hindi, Tamil, Gujarati, Bengali & Punjabi. It has voice portal & mobile app.

  • 👌 MeraAspatal app seeks patient feedback to create more responsive & patient driven healthcare service.

  • 👌 Few such initiatives like Mission Indradhanush (launched in 2016) which tracks immunization of children & helps parents in carrying out timely & complete immunization programme.

  • Another intervention that uses mobile phones extensively is Kilkari initiative. It is 72 message series delivered from pregnancy onwards to systematically prepare woman & her family abt pregnancy issues, child birth & child care.


Effort over years have borne fruits & due to sustained messaging, effective follow up & constant up gradation has resulted in registration of 12 cr. pregnant women & 11 cr. children under Mother & child tracking system.

Tele-Medicine: A New Healthcare Opportunity

  • Tele-medicine is used across world as one of most powerful public health tools. Countries like USA & South Korea are using it practically since 1980s. It is effectively practiced even in under-developed countries of Africa such as Zambia (where it was used during EBOLA outbreak).

  • India has roughly 550 million internet users today out of which 210 million users are rural users. 210M rural populations today have access to internet.

Image of New Healthcare Opportunity

Image of New Healthcare Opportunity

Image of New Healthcare Opportunity

W/use of tele-medicine any Indian citizen irrespective of his location can have access to best healthcare opinion & treatment as anyone else in country.

Current status of Tele-medicine

NEHA & Digital India are using e-health means & programs in their campaigns.

📝 Effective use of Tele Medicine by Hospitals

  • Apollo hospitals were one of 1st to set-up tele-medicine facility in rural village called Aragonda 16 km from Chittoor (population 5000, Aragonda project) in Andhra Pradesh.

Facility in rural village called Aragonda 16 km from Chitoor

Facility in Rural Village Called Aragonda 16 Km from Chitoor

Map of facility in rural village called Aragonda 16 km from Chitoor

  • All India Institute of Medical Sciences (AIIMS), New Delhi.

  • Sanjay Gandhi Post Graduate Institute of Medical Sciences (SGPGIMS), Lucknow.


Countries like USA & South Korea are using it practically since 1980. It is effectively practiced even in under-developed countries of Africa such as Zambia.

Swachh Bharat Mission: India’s Sanitation Revolution

  • Gandhiji published works devote significant attention to cause of public sanitation, on parity w/his focus on Satyagraha, Ahimsa & Khadi.

  • In his book “Ashram Observances in Action”, Gandhiji writes that sanitary service is essential & sacred service & yet it is looked down upon in society, w/result that it is generally neglected & affords considerable scope for improvement.

  • Public Sanitation is accorded significant importance in Gandhiji life in South Africa. In 1898, Gandhiji family was living in Durban & it was practice that Gandhiji or Kasturba would clean out chamber pots themselves.

  • In his book “My Experiments w/Truth” Gandhiji writes, plague broke out in Bombay in 1897 & there was panic all around.

  • Gandhiji offered his services to State in sanitation department. Gandhiji laid special emphasis on inspection of latrines & carrying out improvements.

  • In his inspections of untouchable’s quarters Gandhiji found that they were beautifully smeared w/cow dung & few pots & pans were clean & shining.

  • Gandhiji vision is embellished in Fundamental Rights – Article 17 Abolition of Untouchability - ‘Untouchability’ is abolished & its practice in any form is forbidden.

  • 👌 Govt. celebrates Gandhi Jayanti – 2nd Oct. as Swachh Bharat Diwas.

  • 👌 Women Swachhagrahis were appointed & Swachh Shakti Awards were instituted to further enhance women involvement w/program.

Kaya Kalp (Clean Hospital) Campaign

  • 👌 Ministry of Health & Family Welfare launched Kaya Kalp (Clean Hospital) Campaign on 17th June 2015 under Swachh Bharat Abhiyan.

  • Implementation experience in individual dept. was one of seriousness of purpose & intense passion amongst all stakeholders.

  • AIIMS Institutional response was to launch “Clean & Green AIIMS” campaign.

  • Campaign in 2016 & 2017 & was adjudged cleanest hospital in India in 2017. It was phenomenally successful campaign, implemented in India’s largest public hospital w/33.41 lakh out patients per annum, 2362 in-patients & 12000 employees.

  • Mechanized cleaning was introduced thru MoU b/w AIIMS & HLL Life Care Ltd. , for mechanical cleaning of outer areas.

