Access and Barriers
to Care within the
Indian Healthcare System
Population: 1,103,956,000
Area: 1, 269,221 sq miles
Languages: 14 including English and Hindi
Religions: Hindu, Muslim, Christian, Sikh,
Buddhist, Jain, Parsi
Life Expectancy: 63
GDP per capita: $2,600 USD
Literacy %: 60
GDP spent on heath care: 1.4%
Health care expenditures: 74% out of
pocket
Observership at Christian Medical College, Vellore, Tamil Nadu,
Southern India.
June-July 2014
Lauren Andrus, University of Kansas School of Nursing
(National Geographic, 2014)
Objectives:
A Community Outreach Nurse checks a blood
pressure during a rural patient home-visit.
June 2014
To assess the issues that surround access
and barriers to public healthcare in India.
 Identify populations that utilize private vs
public sector care and relative access to care
 To study the barriers to care in India, such as
economic status, language, and geographic
location.
 To evaluate maternal care in rural/economically
disadvantaged communities and observe
quality and access of care for the expectant
mother.
 To study emergent care in India, access to care,
and emergent situations that are requiring
immediate care.
 To explore recommended broad methods for
improving care access that may be applicable
or appropriate to this particular healthcare
setting.
Background.
 Government healthcare is low cost, but has limited
reach and underfunding causes serious barriers to care.
Government care is seen as inferior and more difficult to
access (Chang, et al., 2013).
 22 official languages, which can affect communication
between patient and provider (Narayan, 2013).
 22-27% of the population lives in extreme poverty,
making healthcare unaffordable, especially in rural areas
(68.84%) despite government reforms to increase
access (Ghosh, 2014).
 High out-of-pocket costs for care and prefers private
for-profit institutions, compound the issue of
affordability of care for the poor. (Chang, et al., 2013)
 India has 1/5th of the global burden of absolute maternal
deaths (Montgomery et al. 2014).
 Poorest and more rural states have highest maternal
mortality rates (397 per 100k) vs richer, urban states (119
per 100k) (Montgomery et al. 2014).
 Unintentional injury is the cause of 7% of all deaths in
India, 27% being vehicle accidents. 80% of unintentional
injury deaths occur in rural areas (Jagnoor et al., 2012).
A slum in an urban area of Vellore. July 2014
Treatment room at the Low Cost Effective Care Unit, Vellore.
June 2014.
CMC and Peripheral Clinics.
 Well-respected private hospital and training
facility for health-related professions
 Founded as a single- bed institution in 1900
by Dr. Ida Scudder who recognized the
need for accessible care for urban and rural
patients in need.
 Long-standing tradition of community
outreach, free clinics and efforts toward
the improvement of accessibility of
healthcare to the less fortunate.
Firsts at CMC
•First College of Nursing in India (1946)
•First reconstructive surgery on a leprosy patient (1948)
•First successful open heart surgery in India (1961)
•First Rehab unit opened in India (1966)
•First Kidney Transplant in India (1971)
•First Bone Marrow Transplant in India (1986)
• CMC provides care on all three
levels, primary, secondary, and
tertiary.
• Mission is to provide accessible ,
quality, affordable care for the
people of the surrounding area,
both urban and rural.
• Developed several initiatives to
work with the community, and
partner with government
programs to provide care to
those in need.
Primary Care
CMC & Clinics
CONCH – College of Nursing Community
Health initiative.
Nurse-run clinic provides primary care in the
surrounding villages and underserved urban
areas.
Medication is provided to patients who cannot
afford it.
CHAD – Community Health and Development
Clinic has 120 beds
Lower cost care is available here.
RUSHA -- Rural Unit for Health and Social
Centrally-located 69 bed rural clinic serves the
outlying populations. Also houses a
community college that helps to train students
to have a career to fight unemployment.
LCECU – Low Cost Effective Care Unit
46 bed clinic serves over 20,000 in the urban
area of Vellore.
Extremely low costs to those in need. Demand
for these services is high, and only 250 patients
can be seen a day
CMC Hospital – Tertiary care facility and 2,632.
bed hospital, with outpatient facilities to serve
over 2.1 million patients a year. 39 Operating
rooms. 19 ICUs.
CONCH, LCECU
CHAD, RUSHA
Secondary Care
LCECU
CHAD, RUSHA
Tertiary & Emergent Care
CMC Hospital
CHAD, RUSHA (limited services
available)
The waiting room to be seen by a medical professional at RUSHA. June 2014.
