1. Connecting Rural Health Services
• Spanning 29.8 lakh sq. km (approximately 90 percent of the land area)” and 6,38,000 villages, the rural healthcare system serves two-thirds of the country’s populations.
• It truly characterises the country’s nervous system with a network of government owned and operated Sub-Centers, Primary Health Centers (PHCs), and Community Health Centers (CHCS) designed to deliver primary healthcare to the rural population.
• Over the last several years, the Government of India through the National Health Mission, National Health Policy and Ayushman Bharat, among other initiatives, has improved the health of its population, narrowing the rural-urban and rich-poor divide.
• Yet, disparities remain, and rural healthcare is faced with several challenges. All stakeholders have widely acknowledged the importance of a comprehensive healthcare system, especially amidst the unprecedented COVID-19 pandemic.
Rural Healthcare System
• The National Rural Health Mission (NRHM) was launched in 2005 to provide healthcare services to the rural population initially with a focus on 18 states which had weak public health indicators and/or weak infrastructure.
• The states included Sikkim, Chhattisgarh, Jharkhand, Jammu and Kashmir, Himachal Pradesh, Manipur, Mizoram, Meghalaya, Madhya Pradesh, Nagaland, Arunachal Pradesh, Assam Bihar, Orissa, Rajasthan, Tripura, Uttarakhand, and Uttar Pradesh.
• The mission envisaged architectural correction of the health system by building accountability to the community, management of human resources, convergence of efforts across departments, schemes and programmes, targeted innovations and interventions, flexible financing, as well as rigorous monitoring and evaluation for improvement of health indicators Also, the Mission committed to increasing public expenditure on health from 0.9 percent of GDP to 2-3 percent of GDP.
The core strategies of NRHM are as follows:
• Capacity enhancement of Panchayati Raj Institutions (PRIs) to own, control and manage public health services, Developing a health plan for each village through the Village Health Committee of the Panchayat,
a) Developing and implementing an inter-sectoral District Health Plan, including drinking water, sanitation and hygiene, and nutrition through the District Health Mission,
b) Strengthening effective curative care at rural hospitals and ensuring measurability and accountability through Indian Public Health Standards (IPHS), Capacity development for promoting healthy lifestyles and adoption of preventive healthcare. Also, promoting collaboration with the non-profit sector, especially in underserved areas.
Gaps in Rural Health Services
• Detailed information on health infrastructure and human resources is provided in the Annual Rural Health Statistics Report.
• The Report highlights vast resource gaps which hinder the rural population from accessing quality healthcare.
• The findings showcase infrastructural improvement with PHCS housed in government buildings increasing from 69 percent in 2005 to 89 percent in 2020; CHCs in government buildings increased from 84 percent in 2005 to 96 percent in 2020.
• In terms of manpower, however, it was found that a large proportion of posts are vacant across all tiers of the health system.
• At the PHCs, as of 31 March, 2020 approximately 40 percent of the posts sanctioned for Health Assistants (both male and female) were found vacant. The Report also notes a shortfall of approximately 70 percent of health assistants (male and female).
• Additionally, around one-fourth of the sanctioned posts of doctors were found vacant. The Report brought forth the manpower situation at CHCs as of 31 March, 2020 wherein, 68 percent of Surgeon, 56 percent of Gynaecologist/Obstetrician, 67 percent of Physician, and 63 percent of Paediatrician positions were found to be vacant. Strengthening Rural Health Services Experiences and evidences from different states in India and across the world can be leveraged to guide improvements in healthcare in rural India.
(a) Connecting Communities through Technologies
o Rural India witnessed three times the percentage growth compared to urban internet users which increased 4 percent in 2020.
o Overall, internet users comprise 67 percent of the urban population and 30 percent of the rural population, according to The Internet and Mobile Association of India (IAMAI) Kantar’s ‘ICUBE 2020’ report.
o This rapid expansion of mobile phones and the internet can be leveraged by taking advantage of technological advancements in delivering e-health services. Telehealth can be used to increase access to specialist consultations from an accessible PHC/ CHC.
o The Government of India has piloted several projects to deliver telehealth with the Indian Space Research Organisation (ISRO), Department of Information Technology (DIT), Ministry on External Affairs, Ministry of Health and Family Welfare, and various state governments. A key initiative is ISRO’s Village Resource Centre (VRC) which provides a variety of services such as education, telemedicine, online-decision support, interactive farmers’ advisory services,
o tele-fishery, e-governance services, weather services, and water management. VRCs serve as learning centers as well as provide connectivity to specialty hospitals, thus bringing the services of specialist doctors to remote villages.
