Abstract
Healthcare in rural India presents unique challenges and opportunities. While global health metrics emphasize indicators like life expectancy, mortality rates, and healthcare infrastructure, they often fail to capture the socio-cultural nuances of rural communities. Rural India, with its strong familial ties and deep-rooted traditions, exhibits resilience but also faces rising lifestyle diseases, medical indebtedness, and gaps in healthcare access. The imbalance in doctor distribution, high costs of medical education, and reliance on informal practitioners further complicate the scenario. Solutions must integrate community participation, health education, promotion of local dietary habits, and strengthening of primary healthcare. Leveraging technology, preventive healthcare measures, and strategic private sector involvement can bridge critical gaps. A shift from a top-down approach to locally driven solutions is crucial for sustainable health improvements. As India's rural economy evolves, proactive, culturally sensitive interventions will be essential to ensure equitable healthcare access and improved well-being for millions.
Introduction
A practising clinician is uniquely placed in society. People visit a doctor out of compulsion, never as a choice. The physician sees aspects of society which are not usually perceived by others. Many times, these experiences as a healthcare practitioner provide insights that often diverge from conventional perceptions of health and well-being.
Consider this anecdote: A few years ago, a woman visited my rural clinic complaining of knee pain. Inquiring about other ailments, as is my practice given the prevalence of arthritis in multiple joints, she replied cheerfully that she had no other problems in her life. She felt blessed and had little to complain about, save for some minor knee discomfort.
Contrast this with another patient, a young woman from a prosperous Hyderabad family who had attended a prestigious Delhi university. Despite her privileged background and education, she was deeply troubled by the injustices she perceived around her. Driven by a sense of social responsibility, she dedicated herself to assisting others, often becoming involved in legal battles on their behalf. While undeniably intelligent and driven, she displayed signs of depression and mental distress, burdened by the weight of the world’s problems.
By conventional metrics, the second woman would score highly. She was urban, educated, and financially secure. Yet, her mental health was demonstrably poorer than the seemingly less fortunate villager.
This raises a fundamental question: What truly constitutes health? Global health organizations like the WHO, CDC, and World Bank typically rely on indicators such as:
• General Health Metrics: Life expectancy, infant and maternal mortality rates, morbidity rates.
• Physical Health and Lifestyle Metrics: Smoking and alcohol consumption, physical activity levels, caloric intake quality, obesity rates, blood pressure levels.
• Mental Health Metrics: Suicide, depression, and anxiety rates, substance abuse rates.
• Public Health Metrics: Vaccination coverage, malnutrition rates, air and water pollution levels.
• Nutrition and Dietary Metrics: Daily caloric intake, caloric quality, prevalence of diabetes, cholesterol levels.
• Healthcare Indices: Doctor-patient ratio, hospital bed ratio, emergency response times.
• Quality of Life Indices: Happiness index, health awareness levels.
These indices guide policymakers, healthcare providers, and the insurance industry. However, they may not fully capture the nuances of health in diverse settings like rural India.
Historically, rural India has been home to the majority of the country's population. In 2021, approximately 64.13% of Indians resided in rural areas (pib.gov.in). While "rural" often implies an agrarian economy with traditional practices and static social norms, this is a sweeping generalization. Rural India encompasses a wide spectrum, from Delhi's "urban villages" to peri-urban areas absorbed by expanding cities and remote, inaccessible settlements. A single definition cannot encompass this diversity. The perspective shown here has been shaped by over fifteen years of fieldwork in a village on the outskirts of Hyderabad.
The per capita income in rural India is approximately Rs 184,000 per annum (about $2,150 USD), compared to the national average of Rs 212,000 ($2,500 USD). This figure masks significant disparities between agriculturally prosperous states like Punjab and Haryana, and lower-income states like Bihar, Jharkhand, and Odisha.
Socially and culturally, rural India presents a unique landscape:
• Family Bonds are very strong: Extended family systems remain a remarkable feature of rural societies, in stark contrast to the nuclearization and individualization prevalent in urban areas. Families and communities provide unwavering support to patients in vegetative states for years, a testament to the strength of these ties.
