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Challenges of Rural Healthcare

Rural India, Healthcare Infrastructure, Human Behavior, Prabuddha Gram

In collaboration with office of Principal Scientific Advisor to GOI, Invest India Office, and Bharat Forge Ltd.

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Office of the Principal Scientific Adviser
to the Government of India

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Under Prabuddha Gram Yojana, We did the design research to point towards the underlying challenges and insights about rural health behavior and solutions for immediate effect and long-term directions

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Prabuddha Gram Initiative 

AN INTEGRATED VILLAGE DEVELOPMENT SCHEME, ENVISAGED TO BE IMPLEMENTED THROUGH AN INTER-MINISTERIAL COLLABORATIVE FRAMEWORK.

Leading academic and research institutions are chosen to support ministries in the planning and implementation of this initiative.

The National Institute of Design is one of these privileged research institutions, and the students of Strategic Design Management pursuing masters at the National Institute of Design have been involved in the study of the Challenges in Rural Healthcare in the context of Prabuddh Gram. 

 

Rural Healthcare is one of the 9 focus areas of the Prabuddh Gram Initiative. It is the central pillar of the rural society and economy hence it is needed to be understood at a behavioral level to get deep insights that help to establish a robust and empathetic healthcare system.

Road
Planning

Village 
Architecture 

Integrated smart transport system

Waste Management

Healthcare

Sustainable water and energy utilization

Agriculture

Education

Local Craft and culture

Atrauliya Block,

Azamgarh District

 

Population: 900+

M/ F Ratio: 1000:962

Literacy: 59%

Atrauliya CHC:   2KM

Bihura, Uttar Pradesh

Bhiura is a peri-urban village, located on the Gorakhpur link expressway (under construction) - starting from the Poorvanchal expressway near Azamgarh and ending at the city bypass of Gorakhpur.

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Bihura, Uttar Pradesh

Telwa, Bihar

Narayana, Rajasthan

Daula, Haryana

Belagal, Karnataka 

Key location of selected villages under
Prabuddha Gram initiative

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we began with the research methodology towards understanding the people and their behavior towards healthcare in general

.01

SECONDARY RESEARCH

The research started with studying the information already available in secondary sources like newspaper articles, ground reports, official documents, etc. to understand the current scenario of rural healthcare.

.02

PILOT STUDY

A few assumptions and hypotheses were drawn according to this secondary research. A pilot study was then conducted in a nearby village to check if these assumptions were right or wrong and to further understand the ground reality in rural areas. Tools used for the study were the sub-center observation Method and Semi-Structured Interviews.

.03

OBSERVATIONAL STUDY

To gather more reliable insights by capturing instances/ data on what participants do as opposed to what they say they do.

.04

SEMI-STRUCTURED
INTERVIEWS 

This method opted to draw out more specific inferences by asking repeated follow-up questions. Leading with open-ended questions which are questions that can't be answered with a simple "yes" or "no."

.05

GROUP DISCUSSION

It is a systematic exchange of information, views, and opinions about a topic, problem, issue, or situation among the members of a group who share some common objectives and social setting.

.06

OBSERVE, THINK
& WONDER

The Observe-Think-Wonder strategy is an artful thinking routine from Harvard's Project Zero. The purpose of this routine is to allow students time to thoughtfully consider not only what they’re observing, but also what those observations mean.

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ARTIFACT ANALYSIS 

A process to better understand how prescribed medicine is being used by its users and the culture in which it typically exists. It also serves as an opportunity for us to systematically generate insights and inspiration for future product/service designs.

RESEARCH FLOW

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Secondary Research

Mapping Problem
Areas

Pilot Study

Analysis

Primary Research

Analysis

Insights

Design Direction

Understanding the rural healthcare function, structure etc. with understanding the demographic of particular village.

Finding the directions for research to make appropriate assumptions and hypothesis.

Studying similar village as pilot study via on ground visit.

Analyzing Pilot Observations to create directions for Primary Research.

Visiting Bihura village to study and gather information for making meaningful research.

Aggregating and analyzing data obtained from primary research.

Integrating and disintegrating inferences to form insights.

Leveraging the insights to create meaningful product and services.