o Nearly 461 VRCs have been established in the country with nodes including 81 expert centres. Similarly, the Indian Council for Medical Research’s, Arogyasri, is another internet-based mobile telemedicine system that integrates multiple hospitals, mobile medical specialists, and rural mobile units/clinics.
o The adoption of telemedicine has been accelerated considerably during the COVID-19 pandemic thereby providing an important opportunity to extend its coverage to various parts of the country and connecting citizens with quality as well as timely medical advice from doctors and specialists.
(b) Analysing Data on Key Health Parameters Undertake a Pulse Check on the Nation’s Health
o Information from the National Family Health Survey, Annual Health Survey, and Rural Health Statistics Report enables the Government of India to evaluate and course-correct policies and programmes related to population health and nutrition.
o Concurrent diagnosis and consolidated efforts in the monitoring of healthcare-related input, output, and outcome indicators can provide concurrent insights into the bottlenecks and areas for improvement with respect to increasing access to quality healthcare.
o NRHM’s Management Information Systems (MIS) are intended to monitor the health indices of the population and the functioning of the healthcare system.
o However, it could benefit from rigorous monitoring of the utilisation and engagement of local conement of local communities.
(c) Embedding Comprehensive Healthcare Management in Nursing and Medical Education to Efficiently Serve Rural Communities
o The objective of primary healthcare is to provide gate keeping functions van OPD and deliver a range of basic services.
o This would lead to appropriate utilisation of primary health facilities and reduce the burden at the secondary and tertiary levels of care by reducing unnecessary referrals.
o Creating cadres of health professionals from the rural areas themselves who can be trained to deliver essential and basic health services is of the essence.
o An example of this is the Mid-Level Providers who are a key part of the team at Health and Wellness Centres being operationalised under the Ayushman Bharat programme.
(d) Revitalising the Trust of Communities in Primary Healthcare to Minimise the Burden on Secondary and Tertiary Healthcare Facilities.
o In an ideal healthcare system, the primary care level serves as the first point of contact for patients and also integrates seamlessly with other levels of the health system.
o However, due to gaps in implementation, many patients first encounter the health system at the secondary or tertiary levels of care.
o Evidence suggests that community participation including household visits by health staff, group meetings for education and support on health issues, as well as outreach workers providing health services in the community can go a long way in bolstering community engagement.
o Therefore, a focused approach toward community involvement integrated with strong referral mechanisms has the potential to revitalise the trust of communities in the public health infrastructure.
(e) Providing Accommodation and a Supporting Ecosystem for Medical Doctors and Their Families
o The Shyama Prasad Mukherji Rurban Mission (SPMRM) of the Ministry of Rural Development envisages the infrastructural development (technological and basic services) of village clusters that stimulate economic development in the area.
o Panagariya, 2014 provides consideration to a housing township wherein government employees of all the departments (health, education, water and sanitation, police, bank, road and transport, post and telecom) can be housed at the block level.
o Provision of facilities like schools, playgrounds, community centres, supermarkets, etc. can provide a significant stimulus to the workforce which is otherwise discouraged to locate themselves in rural areas.
o The National Thermal Power Corporation townships (Lakhimpur Kheri, Uttar Pradesh and Korba, Chhattisgarh) and Indian Oil’s township (Barauni, Bihar and Noonmati, Guwhati) attract and retain talented individuals.
o Alongside competitive salaries, such townships can play an important role in encouraging Indian doctors and specialists to be based in these RURBAN areas and serve the rural population.
(f) Focusing on Social Determinants of Health
o There are certain initiatives of the Government which also have a critical albeit indirect impact on strengthening access to health services for the rural population.
o For instance, the Pradhan Mantri Gram Sadak Yojana (PMGSY) has provided all weather road connectivity to around 1,55,719 habitations since its inception till 10 March, 2022.
o In 2019, the Government launched PMGSY-111 for consolidation of 1,25,000 km through routes and major rural links connecting habitations to hospitals, among other essential facilities.
o Similarly, schemes which aim to alleviate poverty, deliver education and nutrition services as well as provide suitable economic opportunities play a crucial role directly and indirectly strengthening the linkages between people in rural areas and essential health services.