• There is a deep Cultural Connection to the Soil: Rural societies often possess a deep sense of geographical rootedness, viewing the earth as a nurturing mother. Local stories and legends (“sthalapuranas”) play a major role in shaping day-to-day behaviour
• There is a limited focus on lifestyle: The increasing awareness of exercise and lifestyle changes sweeping urban areas has not yet fully reached peri-urban regions, contributing to a rise in chronic health problems.
However, this connection to tradition can also present challenges in healthcare:
• Healthcare in the Grip of Local Practitioners: Rural communities often rely on local, often unqualified, practitioners who have gained skills through informal experience. While they may provide valuable services for minor ailments, they can significantly influence treatment choices for major illnesses. It is common knowlege in the healthcare industry, that their margins depend on the “kickbacks” provided to these medical middlemen. Quality and emphasis on cost-effectiveness are not primary concerns of hospitals which depend on these intermediaries.
• Preference for the "Best" Available: Even in rural areas, there's a growing desire for advanced medical treatments, sometimes without a full understanding of their appropriateness or limitations. Often, families go into deep debt because of getting treated in an upscale hospital in urban areas rather than effective treatments at smaller medical centres.
• Medical Indebtedness: Many families go below the poverty line because of preferences for expensive treatments which they believe are state-of-the-art.
Recent trends include
Currently, rural health in India faces numerous challenges. The prevalence of chronic conditions like diabetes, hypertension, and hypercholesterolemia is increasing, leading to cardiac and neurovascular complications. These trends are largely driven by lifestyle changes, including increased reliance on motor vehicles and the mechanization of agriculture, reducing physical activity. Additionally, diets rich in carbohydrates have become more common. Regular physical exercise is often viewed as an unnecessary luxury, associated with affluent urban lifestyles. “We (villagers) are very hard working people and do not need to exercise” is commonly heard.
Daily habits in rural areas reveal notable behavioral shifts. People are less likely to walk to neighboring villages, preferring autorickshaws or personal vehicles. The traditional image of farmers plowing fields with bullocks is also fading, as nearly the entire cropping cycle is mechanized.
Another insight is that farmers who produce fresh vegetables or milk often sell these products to urban centers, consuming refined foods like polished rice instead. The increasing consumption of pre-packaged and processed foods also contributes to chronic medical illnesses.
Unfortunately, modern medicine is still often referred to as "English" medicine, perceived as effective but expensive. It is not perceived to have organic connections to local attitudes. The health paradigms used by healthcare professionals often clash with deeply held cultural beliefs. For example, introducing eggs into school mid-day meals, while based on sound nutritional principles, can offend communities that abstain from animal products.
The declining fertility rate in India is also reflected in rural areas. The overall fertility rate in India is about 2.0 (which is below the replacement rate of 2.1). In rural areas of India as a whole it is about 2.2. In Telangana, the TFR in rural areas is about 1.8.
In addition, there is an out-migration of rural youth to urban areas driven by a need for better education, employment opportunities and a perceived improved quality of life.
Both these factors are contributing to a decline in rural youth work force and “elderly staying alone”.
Looking ahead, as India transitions into a middle-income economy, significant changes in the health scenario are expected. NITI Aayog projects a middle-class expansion in rural areas, with mean incomes reaching Rs 2.7 to 3.6 lakhs per year by 2036-37. By 2045, the average per capita GDP is expected to be $18,000 to $20,000 at current rates, with rural incomes converging towards this level.
Consequently, rising rural incomes will also bring fresh health challenges. A significant increase in non-communicable diseases is anticipated, with rural India potentially seeing a 57% rise in cardiovascular diseases and a 69% rise in diabetes (Critical rural area health issues in India. PharmaBiz. Vinod Sawantwadkar. December 19, 2024.). Neurovascular illnesses, cancer, and other chronic conditions are expected to surge as well.
Mental health illnesses pose particularly challenging problems, especially in rural settings. Barring genetically linked conditions, many mental health issues are rooted in the existing social environment. Whether it’s a farmer facing drought or an abused wife, treatment is often ineffective without addressing the underlying social factors. A recent study (bwhealthcareworld, Rural India faces growing healthcare challenges: The state of healthcare of rural India report -2024) highlighted these issues. As the proportion of the rural population over 60 rises above 14% by 2040, geriatric mental health issues, particularly dementia, are also expected to increase. The incidence of dementia is about 7.4% of the population > 60 years of age (Alzheimers Dement. 2023 Jan 13;19(7):2898–2912. Prevalence of dementia in India: National and state estimates from a nationwide study). However, the strong sense of community and family in rural areas might help mitigate the effects of this problem.
