The current problems regarding health services faced by health care servants in rural Maharashtra: An onfield report

The current report deliberates the challenges encountered by the various sectors of healthcare workers while executing their services. The study is confined to Indian state of rural Maharashtra precisely involving the small town Masur and Karad city of Satara district. Here, we tried to better comprehend the daily problems confronted by the health workers while rendering their services especially in rural area. For the purpose we met with the various health workers including physician, nurse, blood bank founder, and the pharmacist. All of them highlighted the problems they dealt with while rendering their daily services and also emphasized on implications of covid 19 on their duties. Niti Ayog has already warned center regarding the possibility of third wave of covid 19 by the end of September 2021 with 4-5 lakhs daily cases. Indeed, this is alarming and may curtail current health care system. Taking into account the daily challenges confronted by the healthcare personals and possible damage by covid 19, the current heathcare system especially in rural Maharashtra need a substantial boost.


Introduction
India's healthcare situation seems to be at crossway, where there are some optimistic accomplishments on the health indicator, but agonizes some serious inadequacies in care delivery. Thusfar our country succeeded in polio eradication [1], managing tropical epidemics [2] and controlling HIV to significant extent [3]. Though, non-communicable diseases (NCDs) put an enormous economic encumbrance significantly affecting community health budgets. New strategies need to be devised in quest to strengthen healthcare supply and progress commercial prospects. Indeed, an insight from healthcare leaders can serve as a pillar in building future of healthy India. Amid the current efforts there are several obstacles in revolutionizing healthcare system in India. Some of these comprise poor accessibility to basic healthcare services, scarcity of medical recruits, quality assurance, and insufficient health outlay besides lack of research impetus.
Here it is necessary to realize that these challenges cannot be fixed by the government alone. The participation of private sectors is vital alongside government's effort. In this project we tried to understand the real challenges faced by the healthcare workers while executing their duties especially in rural area.

Methodology
The current project is a part of a continuous improvement program (startup cell) in collaboration with OpEx Accelerated Pvt. Ltd., Kolhapur, Maharashtra, India. The project involves an on field survelliance of the current problems faced by the heathcare servants in executing their services especially in rural areas of Maharashtra. For the purpose we visited different heath care workers in the specified area wherein they deliberated their experiences and challenges faced by them while executing their duties.

Geographical location
The surveillance was carried out within the boundaries of Masur and Karad. Masur is a small town in satara district and belongs to Maharashtra state, India. Geographically it is located at 17°24 ′ 0″ North and 74°10′ 0″ coordinates [4]. Karad is a taluka place in Satara district of Indian state of Maharashtra and is known for Krishna and Koyana river confluence, Preeti Sangam [5] and is located at 17° 28′ 59″ north and 74°12′ 0″ coordinates. Based on the Adhar estimate 2021 [6] the total population of Karad taluka is 618,183.

A visit to a doctor
In the quest to understand the current health care challenges faced by the rural medical practitioner we approached Government Hospital (Primary Health care center) of Masur on March 7, 2021. Theirin Dr. Lokhande (MBBS) explained us the problems faced by rural doctors in health care services.

A visit to a blood bank
We visited Mahalaxmi Blood Bank located at the back side of city police station Karad, on 3 March 2021. The purpose of the visit was to comprehend the problems regarding health services faced by all healthcare servants of blood Bank. Miss. Vina Vivek Dhapare (BSC, DMLT), the founder of the blood bank explained the various problems faced by blood bank servants while executing health services.

A visit to a retail Pharmacist
On 4th March 2021, we visited Kirti Medical, Warunji Phata Karad. The purpose of the visit was to understand problems regarding health services faced by Pharmacist. Mr. Sudhakar Jadhav, the owner of the firm, shed the light on the problems faced by pharmacist in health care services.