(g) Prioritising Primary Healthcare to Address Rural-Urban Gaps
o The Annual Rural Health Statistics Report throws lightongapsin manpower and infrastructure in rural areas which need to be addressed.
o The 15th Finance Commission also recommended a strong focus on primary healthcare. Thus, it is imperative that budgetary allocations and implementation of key initiatives like the National Health Mission, Pradhan Mantri Jan Arogya Yojana (PM-JAY) are prioritised.
o An important step by the Government in this context has been the launch of the Pradhan Mantri Swasthya Suraksha Yojana (PMSSY) which aims to rectify the inequities in the availability of affordable healthcare facilities across the country.
• Thus, while examples of efforts in connecting rural health services are ample across the nation, they are fragmented with regional successes.
• The National Rural Health Mission through its Nationwide purview and with its financial and human resource can identify, adopt and scale such innovative solutions to address the equity gaps in rural areas.
• The 15th Finance commission also commended a strong focus on primary healthcare.
2. PMGSY – Changing Nature of India’s Rural Roads
• India lives in more than 6.5 lakh villages where 69 percent (89 crore) of her population is rural. The country’s 650 plus rural districts have 14.5 crore farmer households.
• The prime occupations of the rural population are – cultivation, agricultural labour, rural artisanry, retail business/small services, etc.
• The large size and share of the rural population, their prevalent socio-economic situations and the desired levels of quality of life demands an all-round improvement in the rural infrastructure.
• Improved infrastructure is the key to achieve the objectives of an equitable and inclusive growth with social justice.
• The country, during the last seven decades of planning and coordination, has devised and launched a series of strategic approaches to economic growth.
• The country’s economists, planners and policy makers have always visualized a vibrant rural India and advocated persistent improvement and expansion of rural socio-economic infrastructure.
• A strong rural road infrastructure ensures economic development through reduced cost of production and logistics, increased productivity, improved economies of scale, enhanced employment and improvement in public and private investments in rural farm and non-farm activities.
• It has its own systemic linkage effects and it provides better avenues of marketing of farm and non-farm products and services are facilitated in a rural set up.
• Infrastructure is also considered as one of the five inherent pillars of the Aatma Nirbhar Bharat in addition to the economy, system, vibrant demography and demand.
Need of Rural Connectivity
• Market access and business sustainability are positively correlated with connectivity. The modern day rural transformation is largely driven by the improvements in the rural-urban transportation and connectivity to markets.
• The occupations of rural areas will become viable, profitable and acceptable only when there is an all-weather rural connectivity.
• Improved transportation networks help in connecting markets for smooth and timely transactions of commodities and services.
• Poor road connectivity not only limits market access of marketable products and services but also reduces competitive advantages.
• The benefits of enhanced agriculture productivity are often wasted due to lack of proper market linkages.
• A good road infrastructure connects the rural areas with the nearby urban or semi-urban areas and ensures a quick flow of services and goods to meet emerging demands.
• It ensures a competitive advantage and helps in improving the inventory, storage, supply chain, and operations management.
• The competitive advantage is measured in terms of efficient supply of natural resources, significant reduction of harmful elements, creation of diversified and sector-specific jobs, improved are also the standards of community health and education and improved quality of life of people.
Rural Road Growth
• The country has the second-largest road network in the world. There is a consistent effort to connect rural communities for ensuring them basic amenities and the necessary markets.
• The road network has not only helped to place and transport goods and services to the right destination at the right time, but it has also supported sustaining their livelihood.
• Rural road transportation has gradually increased over the years with the improvement in investments in projects connecting the villages with cities and towns.
• Rural roads are constructed through various schemes/ interventions of multiple institutions viz. Panchayati Raj Institutions, (Zila Parishad, Panchayat Samiti, Gram Panchayat), Pradhan Mantri Gram Sadak Yojana (PMGSY) and State Public Works Departments.
• Roads in the rural sector are the core of rural development. Roads have helped in promoting access to economic and social services, thereby generating increased agricultural productivity, non-agriculture employment as well as non-agricultural productivity, which in turn expands rural growth opportunities and real income in the hands of the people.
• Basic Road Statistics of the Ministry of Road Transport and Highways as presented within the Annual Report 2021-22 provides data about the total road length in the country and the category wise breakups.
