On Wednesday, the Supreme Court of India spoke about a big digital divide in the country that might hinder vaccination drive. The apex court was talking of the rural-urban digital divide while adjudicating on the Covaxin policy of the Union government. It quoted the data of the NSO (National Statistical Office) survey of 2018 that said that only four per cent of rural households and 23 per cent of urban households possessed a computer.
India indeed has to cover a long distance. Internet penetration, availability and use of mobiles, affordability, etc, would be crucial factors that would determine the government policy on vaccination of all adults by the end of 2021. I do not doubt that the government is working overtime to plug the gap and use the huge infrastructure it has to make this Herculean task possible.
Meanwhile, the observation of the apex Court throws up the larger issue of the urban-rural divide which needs to be discussed and studied. The current debate in the media on this divide appears as if they have discovered something new. A narrative is being built that the Co-win app that mandates registration of beneficiaries of vaccination was actually a tool to favour the haves over the have-nots. This is not true. The flip side is that the debate has allowed us to talk of other issues concerning the divide in this country which the government has been trying to bridge.
Nearly, 65 per cent of the Indian population live in rural areas. And migration to cities for better jobs, since agriculture cannot sustain the huge labour force, is happening at a rapid scale. Former President late A.P.J. Abdul Kalam gave the PURA (Providing Urban Facilities in Rural Areas) vision to check this migration and make life more wholesome for people living in rural areas.
Most people in rural areas live a life of deprivation and not glory, contrary to a heavenly picture depicted in movies and folklores. They do not have gainful employment, entertainment, or other systems that make life more meaningful. Every day is not a new day, but the same old dreary drudgery of the previous days.
India has 741 districts and close to 6.64 lakh villages. Some of the villages are very remote and the only way for the government to reach there is the vast network of the administrative structure. This is used to implement any government programme whether it is free ration or other programmes concerning the poverty alleviation.
The delivery system indeed suffered due to corruption and we are all aware of the honest confession of late Prime Minister Rajiv Gandhi who said in 1985 that only 15 paisa of the rupee sent by the government reaches the intended beneficiaries. Urban bred cultured people were pocketing the money meant for the poor.
This was happening even for employment provided by the Union Government under MNREGA (Mahatma Gandhi National Rural Employment Act). The much-needed JAM (Jan Dhan Yojana account, linking the accounts with Aadhar Card and SMS through Mobile) has ensured that workers get their wages in time and also that they received the messages on their mobiles. Close to 14.17 crore workers are registered in MNREGA and are getting the wages transferred directly into their accounts. Who lost in this process is not difficult to guess- the middlemen.
There was a big divide in terms of access to the banking system. As of March 2021, 42 crore accounts were opened under Jan Dhan Yojana. When Prime Minister Narendra Modi had announced access to the banking system for all, the country had about 40 per cent of people outside the banking system and they depended mostly on money lenders for their needs. More than 80 per cent of Indians are now linked to the banking system.
There was a big divide in the country in terms of access to toilets. Before the Modi government came to power, only about 40 per cent of people had access to a household toilet. In five years, the government built 11 crore toilets and bridged this divide. There was a divide based on the use of cooking gas in the kitchen. More than 80 million gas connections have been provided and an additional 10 million is the target for 2021. This is having a tremendous positive impact on the healthcare of women who suffered due to poisonous smoke. This also polluted the environment and endangered community health.
There is a big divide in terms of access to quality education. Private education is unaffordable and government schools are not efficient. Those educated in English medium schools are becoming part of the ruling elite and those from government schools try to adjust to whatever positions they get in society. The New Education Policy is seeking to redefine the horizon and increase accessibility to quality education.
Setting up of 5,000 Atal Tinkering Labs, seven IITs, seven IIMs, 14 IIITs, one NIT, and four NIDs shows the vision of the Prime Minister. Twenty world-class Universities have been set up besides putting focus on empowering youths through imparting skill based education. Education of girl child has been given priority through incentivisation. The education divide is too big, but the country is moving closer to one syllabus and quality education. Since education comes under respective states, a focused approach is needed to make government schools more enviable and productive.
Let us now try to see the situation on health infrastructure. There is a network of about 200,000 Primacy Health Centres in the country including both urban and rural areas. A full understanding of healthcare facilities is a must to understand this divide.
At the lowest level is the Sub Centre that caters to the population of 5000 in plain areas and 3500 in hilly, tribal or difficult areas. Each centre is manned by one Auxiliary Nurse Midwife (ANM) /Female Health Worker (FHW) and one Male Health Worker (MHW). One lady Health Visitor (LHV) supervises six Sub Centres. The Union Government pays the salary of ANM and LHV while the salary of the Male Health Worker is borne by the State governments.
Imagine one ANM catering to a population of 5000 people spread over many villages whose population ranges from 500 to 1500. And these ANMs are not medical experts but know merely to give an injection in times of need, can help in child-birth, and give a few standard medicines.
At the middle level is Primary Health Centre catering to a population of 30,000 in plain areas and 20,000 in tribal, hilly, or difficult areas. This is the first contact between the villagers and a Medical Officer. This is maintained by the state government under the Minimum Needs Programme (MNP).
The Medical Officer is supported by 14 paramedical and other staff. This is a referral unit for six sub centers and has 4-6 beds for patients. The services provided are curative and preventive medical care, and promotive and family welfare services.