Did you know 

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In India, on an average, a government doctor attends to 11,082 people, more than 10 times than what the WHO recommends (1:1000)

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PHCs in India have only one doctor while about 5% have none

UP

emerged the worst performers, with less than five per cent PHCs following the norms

Distribution of services as per population density

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Up to 1000
Population 

5 to 6 villages

30 to 40 villages

Caters up to 100
villages

Village Level

Sub-centers (SC) delivery/ Antenatal 

Primary
Health System (PHC)

Community
Health
System (CHC)

Comprehensive emergency obstetric and newborn care (CEmONC)

Basic emergency obstetric and newborn care (BEmONC)

1-2 Auxillary Nurse Wife (ANW),
1 Male Multi Purpose Worker (MPW)

ASWA/ AWW/ Community Based Organization/ Women's Group

ANM: Auxiliary Nurse Midwife        ASHA: Accredited Social Health Activist      CHC: Community Health Center       PHC: Primary Health Center       SC: Sub Center

Distribution of Health Centers

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Community
Health
Center (CHC)

Each district have 01 CHC with 30 bedded facility

It serves as a referral center for 4 PHCs and also provides facilities for obstetric care and specialist consultations

Primary
Health
Center (PHC)

Referral Unit for 6 sub-centers, 4-6 Bedded, Manned with 1 Medical Officer and 14 Subordinate Paramedical Staf

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Sub
Center (SC)

Each PHC have 06 SC 

 

The primary point of contact, easy to access, Manned with 1 Auxiliary Nurse Midwifery and 1 Multi-Purpose Health Worker (M/ F)

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Role of
ASHA & ANM

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ASHA

Register and cares for pre/ post-natal mothers at home

Maintain records of all the services like birth and death

Register and follow all eligible couples, carryout family planning services and distribute preventives like condoms and contraceptive

Provide immunization and nutritional advice to mother and children

Provide treatment of minor ailments 

Spread awareness about communicable diseases 

ASHA

Mobilize community and facilitate in accessing health and health related services

Counselling of birth preparedness, escort for institutional delivery, antenatal care, immunization, family planning

Organization of VHND promotion of household toilets

Detection referral confirmation, registration of cases like malaria, TB, leprosy, RTI/STI

Depot holder of drugs such as ORS, IFA, Chloroquine disposable delivery kit, oral pills and condams

Survey of health and related events

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Some of the key findings of secondary research helped us to make assumptions and hypothesis for pilot study further

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COVID AND
VACCINATION

Covid-19 Vaccine Hesitancy: Believing vaccination leads to death.

Rural people trust alternative unauthorized healthcare providers and feel they are immune to diseases.

People deny, stigmatize Covid-19 Positivity and are ignorant towards prevention & medication.

See tangible as treatment for diseases.

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HEALTHCARE

Lack of commitment to the healthcare process awareness towards health investment.

Males make quick decision on health compared to women.

Vaccine Preventable Diseases is placed in less priority zone until it's too late.

Unavailability of functioning healthcare centers near by, travel long distances to get a proper healthcare treatment.

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DOCTORS AND WORKERS

Low Doctors to Patient Ratio. (India is 1:1456 against the WHO recommendation of 1:1000) 1:19962 in UP.

Shortage of Human resources.

Health workers lack rural/cultural sensitivity.

Healthcare providers are hesitant to work in rural areas.

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MEDIA

Information flows through unorganized channels in Rural areas.

Lack of information and awareness about Covid-19.

Word of mouth, Key tool for Misinformation spreading.

System and Technology are not designed keeping the Rural people in mind.

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BALANCE DIET AND HEALTH

Lack of a balanced diet: Low availability and Management of nutritious food.

Labor intensive work in harsh conditions.

To familiarize ourselves with rural context we did
pilot study  

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Unnao District

Samadha Village,
Unnao District, Uttar Pradesh

Population Size: 1500 +

Total No. of Houses: 317

Total Literacy Rate: 56.8% Approx.

We used Observational and Semi-structured Interviews with People, Officials, Locals and other staffs to underline key observations

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AWARENESS 

Villagers consider posters and banners as an ineffective and an age old way of awareness and communication, instead TV, social media, newspaper are considered to be a better source of information

People believe there is a difference between Urban area Covid vaccines and Rural area Covid vaccines.

Villagers were reluctant to take medicines which were given during health campaigns.

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HEALTHCARE
SERVICES

For past 10 years, Sub-Center was opened only for Vaccination of Kids by ANM.

Both Sub Center and CHC was not maintained well. Damages on wall, algae, dampness and discarded equipment was clearly visible. Very few patients were seen at CHC.

Government medical staff expressed their reluctance towards working in a Rural setup.