Road accidents and other forms of trauma are significant public health concerns. Data from ‘Road Accidents in India-2022’, published by the Ministry of Road Transport and Highways, showed that approximately 70% of fatalities in road accidents occurred in rural areas. This figure is likely to increase with the development of road networks and increased motor vehicle usage. Rural accidents present unique challenges, as patients may not reach a competent center within the critical "golden hour" after injury. It is common to see pedestrians, two-wheelers, and non-mechanized transport vehicles sharing highways with high-speed heavy vehicles. Overall, despite ongoing efforts, rural society will likely face significant challenges in this regard (https://iihmrdelhi.edu.in/blog/healthcare-challenges-in-rural-india/).
Healthcare Infrastructure
Addressing structural challenges in providing healthcare reveals several issues. The current doctor-patient ratio in India is 1:836. While this is better than the WHO recommendation of 1:1000, this number is skewed towards urban areas. This number is about 1:11000 in rural areas
(https://www.expresshealthcare.in/news/bridging-the-urban-rural-divide/445455/).
According to the National Medical Council of India, the ratio of urban to rural doctors is 3.8:1, meaning approximately 26% of doctors serve about 72% of the population (Dr. A. Marthanda Pillai: Issues of Rural Health in India).
The reasons for the scarcity of doctors in rural areas are multifaceted: a preference for urban centers with better lifestyles and career opportunities, lack of incentives, inadequate infrastructure, and, in some cases, personal safety concerns. Unlike China in the 70s, India lacks a "barefoot doctors" program. However, efforts are being made to fill this gap through community health workers and other mid-level healthcare providers.
There is also a shortage of hospital beds in rural India (about 0.9 beds per 1000 people) (xpresshealthcare: Gaps in Indian rural healthcare. Shyamal Santra, Public Health & Nutrition Expert), as well as fewer medical stores compared to urban centers.
Turning to Medical Education, it is estimated that there are 706 medical colleges in India (mbbsapp.com). Of these, 386 are in the government sector, and 306 are in the private sector. The seat capacity is about 108,900 MBBS seats every year. While exact numbers are not available, a significant proportion of about 46,000 foreign students study in India. In addition, about 20,000 Indian students go abroad every year for MBBS studies
(https://www.universityworldnews.com/post.php?story=20240822135849204)
After this period, most medical students pursue a postgraduate medical course. As of December 2024, India has a total of 73,157 postgraduate (PG) medical seats, including 57,866 MD/MS and 11,472 DNB seats (https://www.shiksha.com/medicine-health-sciences/articles/neet-pg-seats-in-india-blogId-62867).
As can be seen from the above figures, there is a significant bottleneck in the medical education field. This is a situation where the average medical student who dreams of being an independent medical consultant knows he has to go through a specialization training program for a further few years. Yet, he/she has to fight it out in another entrance test.
There is yet another aspect to medical education. Almost half the medical colleges in India are in the private sector. The students have to spend enormous sums of money to become doctors. In private medical colleges in and around Hyderabad, it is anywhere between Rs. 2.7 lakhs/annum to Rs. 14.7 lakhs/annum, depending on the college and type of seat. That is, a medical student who completes a four-and-a-half-year course will have to spend anywhere between Rs 13 lakhs to Rs 70 lakhs a year (https://meducate.in/telangana-medical-college-mbbs-fees/).
Since postgraduate medical training is more or less accepted as a necessity to practice medicine, most graduates from private colleges who do a 3-year Masters course have to pay an additional Rs. 7.75 lakhs / annum to Rs. 24 lakhs / annum. That is, they pay a further total amount of about Rs. 23 lakhs to 72 lakhs overall.
Considering the huge investment in obtaining a degree in the medical field, it is no surprise that the costs of healthcare are spiraling in India.
A caveat needs to be added to these figures. For those fortunate enough to obtain a seat in a government medical college, the fees are a lot lesser, typically Rs. 10,000 to Rs 50,000 per year.
Implications for healthcare: While it is well accepted that there is a deficiency in the number of doctors in India, the answer to our healthcare problems does not necessarily lie in hospital based healthcare. It is common knowledge that most politicians take pride in saying that they have opened more medical colleges in their state. However, curative medicine is only a small, but very visible part of healthcare.