• The total road length in the country has increased impressively from 3.99 lakh km in 1951 to 63.71 lakh km in 2019 at a compound annual growth rate of 4.2 percent.
• The percentage of surfaced road length to the total road was 64.65 in 2019. As on 31.03.2019, the total road length in the country was 63,71,847 km out of which rural road length was 45,41,631 km.
• The share of the rural roads was the highest at 71.27 percent, followed by district roads (9.94 percent), urban roads (8.5 percent), State highways (2.82 percent) and National Highways (2.08 percent) of the total road network in the country.
PMGSY and All-Weather Rural Connectivity
• Rural Roads’ is a State subject. The Pradhan Mantri Gram Sadak Yojana (PMGSY), as a part of the poverty reduction strategy of the Government of India, was implemented on 25 December 2000.
• This was conceived as a one-time special intervention to provide road connectivity by way of a single all-weather road to the eligible unconnected habitations as per core-network with a population size of 500+ in plain areas.
• For special category States viz. Arunachal Pradesh, Assam, Himachal Pradesh, Jammu and Kashmir, Manipur, Meghalaya, Mizoram, Nagaland, Sikkim, Tripura, and Uttarakhand and identified areas under the Desert Development Programme, Schedule V tribal areas and selected tribal and backward districts as identified by the Ministry of Home Affairs, the aim is to connect eligible unconnected habitations with a population of 250 persons and above.
• In respect to most intensive integrated action plan (IAP) blocks as identified by the Ministry of Home Affairs, the unconnected habitations with a population of 100 and above have been included under PMGSY.
• The scheme allows for the upgradation of the existing roads in those districts where all the eligible habitations of the designated population size have been provided with all-weather road connectivity.
• The Government of India has identified a total of 1,78,184 habitations in the population size of 250 plus and 500 plus for coverage under PMGSY.
• While States have provided connectivity to 16,086 such habitations out of their own resources, 4,722 habitations have either been dropped from the original target list or were not found to be feasible for implementation. So far, 1,57,376 habitations have been covered under PMGSY and the remaining are proposed for completion by September 2022.
Use of Green Technology
• PMGSY promotes the use of new and green technology in the process of rural road construction.
• Locally available materials are used in road construction activities to promote cost effective and fast construction.
• Under PMGSY III, the States and Union Territories (UTS) are to mandatorily construct roads by using waste plastic within the minimum 15 percent of road length prescribed for new technologies.
• The basic aim of the use of modern technology in rural road construction is to ensure a safe environment, reduce overall expenditure without compromising on quality, prolonging the life span of roads, and ensure road safety, among others.
• Some of the techniques and technologies used under PMGSY are as follows.
1. Use of cell filled concrete to ensure flexible concrete and crack-free surface.
2. Use of paneled cement concrete to guarantee durability.
3. Use of roller compacted concrete pavement to enable simple, fast and economical construction with longer service life.
4. Use of cement stabilisation to improve soil strength, stability and to reduce, maintenance cost.
5. Use of Terrazyme to reduce the construction costs while increasing the overall quality of road structures; it is easy to use, not harmfulto the environment or its users and it guarantees a better and longer-lasting road.
• Cold mix technology uses cold mix binders (where heating of bitumen is not required) resulting in saving on fuel and the environment.
• Use of ‘Green Technologies’ and non conventional materials like waste plastic, cold mix, geo-textiles, fly-ash, iron copper slag, etc. in rural roads to ensure reuse of wastes.
• PMGSY’s Electronic Maintenance of Rural Roads (eMARG) is an enterprise e-governance solution for road maintenance.
• Launched with effect from 1 February 2019, this system offers a blue-print on how effectively issues and concerns on maintenance of infrastructure can be resolved across government departments with the use of smart Information Technology and contract management.
• As a Geographical Information System (GIS)-based enterprise e-Governance solution, eMARG focuses on safe and durable upkeep of PMGSY roads in all types of circumstances and involves performance-based evaluation of roads for provisioning and ensuring appropriate maintenance-related payments.
Issues and Challenges
• Rural Connectivity has remained a critical antecedent in the socio-economic development drives of rural people. Connectivity ensures access to amenities viz. education, health marketing, etc.
• There had been skewed and less than potential development of the rural road network in the country.
• Some States provided cent percent connectivity while some others did not have enough financial resources at their disposal and consequently connectivity remained at low levels.