ASHA workers were considered for maternity and child care only.

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ECONOMY

Villagers gave first preference to over the counter medicines for any health related problem rather consulting a doctor.

CHC was 1.8Km away from the village, still people rushed to private facilities during night time emergency which were more than 5Km away from the village.

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ENVIORNMENT 

Drainage channels were present at some parts of the village and grey water was being directed towards ponds.

Accumulation of garbage all around the village. No government cleaning/ cleanup facility found in near vicinity.

Most of the toilets were built in front of their homes and were left abandoned or used them as storage rooms.

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To analyze the context of the Prabuddh Gram village: Bhiura, an on-ground Primary Research was conducted

Two students from NID stayed near the village for 3 Days to conduct an Observational Study of the Village, Community Health Center, and nearby market areas where chemists/ pharmacists were located. Personal Interviews and Group Discussions with Kids, Young Adults, and Elders were conducted to get deeper insights regarding their general awareness, health belief, approach towards illnesses and diseases, preventive measures, and general outlook towards the village environment

Key Actions:

Medical workers and Doctors at CHC were also interviewed and observed in uncontrolled natural working conditions to get more insights into their behavior towards patients, fellow medical staff, other staff members, equipment, and infrastructure

CHC infrastructure was closely observed in terms of facilities provided to both patients and medical staff members, spatial arrangements, maintenance, the flow of services, and ambiance.

One of the students also acted as a self-participatory patient to generate more insights into the Rural Healthcare system.

Management of patients and processes during Covid-19 vaccination day was also observed to identify gaps in the service and get a better understanding of the patient’s journey

Observational Study started with first
Community Health Center (CHC) at Atraulia Block

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Key Findings:

Doctors, nurses and other medical staffs were not in their uniforms.

Doctors were diagnosing patients casually. Patients felt they're not diagnosed properly

The layout was confusing and visible modifications were seen based on requirements which were creating further problems and confusion

It was observed that some doctors saw multiple patients during consultation

Medicine dispensary at
the CHC Atrauliya

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Pharmacist checks Patient's slip

Pharmacist gives medicines

Pharmacist orally gives instructions

Some medicines fell from patient's grip and he tries to pick them up

Patient asks for another medicine

Patient patiently waits

Patient takes them

Patient checks the medicines

Pharmacist gives him

Pharmacist didn't reach out to help the patient

Key Findings:

Medicines were given loosely in hand and instruction of doses were given orally

Lack of proper medicine storage facility and dispensing window

Lack of empathy towards rural patients considering their anxiety and unawareness towards Rural Healthcare

Vaccine registration & vaccination process
at the CHC Atrauliya

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Key Findings:

There was no temperature screening or mask vigilance at CHC. Some patients were not using mask/ not wearing them properly

Registration process differ from first time of dose vaccination and second dose, this enough created confusion over the what step should be followed 

Long waiting ques for an our at registration desk made misinformed and lost

No special category lines were introduced for any of the old age, women's etc.

We conducted a drawing/ art exercise
at bihura village with kids (06- 16 Yrs.)

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Key Findings:

Observe 

School infrastructure with toilet, banyan tree and school building is made where a man can be seen taking oxygen from the tree

Emphasis is given to cleanliness and dustbin in the drawings

Kids were fully aware of toilets and it's significance, relationship with cleanliness and hygiene

Kids drew villagers in cleaning effort signifying its cohesive importance towards hygiene

Think

Kids are aware of the fact that tree are the major source of oxygen and its very important for a clean environment

Kids understand the importance of how small step towards cleanliness can make country great

Kids understand importance of cleanliness and placement of dustbin in their house

Kids understand importance of using toilets and associate it with clean village

Wonder

Though kids believe in cleanliness still nobody takes initiative to keep village clean

Kids are aware of Dustbins and waste production, yet non of them use/ have a dustbin at home

Many households lack proper toilet and kids also defecate in open. Why kids don't ask/ demand a toilet or discuss it's importance with their parents?

Photography & Selfie experiment
with youth (17- 22 Yrs.)