Populations that utilize private vs. public
sector care.
 Private care preferred by all populations in
India. Private staff seen as competent, better
trained, and care is of higher quality despite
out of pocket cost (Chang, et al., 2013).
 Government health care is underfunded,
understaffed, poorly accessible (find quote).
 CMC utilizes profits from paying patients via
private rooms and elective procedures to find
care for the economically disadvantaged
 Holistic care with their programs that serve all
Diabetes management class at LCECU
economic, religious, and social backgrounds.
Vellore. June, 2014.
 CMC partners with government initiatives to
meet healthcare quality improvement goals.
 Community outreach clinics focus on primary
interventions to improve overall health for
their patients, helping to prevent illness.
 Emphasize the importance of patient teaching
and management for long-term illnesses such
as diabetes, hypertension, high cholesterol
and heart disease.
CONCH nurses give a presentation on intestinal parasites at a government school.
July, 2014.
Barriers to care.
 Underutilization of
government system
 Underfunded government
health system
 Extreme poverty
 Reduced Rural Access
 Language barriers
 High-out-of pocket costs
CONCH Equipment Kit used during rural visits.
June 2014.
A girl awaits care with her mother at RUSHA. June 2014.
Local Strategies to Address Improved
Care Access.
 CMC wards have a “free” bed, that doctors can use for a
patient that is unable to pay.
 Programs are in place to help offset the cost of
expensive treatment dispensed by committee on an asneed basis.
 Nurse-run clinics – CONCH perform house calls daily in
rural villages to help those that cannot afford travel to
CMC.
 Assessment includes a record of the family, main health
complaints , occupation, the quality of the dwelling -updated with every change within a family.
 RUSHA – Rural clinic is more accessible to patients, and
also performs visits to outlying areas.
 CHAD serves a “block” of 82 villages of the Kaniyambad
area(250,000 pop.), holds doctor and nurse-run clinics
 Community liaisons are used to coordinate clinics,
address language barriers
Keeping costs low to
help make care more
affordable:
CMC registration fees:
Hospital: 120 Rs
CHAD: 60 Rs
LCECU: 20 Rs (one
time fee).
Rural & Home Visits
via CONCH, CHAD: No
cost.
System Strategies to Address Improved
Care Access.
 “Financial inability was cited as one
of the most predominant reasons for
not seeking care by the rural and
poor population. The situation seems
to be further worsening for the poor
and rural population (Ghosh, 2014)”.
 High out of pocket costs have made
care unaffordable for the poorest
(Gill et al., 2013).
 Government ambulances are
available for free to help transport
women to the hospital for birth.
 Government scheme to implement
free generic medicine schemes in
Tamil Nadu (Chang, et al., 2013) to
reduce costs.
Patient records at RUSHA. June 2014.
•
Some government agencies incentivize
rural caregiving (Gill et al. 2013).
•
India spends only 1.4% of GDP on
government health (vs 5% global average).
•
Increased funding for government system
a priority to attain global median of 24
beds per 10k pop (Jehani, 2012).
Community and Local Strategies to
address Maternal Mortality Rates
 50% of deaths occur at home, 13% in transit to
health facility, 25% of these deaths are due to
maternal hemorrhage (Montgomery et al., 2014).
 Institutional births are encouraged to reduce
complications. CMC has partnered with the
government system to bring antenatal care to
women in rural areas
 Utilization of birth cards that track gestation, and
the post-partum condition of the child including
vaccinations and growth.
 CONCH performs home visits, well-baby and wellwoman check ups post partum.
 Vitamins and medications provided to support
women during pregnancy
 Education provided on breastfeeding, diet and care
for infants.
CONCH nurse arriving to conduct an antenatal health clinic in a
rural community.
June, 2014.
Overall maternal mortality rate has decreased by ~50% and was reported at 200 deaths
per 100,000 live births as of 2010.
Tamil Nadu has reached the Millennium Development Goal of a maternal mortality rate
ratio less than 109 deaths per 100,000 live births (Chang et al, 2013).
Community Strategies to Address
Emergency Care.
 Level I emergency & trauma services
 First nurse-run triage in India.
 Walking triage implemented to assess patients that
may have heart attack and stroke that may be waiting
in line.
 Developing separate ED for chest pain.