In the history of medicine, the most drastic fall in mortality was brought about by robust public health interventions. The control of infectious diseases such as smallpox, plague, diarrhea, tuberculosis, etc., were brought about not through hospital-based institutions, but by sound implementation of preventive health measures such as clean water, sanitation, vaccination, and public health infrastructure (https://www.britannica.com/science/preventive-medicine). The availability of good-quality food grain also helped to reduce malnutrition-related deaths. The memory of the Bengal famine of 1943 is still fresh in our minds.
Similarly, cardiovascular diseases which are burgeoning in our country can be prevented to a large extent with the promotion of a healthy lifestyle. Such diseases follow a classic inverted “J” shaped curve. The incidence increases as wealth rises and then reduces with further prosperity.
(https://www.ncbi.nlm.nih.gov/books/NBK45694/). For example, Amsterdam, Netherlands is often referred to as the “bicycle capital of the world” because of the extensive grid of bicycle friendly infrastructure. Consequently the incidence of heart disease was found to be lesser in regular cyclists. In a famous study published in 2016, Blond et al found that there was a significant decrease in heart disease among Danes in the age of 50-65 years who cycled regularly
(https://www.ahajournals.org/doi/pdf/10.1161/circulationaha.116.024651).
Indian diet: Our diet may not be as perfect as we all like it to be. With an excessive focus on taste, the nutritive quality takes a back seat. Indian diet tends to be rich in refined carbohydrates, excessive quantities of sodium and reduced quantities of potassium, reduced quantities of proteins and micronutrients lead to an imbalanced metabolism.
Solutions
Most urban based policy makers tend to have a top-down approach to rural problems. There is a hint of a “we know better” attitude. However, most people living in the countryside have an excellent grasp of their problems. The solutions that are thrust on them may be alien to their practices hence are not regarded favourably. Involving the community and developing a sense of ownership will certainly help to achieve the stated results.
1. Education with a focus on health. Long term health starts young. Be it awareness about pollution or biodiversity or about physical fitness. Young impressionable minds carry the message for longer durations.
2. Encouraging local foodgrains. Ayurvedic food beliefs emphasize seasonal, fresh and locally sourced foods. The concept of “sattvik” foods with emphasis on fresh vegetables and fruits, while suggesting moderation of meat and dairy products synchronize with locally held food beliefs.
3. Health attitudes are to be integrated into local social and cultural practices. In many cases, health messages by the Government are in English and not in the local language limiting their penetration.
4. Strengthening Primary Healthcare. The role of the Asha worker and the mid-level workers is to lauded. Many are members of the local community and perform an excellent role.
5. Encouraging private sector participation in rural healthcare. Given the fact that investing in healthcare seems to be a low priority, encouraging establishment of low-cost multi-specialty hospitals with adequate Government support will be useful. The Ayushman Bharat scheme, while being popularized as a game-changer is actually disliked by many hospitals due to their low rates of reimbursements, delayed payments, etc. (https://www.livemint.com/industry/private-hospitals-pull-back-on-ayushman-bharat-amid-low-state-funding-11715151502802.html).
6. Investing in preventive healthcare has always been known to lead to greater long term health outcomes. The recent push by the Government of India to build household toilets in rural areas is a case in point. This has led to an increase in safety, security and self-respect of women (https://swachhbharatmission.ddws.gov.in/sites/default/files/Studies-and-surveys/Safety-security-and-dignity-of-women.pdf).
7. Leveraging Technology: The presence of technology, especially wireless technology and information is ubiquitous. There are several instances where patients forward their medical records ahead of their visit so that the medical team may be aware of the patient’s problems. This is especially useful in critical conditions where the appropriate specialists are made available even before the patient reaches the hospital. Going forward, telemedicine will have a significant impact. (Remote robotic technologies or robotic surgeries are unlikely to gain acceptance due to legal issues.)
8. Incentivizing physicians to practice in deserved areas. This has been an accepted method for most industrialized countries to provide rural healthcare. However, there seems to be no such mechanism in place in our country.
Conclusion
The rapidly changing economic scenario is reflected in changing healthcare challenges. In rural India these are significant but are not insurmountable. By working together and prioritizing the health and well-being of rural communities, we can create a brighter and healthier future for all.
