After 10 years of rural health mission, doctor shortfall up

Posted in Pengantar Mingguan

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Samarin Bai, a 50-year-old Baiga tribal woman from Mahamai village lives in the dense Achanakmar forests of Bilaspur district, Chhattisgarh. A few days back, she decided to see a doctor for the big lump that had developed at the base of her neck and various other problems. Although there is a government sub-centre 6kmsix kilometers away, she knew that there was only one auxiliary nurse cum midwife (ANM) who wouldn't be able to help. So she trudged through 14km of rain-soaked forest to a health centre in Bamhani village set up by a local NGO, Jan Swasthya Sahyog (JSS). A doctor visits this centre every week and he diagnosed a dangerous thyroid enlargement which needed quick surgery. Samarin Bai waded across a monsoon swollen river and was transported by the JSS van to their hospital at Ganiyari, some 70km away. She is recovering there now.

Yogesh Jain of JSS narrates this story as an example of what is routine in the area. Healthcare delivery is so patchy and deficient that people travel dozens of kilometers to get treatment. "In the 10 years since the NRHM was launched, some improvement is there, buildings are there, some more equipment is there, upkeep is better. but doctors and key healthcare personnel are still deficient," he told TOI.
Recently released government data on the rural health infrastructure and personnel confirms that Samarin Bai's problem of not finding doctors nearby is not a rare example from some inaccessible forest. At the country level, there is a staggering shortfall of 81% of specialist doctors, 12% of percent general physicians, 21% nurses and 5% of auxiliary nurse cum midwives. Among technical support staff, shortfalls range from 29% percent for pharmacists to 45% percent for laboratory technicians and 63% percent for radiographers. But what is more shocking is that since a decade ago, many of these shortfalls have increased except for nurses and ANMs.

A bizarre aspect of this data put out annually by the ministry of health is that in many categories of health personnel, some states have surplus appointments while others have shortfalls. For example, at the country level, 25,308 doctors are required going by the Indian Public Health Standards (IPHS), which says that one doctor is needed for every primary health centre (PHC). But actually, there are 34,750 doctors sanctioned. 25 states have surplus doctors in position compared to required, the total surplus working out to 5,115. On the other hand, the remaining states have a combined shortfall of 3,002 doctors.

T Sundararaman, professor at the Tata Institute for Social Sciences and former executive director of the government's National Health Systems Resource Centre says,has an explanation. "IPHS recommended two doctors and one ayush doctor per PHC. In 2011, the doctors per PHC was revised downwards. But doctors are - unlike ANMs - paid only by the states. So many states, like Tamil Nadu, have two doctors per PHC as sanctioned. The 'required' number is the statistics department's interpretation of IPHS to mean that only one doctor is required per PHC. They have no basis to do this, and one doctor per PHC is not viable. The short falls are genuine - the over appointments are not," he told TOI.

This puts the whole data in a new light. The surpluses shown in healthcare personnel in many states are not real - they arise because goal posts are shifted by lowering requirements. In reality the shortages are all round. This would apply to ANMs too which are 'surplus' in 25 states/UTs amounting to a whopping 42,548 for India. This is because the earlier standard of two ANMs per sub-centre has been diluted to one. Despite this several states don't even have that sole ANM in many sub-centres.


In fact, the norm of having a sub-centre for every 5000 persons (or 3000 persons in tribal and hilly areas) is crumbling fast. Currently, the national average is over 5400, with some states like UP having an above 7000 average. Similarly, the national average of population per PHC is nearly 33,000 against the norm of 30,000 and the average for community health centres (CHC) is running at 1.5 lakh compared to the prescribed norm of one lakh per CHC.

Source: http://timesofindia.indiatimes.com/india/After-10-years-of-rural-health-mission-doctor-shortfall-up/articleshow/48893334.cms

Community participation in rural health: a scoping review

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Ketimpangan kesehatan yang besar antara penduduk urban dan rural telah menjadikan kesehatan rural menjadi prioritas di berbagai negara, termasuk Indonesia. Walaupun memang ada kesamaan antara daerah-daerah rural, terdapat peningkatan pengakuan bahwa satu pendekatan untuk semua kesehatan rural menjadi tidak efektif karena gagal dalam menyesuaikan pelayanan kesehatan dengan kebutuhan penduduk lokal.

Partisipasi masyarakat kemudian diajukan menjadi salah satu strategi untuk melibatkan masyarakat dalam mengembangkan pelayanan kesehatan yang responsif secara lokal. Kebijakan yang kini ada di beberapa negara mencerminkan keinginan untuk tingkat partisipasi masyarakat yang tinggi dan bermakna. Terdapat celah yang signifikan dalam memahami seberapa lebih tinggi tingkat partisipasi masyarakat yang terbaik untuk ditetapkan dalam konteks rural. Untuk mengidentifikasi beberapa contoh, Kenny, et al. kemudian menelaah contoh dalam literatur internasional mengenai tingkat partisipasi masyarakat yang lebih tinggi dalam pelayanan kesehatan rural.

Studi ini menggunakan scoping review untuk memetakan bukti yang ada berdasarkan tingkat partisipasi masyarakat yang lebih tinggi dalam perencanaan, desain, manajemen, dan evaluasi pelayanan kesehatan rural. Kata kunci pencarian adalah pengembangan dan pemetaan. Database yang telah terseleksi dan alat pencarian internet digunakan untuk mengidentifikasi 99 studi relevan.

Dari studi di atas, penulis mengidentifikasi enam artikel yang paling dekat dalam mendemonstrasikan tingkat partisipasi masyarakat yang lebih tinggi; gagasan kekuasaan warga negara milik Arnstein (Arnstein’s notion of citizen power). Walau dalam studi tersebut mencerminkan elemen utama untuk tingkat partisipasi, hanya terdapat sedikit detail mengenai bagaimana pembentukan kelompok dan bagaimana masyarakat diwakili. Kebutuhan akan kerja sama yang kuat diulang di beberapa studi, dengan beberapa diantaranya mengidentifikasi dampak dari  interaksi relasi dan ikatan sosial. Pada semua studi, luaran dari partipasi masyarakat tidak diukur secara ketat.

Diperoleh kesimpulan bahwa dalam lingkungan yang dikarakterisasi oleh meningkatnya minat dalam partisipasi masyarakat terhadap pelayanan kesehatan, pemahaman yang lebih besar dari tujuan, proses, dan luaran merupakan prioritas bagi riset, kebijakan, dan praktek.

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Rekomendasi untuk Memajukan Kesehatan di Area Rural dan Terpencil

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Hampir 340 rekomendasi untuk meningkatkan pelayanan kesehatan di area rural dan terpencil telah dibentuk oleh delegasi yang mengikuti Konferensi Kesehatan Rural Nasional ke – 13 di Darwin. Dari 340, dipilih 10 rekomendasi terprioritas yang jika diimplementasikan, dapat meningkatkan akses, keterjangkauan biaya, keamanan dan kordinasi yang lebih baik untuk masyarakat yang tinggal di area rural dan terpencil di Australia.

Termasuk dalam 10 prioritas rekomendasi adalah, kesehatan dan kesejahteraan yang lebih baik bagi masyarakat pedalaman; koneksi digital yang cepat, dapat diandalkan, dan terjangkau; terjaminnya kemananan pangan di area rural dan keberhasilan implementasi Asuransu Nasional.  Selengkapnya

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