  • Signages were put up across AIIMS campus along w/additional dust bins across all AIIMS campuses.

  • Electronic scroll boards for health & hygiene promotion were introduced.

  • AIIMS introduced washroom check lists for sanitation staff in all pvt. wards.

  • Bio-Medical Waste & Infection Control protocols were established & group of sanitary experts in subject were created.

Other Important Notes

National Health Agency (NHA)

  • For focused approach & effective implementation of PM-JAY, autonomous entity, National Health Agency (NHA) was constituted.

  • Established as Society on 11th May 2018, National Health Agency is registered under Society Registration Act, 1860. State Govt. are expected to set up State Health Agencies (SHA) to implement PM-JAY.

  • National Health Agency (NHA) will provide overall vision & stewardship for design, roll-out, implementation & mgmt. of Pradhan Mantri Jan Arogya Yojana (PM-JAY) in alliance w/state govt.

E-Governance Initiative

  • Ministry of Health & Family Welfare is promoting eHealth or Digital Health i. e. use of Information & Communication Technology initiatives in direction of “reaching services to citizens” & “citizens empowerment thru information dissemination”

  • 📝 Purpose of E-Governance initiatives is to:

    • Ensure availability of services on wider scale

    • To provide health care services in remote & inaccessible areas thru telemedicine

    • To address health human resource gap by efficient & optimum utilization of existing human resource.

    • To improve patient safety by access to medical records & helps reduce healthcare cost.

    • To monitor geographically dispersed tasks & effective MIS for meaningful field level interactions.

    • To help in evidence based planning & decision making.

    • To improve efficiency in imparting training & capacity building.

National Nutrition Month (Poshan Maah) witnesses overwhelming People’s participation

👌 Sept. was celebrated as Rashtriya Poshan Maah across country to address malnutrition challenges & sensitize our countrymen regarding importance of holistic nutrition.

National Dissemination Workshop on Anaemia Mukt Bharat & Home-Based Young Child Care

  • Web-portal anemiamuktbharat. info has been developed as part of monitoring mechanism of strategy, which would provide survey data on anemia across beneficiary groups, target prevalence of anaemia as per POSHAN Abhiyan & quarterly HMIS based reporting of program implementation coverage upto district level.

  • 👌 Home-based Care of Young Child (HBYC) program has objective to reduce child mortality & morbidity by improving nutrition status, growth & early childhood development of young children thru structured & focused home visits by ASHAs w/support of Anganwadi workers (AWWs).

  • ASHA will ensure exclusive breastfeeding till 6 months of life, adequate complementary feeding after 6 months, Iron & Folic Acid supplementation, full immunization of children, regular growth monitoring, appropriate use of ORS, appropriate hand washing practices & age appropriate playing & communication for children during each home visit.

Government Initiatives for Adolescent Health

  • 👌 Rashtriya Bal Swasthya Karyakram (RBSK): Systemic approach of early identification & early intervention for children from birth to 18 years to cover 4 ‘D’s viz. Defects at birth, Deficiencies, Diseases, Development delays including disability.

  • 👌 Balika Samridhi Yojana: To change negative family & community attitudes towards girl child at birth, improve enrolment & retention of girl children in schools & raise age at marriage of girls.

📝 Accredited Social Health Activist (ASHA): Key Components of Healthcare Delivery in Rural India

  • ASHA must primarily be woman resident of village married/widowed/divorced, preferably in age group of 25 - 45 years.

  • She should be literate woman w/due preference in selection to those who are qualified up to 10 standard wherever they are interested & available in good numbers.

  • ASHA will be chosen thru rigorous process of selection involving various community groups, self-help groups, Anganwadi Institutions, Block Nodal officer, District Nodal officer, village Health Committee & Gram Sabha.

  • ASHA will receive performance-based incentives for promoting universal immunization, referral & escort services for Reproductive & Child Health (RCH) & other healthcare programs & construction of household toilets.

  • ASHA will be 1st port of call for any health related demands of deprived sections of population, especially women & children, who find it difficult to access health services.

  • She will counsel women on birth preparedness, importance of safe delivery, breast-feeding & complementary feeding, immunization, contraception & prevention of common infections including Reproductive Tract Infection/Sexually Transmitted Infections (RTIs/STIs) & care of young child.

- Published/Last Modified on: November 26, 2018


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