• There were also problems of inadequate funds for maintenance, up gradation and rehabilitation of existing rural roads.
• A network approach and provision of sustainable accessibility with assured maintenance were virtually absent.
• Rural roads are being constructed by Panchayats in the villages with finance commission assistance provided to them through the Finance Commission awards.
• Various development programmes like Mahatma Gandhi National Rural Employment Act (MGNREGA) and PMGSY encourage rightful investment in road assets in rural areas.
• It was PMGSY that relied on standardised and strict quality benchmarking, monitoring and C maintenance processes and procedures.
• This quality-benchmarked rural roads programme with its due emphasis on the superiority of construction has successfully expanded the connectivity in a systematic manner leading to the revitalisation of the rural economy and improved quality of rural life. The quality performance of rural roads relies on the following.
• Discrepancies in District Rural Roads Plans (DRRPs) need to be removed and scientifically collected information on the population of habitations, connectivity status, road inventory with maps and a GIS empowered database should be ensured.
• Such state-specific information base on rural roads would help covering unconnected but eligible habitations under PMGSY.
• Detailed project reports should be prepared by adopting laid-down procedures. Road works need to be completed with required number of bridges and cross drainage structures.
• The establishment of a vibrant monitoring and accountability mechanism is the need of the hour to check cases of undue advantage to road contractors and eliminate poor execution of such works.
• To ensure appropriate fund management within a road project, the States need to ensure adequate fund provisions and to ensure that their share is released as per the timelines and is not diverted to other schemes. The project should conform to the quality norms.
• There should also be a provision through which the States should commit to the maintenance of the road asset for five more years after the initial project tenure.
• Keeping in view the fund requirements and fund position for maintenance, it may be necessary to link the Finance Commission grant-in-aid with PMGSY work execution and maintenance.
• PMGSY has a time-tested quality control, monitoring and evaluation mechanism.
• As per the given standards of the quality benchmarks, the government should map the deficiencies to fix responsibility and accountability on agencies responsible for quality control at the local, state and national level.
• Infrastructure provides the basic outline for economic and social progress of a country.
• The initiatives of the government for building rural infrastructure and the related central sponsored schemes envisage the enhancement of the socio-economic status of rural people.
• A considerable part of the total expenditure under such a programme is considered as development or capital expenditure.
• Many projects aiming at enhancing rural infrastructure including rural roads and bridge construction projects are also routed through the National Bank for Agriculture and Rural Development (NABARD) – the apex financial body for agriculture and rural infrastructure.
• India’s mission of a vibrant Aatma Nirbhar Bharat can be realised through a reinforced rural infrastructure.
• Better rural infrastructure – be it surface, air or water transports, telecom, rural marketing, warehouses, or water supply and power, is capable of facilitating better avenues for rural growth and of appropriately remunerating the activities of the farmers, manufacturers, and service providers in a rural setup.
• Rural roads are recognized as catalysts to rural development and a significant element of poverty alleviation initiatives.
• Considering the importance of infrastructure in the sustenance of rural economic growth, the present government has continued laying emphasis on the creation of rural road infrastructure through development schematic plans and other subject-specific interventions.
• The PMGSY roads are known for their construction quality and durability. To ensure quality in the construction of rural roads, vigorous quality control measures are followed, backed by independent quality checks and measurements.
• The inbuilt clause of five years of maintenance within the construction contract also helped in the maintenance of the newly created assets.
• Since all the eligible rural habitations have been connected, it is required now to strengthen and widen its ambit further to include major link routes which connect habitations to agricultural and rural markets, higher secondary schools and hospitals/ health centers.
• Further, existing roads which got constructed through the three phases of PMGSY shall have a robust maintenance framework with active participation of the respective State/UT Governments.
• As a follow-up action to the rural infrastructure building initiatives, a synchronised approach is required to establish rightful convergence with various other development oriented programmes already in operation like –
o programmes for alleviating poverty,
o generating gainful employment,
o ensuring social security,
o enhancing standard of health,
o sanitation and education being implemented by Ministries/ Departments of Panchayati Raj,
o Rural Development,
o Drinking Water and Sanitation,
o Water Resources,
o Information Technology and Land Resources, etc.
• The future prosperity of rural India depends largely on how the road infrastructure is designed, facilitated, maintained, and made environmentally acceptable.