The third level is Community Health Centre (CHS) for a population of 120,000 in plain areas and 80,000 in tribal, hilly and difficult areas. This is run by the State Government under the MNP. It serves as a referral Centre for four PHCs. Four medical specialists— Physician, Surgeon, Gynecologist, Pediatrician— supported by 21 paramedical staff. It has 30 beds for patients with one OT, X-Ray, Labour Room, and Laboratory.
Above this level are the First Referral Units (FRUs). A District Hospital, Sub-Divisional Hospital, CHC can be declared FRU if it meets criteria such as round-the-clock services for Emergency Obstetric Care, including surgical interventions like caesarean sections, New Born Care, and Blood Storage, Facility on a 24-hour basis.
In 2011, when India had a population of 121 crores, of which 68.84% lived in rural areas, the Sub Centres numbered 148,124, 23887PHCs, and 4809CHSs. A look at the availability of specialists spoke volumes about the system. There was a shortfall of 75% of Surgeons, 65.9% of Obstetricians and Gynecologists, 80.1% of Physicians, and 74.4% of Pediatricians. As of 31 March 2019, these numbers were 30,045 PHCs, 157,541 Sub Centres, 5335 CHCs, and 3204 FRUs respectively.
One can easily make out that the situation is not inspiring for anyone. Many critical ailments go untreated and many districts don’t have enough human resources to deliver healthcare services. The recent observation of the Supreme Court’s observation that even after 70 years of Independence the healthcare infrastructure of the country was not enough to cope with the present crisis should be seen in this context. The exact wordings were “the healthcare infrastructure inherited over past 70 years was not sufficient and the situation was grim.”
It is in this context that the Modi government launched the Ayushman Bharat Programme in 2018 that sought to strengthen the medical system and also provide insurance cover of Rs 5 lakh per year for free treatment to 50 crore poor people or 10 crore poor families that cannot afford critical medical care. By the beginning of 2021, more than 1.8 crore people had used the scheme.
Besides this, the government has already launched the process of establishing Health and Wellness Centres (HWCs) to give primary healthcare facilities to the entire population. The target is to make the existing 150,000 primary healthcare facilities in rural areas fully functional and responsive. By March 2021, already 70,000 HWCs had achieved this feat and more than 410 million people had utilised the facilities.
We must not forget that the decision to have six more AIIMS was taken by the first BJP government at the Centre under late Atal Bihari Vajpayee. The United Progressive Alliance under the Congress added just one more to this number, and the Modi Government decided to open 14 more. The Modi Government also decided to open 157 Medical colleges to handle the huge shortage of MBBS doctors. More than 30,000 seats for MBBS and 24,000 for MDs have been added already.
The WHO norm is one MBBS doctor per 1000 population. Even in national capital Delhi, this ration is one doctor for 2203 people. The situation in other states is: Bihar 1:28,392, Uttar Pradesh (19,962) and Jharkhand (18,518).
The focus on AYUSH (Ayurveda, Yoga, Unani. Siddha, and Homeopathy) should be seen in this context. Never before such a comprehensive thought was given to strengthen healthcare. The focus here in Ayush ministry is keeping people healthy and fit so that they do not need medical treatment. The traditional Indian system of treating ailments has proved its worth and hence must be strengthened not despised. Many of these doctors are much better trained than the quacks operating in the name of doctors.
The Covid-19 crisis exposed the inabilities of the system and the government focused on working faster on this. Union Finance Minister Nirmala Sitharaman announced 137 per cent increase in the health budget of 2021-2022 presented in February. The new allocation was Rs 2,23,846 crore in place of Rs 94,000 crore in the budgetary estimate of the previous year. This includes Rs 35,000 crore earmarked for Covid vaccination.
Considering that India spends just over one per cent of the GDP on healthcare, the Modi government has aimed to increase this expense to at least 2.5 per cent by 2025, which means almost double. This would pale in comparison to what other countries spend on their healthcare such as the United States (16%), UK, Australia (9 per cent), and France, Germany, and Japan (close to 10 per cent). Even Pakistan and Bangladesh spent close to 3 per cent. A direction to set right the mistakes of the past is being set in motion now.
It is in this context that the talk of the digital divide and correct assessment should be made on the abilities of the Government to achieve the vaccination target. As per the statement of Union Minister Sanjay Dhotre in Lok Sabha on 10 February 2021, 37,439 villages (as per the 2011 census) in India did not have internet coverage. This figure was based on data from Telecom Service providers in 2020. Also, about 33 per cent villages of these fell in just two States- Odisha (8,947) and Arunachal Pradesh (3,343).
The number of smartphone users in India was expected to touch 76 crore in 2021. Even in rural areas, people are often seen using smartphones. Those beneficiaries of Government schemes are definitely connected through JAM. Hence the situation is not as dismal as it may appear. Four people can register through a mobile number. And there is administration, local elected representatives, and NGOs too keen to be a part of the programme.
And it goes without saying that where registration through mobile is not possible the traditional system would be used. The existing infrastructure of manpower that exists would be useful to educate as well as assist in this vaccination drive. The divide is there but the Government has the mechanism to implement any such policy whether SBA or Ujjwala Mission or vaccination.
The writer is convener of the Media Relations Department of the BJP and represents the party as a spokesperson on TV debates. He has authored the book ‘Narendra Modi: The Game Changer’. The views expressed are personal.