 7 bed Resuscitation Bay for stabilization of
immediately critical priority 1 patients.
 Trauma Bay for trauma patients that are stable and
awaiting emergency surgery or further assessment.
 Recognized as an International Training Centre for
Accident and Emergency Care by the WHO. The
department trains and awards the WHO Training
Certificate to health professionals of South-East Asia.
 Cost for registration set at 200 RS ($3.32 USD) to
make it accessible to most patients, but no patient
ever is turned away.
The line outside CMC Hospital’s
Emergency Department. June 2014.
Conclusions.
 Complete access to care across the
lifespan, primary, secondary, tertiary,
maternal and emergency is imperative to
the lifelong health of the population and
ideas for improvement should be
examined.
 Government is improving affordable
access to care but change is slow.
Expansion of funding and extension of
universal insurance is necessary.
A slum in a semi-urban area of Vellore.
June 2014.
An urban clinic
run by nurses
in an area close to
Vellore, India.
June 2014.
 CMC is working to bridge the gaps
between government care, and
unaffordable private care in the emerging
country of India.
 CMC is successful at supporting and
partnering with government care
programs to improve access.
 Possible to have the needs of the people
met efficiently and affordably between
the private and public systems.
Clinical Experiences.
The most important clinical experience I had in India
was not all at once, but a process throughout my entire
time there. What I learned was how to rely on more
than words to connect and communicate with patients.
I could not speak the language, and it was incredible to
be able to experience human interaction on the most
basic of levels, through gestures, touch and body
language without speaking, but still being able to ask a
patient where it hurts, to give comfort, or to reassure
when a patient is afraid or in pain.
I believe the ability to connect on this level takes a great
deal of practice and is difficult to master. This skill is
something I can use throughout my entire career to
improve the connection I can make with my patients.
A ceremonial funeral wreath.
June 2014.
Cultural Experiences.
This observership at CMC was incredibly rewarding and rich
because it was a very immersive experience. As such, I was
able to experience the culture in a way that was real and
immediate. I did not visit CMC as a tourist. I was a part of the
culture and the way people lived. I ate the same food, used
the same transportation, went to the same stores, wore the
same clothes and haggled for my rickshaw rides like any
student at CMC would. I saw how
people lived, and I was welcomed
into their homes. I saw and the
challenges and benefits of life in India
first hand. It was incredible to
experience the culture of India this way,
and I feel it would never have been
possible by simply visiting.
A brightly painted house in a village. June 2014
.
Works Cited
Chang, M., Pricipal, A., Aitken, M., & Backliwal, A. Understanding Healthcare Access in India: What is the current state?.
IMS Institute for Healthcare Informatics, 1-46.
http://www.imshealth.com/deployedfiles/imshealth/Global/Content/Corporate/IMS%20Institute/India/Understanding_He
althcare_Access_in_India.pdf
Ghosh S. ,Health sector reforms and changes in prevalence of untreated morbidity, choice of healthcare providers
among the poor and rural population in India. Int J Health Policy Manag. 2014 Apr 2;2(3):125-30. doi:
10.15171/ijhpm.2014.32. eCollection 2014 Apr. PMID:24757689 [PubMed]
Central PMCID: PMC3893075.
Gill, J., & Taylor, D. Health and Healthcare in India. UCL School of Pharmacy, 1-36.
http://www.ucl.ac.uk/pharmacy/documents/news_docs/healthcareinindiajuly2013
India Facts. National Geographic. 2014. Retrieved from http://travel.nationalgeographic.com/travel/countries/india-facts/
Jagnoor J, Suraweera W, Keay L, Ivers RQ, Thakur J, Jha P. Unintentional injury mortality in India, 2005: nationally
representative mortality survey of 1.1 million homes ; Million Death Study Collaborators.
Jehani, B. Where the outlook is healthy. Crisil Reseach, The Hindu. 2012, June.
Narayan L. Addressing language barriers to healthcare in India. Natl Med J
India. 2013 Jul-Aug;26(4):236-8. PubMed PMID: 24758452.
Montgomery AL, Ram U, Kumar R, Jha P; Million Death Study Collaborators.
Maternal mortality in India: causes and healthcare service use based on a
nationally representative survey. PLoS One. 2014 Jan 15;9(1):e83331. doi:
10.1371/journal.pone.0083331. eCollection 2014. PubMed PMID: 24454701; PubMed