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Key Findings:

Straw is generally considered as waste so in any case of damage/ deformity, it might get disowned very easily

No waste segregation & collection system or waste management system

Seeing cow dung kept openly is an unsightly experience for the respondent

The respondents were aware of water pits as disease breeding grounds but collective responsibility was missing

Artifact analysis of
prescriptions & medicines

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Key Findings:

Poor maintenance of storing medicines and slips, generally locals doesn't have government hospitals provided medical prescriptions safe with them

Locals belief since government facilities are free and usually in deteriorating conditions, the medical facility are not trustworthy 

People prefer to consume medicines from private health institutions because of shortage and delay in government hospitals

One resident kept safe a prescription without any name and contact of doctor

Night hall in the village
with focused group discussions

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Group discussion 

  • 18 Males and 15 Females

  • Age group between 30 to 60

  • Time 2 Hours

  • Moderators : Amit, Shubham

Key area discussed 

  • Medicine & Vaccine

  • Infrastructure

  • Staff Behavior

  • Connectivity

  • Quality of care.

Key Findings:

People were feel lost while wearing a mask and perceive them as an obstacle between freedom and social image inside the village

People do not use proper First Aid due to a lack of resources and awareness. They tend to leave cuts/ wounds and animal bites in the open as they believe it will heal faster if it’s dry. Tetanus injections are a far cry as there’s no sub-center in the village

The masks they get/ purchase in the hospitals/ market have a hard time blending with their attire and becomes highlighted. Many women tend to cover their face with a saree as it blends in the social context of the village and somehow acts as a preventive measure

Preventive measures are positioned with a factor of fear to gain more impact but people in the village tend to reject them as having fear in a social scene is a display of cowardice for the villagers

Analysis: Tree mapping with respect to Health Belief Model

The Health Belief Model is a social- psychological health behavior change model developed to explain and predict health-related behaviors, particularly in regard to the uptake of health services.

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Insights: for design direction
towards health belief and 
services 

01.

People in village tend to leave small cuts/ wounds/ animal bites without any treatment since they lack First Aid materials and awareness. This can lead to severe complications.

Opportunity Area

There is need to establish the value of First Aid treatment and make people aware about susceptible illnesses caused by small injuries, animal bites etc.

Design Direction

Medical pouch cum first aid kit for the rural people, where patients can put his/her medicines inside. Also, it is easy to carry, hold and highly durable "Khadi Pouch". 

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02.

People place higher subjective value and associate a sense of ownership with medicines & prescriptions received from private healthcare since they had paid a premium for the treatment resulting devaluing of prescription and medicines received from government healthcare facility as they cost only 1 rupee.

Opportunity Area

There is need to instigate a sense of ownership and value addition towards government provided prescription and medicines.

Design Direction

Medical pouch cum first aid kit for the rural people, where patients can put his/her medicines inside. Also, it is easy to carry, hold and highly durable "Khadi Pouch". 

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03.

Awareness programs fail to produce the desired optimal behavior because they are not propagated through proper channels and target specific age, gender and community.

Opportunity Area

There is an opportunity to design communication strategies defined by it's target audience and propagates through proper channels leaving no person/ kid behind.

Design Direction

Medical pouch cum first aid kit for the rural people, where patients can put his/her medicines inside. Also, it is easy to carry, hold and highly durable "Khadi Pouch". 

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04.

Due to no tangible Healthcare service touch points in the village tend to avoid consulting with ASHA/ ANM at their residence for Health related consultations because social stigma and shyness. This results in infrequent visit to Healthcare facilities and people become more susceptible to illnesses.

Opportunity Area

There is an opportunity to build an infrastructure which caters as a Sub Center-cum-Multi Utility Space, in order to externally trigger villagers to visit this place frequently. Gradually anchoring the need to seek Healthcare services via designed awareness programs.

Design Direction

Medical pouch cum first aid kit for the rural people, where patients can put his/her medicines inside. Also, it is easy to carry, hold and highly durable "Khadi Pouch". 

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05.

First-time mothers when compared to experienced mothers tend to visit CHC more often for health checkups (Antenatal Checkups) as they perceive it as an explorative and recreational activity.

Opportunity Area

There is a potential to tap into the Health Seeking Behavior of the mothers to spread more awareness and foster their trust and ownership towards state medical Healthcare facilities for

Design Direction

Medical pouch cum first aid kit for the rural people, where patients can put his/her medicines inside. Also, it is easy to carry, hold and highly durable "Khadi Pouch". 

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Report
Rural India, Healthcare Infrastructure, Human Behavior, Prabuddha Gram 

Project Mentor:
Prof. Jitendra Singh Rajput 

Team Member:
1. Amit Kumar
2. Kasturika Sonowal
3. Shubham Das
4. Udhayakumar V