Discussion
Dr. Lokhande, the physician at government hospital, spoke at length regarding the challenges they confront while rendering the services to rural patient. Key excerpts during the discussion are as below. The Patient doesn't describe precisely about their sufferings. Some patients hide their actual condition from physician. So it's become difficult to physician to diagnose them. Moreoften patients don't follow the precautions given by doctors. For instance, don't eat oily food, drink only warm water, don't drive upon consumption of certain medications etc. Another concern is patient reluctance to specified dosage regime, as they do not take the medicines prescribed by doctor, on time or do not take it at all. Here, need of proper education and counselling of uneducated rural person is an utmost challenge for the physician. The physician has to explain a lot and that too in a simplified manner so that patient understand his illness and somehow get persuaded by the physician for a recommended therapy. Another but equally important concern the physician raised about was the caring of orphan patient. By definition orphan patients is one who has no primary service provider [7] or colloquially the one who has no family doctor [8]. In the rural healthcare set up to treat an orphan patient is an uphill task for physician, as there is no one to support the patient. If such a patient is suffering a severe accident, mental trauma or any grave illness they requires a great personal care. Similarly while rendering healthcare services to elderly patient and small children, rural health care system exhibits several limitations. This include availability of sophisticated medical instruments, oxygen beds, ventilators, ICUs, pediatricians and surgeons etc. at the health care systems. Also to note that small children and elderly patient are often nonresponsive to doctors guidelines. Economic status of patient is another barrier in the rural healthcare system. Patients with low income become more concerned /responsible about how to heal the disease at low cost. Similarly patients with altered psychology put tremendous pressure on in charge physician. In many circumstances, while executing general surgery in operation theaters, use of anesthesia is recommended. However large patients in the rural area are unresponsive to anesthesia owing to their daily alcohol and wine consumption. In this situation it is very difficult for physician to determine the right anesthetic dose for a patient.  Another concern physician experiences while rendering their services in rural area is the trend of over the counter (OTC) drug. Rural persons mostly being low educated and due to the fear of physician prefer to purchase OTC medicine.
Though by doing so they are not only risking their life but put an added pressure on the physician in case of any adverse reactions. In this regard physician need to search patient's history of medicines, his allergies towards certain medications etc. Fig. 1 & 2 depicts the pictures of visited government hospital.
Miss Shabana deliberated several challenges faced by the nursing personal while executing their role in health care. These challenges are summarized in Fig.3. As per her experience the workload on the nursing personal has surged manifold. Shortage of working professional and the reluctance of the governing bodies in filling up the existing vacancies further add to their plight. Post covid era has certainly witnessed the significance of nursing services. Despite their excellent contribution in serving humanity during the covid period they were often deprived of appreciations and even struggled for remuneration. Besides, during this period they are often imposed with various non-nursing roles substantiating the lack of synchronicity in workflow.

Figure 3
Challenges confronted by nursing personal.

Miss. Vina
Vivek Dhapare highlighted several issues faced by blood bank personal while executing their services. Few excerpts from the discussion are as follows. First of all, people refuse to donate blood due to some intrinsic fear. They come to understand that after donating blood, they will feel weak, or may get sick. This misconceptions need to be dispelled. Some blood donors don't tell servants before donating blood that they are suffering from any disease. Some blood donors do not tell servants before blood donating that they have tattoo on their body and it has not been six months of inscription. This influences blood clotting and other blood tests. Besides, the consent forms given by each blood donors before donating need to be filled carefully. Many a times donor do not reveal their past illness and medication history. This may lead to lots of problems while performing various tests such as HBCG, HBC, LIG, HB, RBC counting, and WBC counting. Similarly the donor should also inform the attending personal about any surgery or operation he has undergone in last 6 months. Ironically, the founder of blood bank also pointed out the tendency of people in spreading rumors such as blood is being misused and black marketed in a blood bank. Such baseless rumors should be stopped else it may eventually let down the reputation of blood bank. Another aspect she highlighted was about the storage of rare blood group like "O -Ve" for the emergency cases. Fig. 4 depicts the working process in the blood bank.
Mr. Sudhakar Jadhav, a retail pharmacist put forth his experience and challenges while executing his services. Fig 5  depicts the view of visited retail pharmacy.
As per his experience, an elderly patients need a frequent verbal advice regarding dose and its frequency of medication owing to their poor sight and low hearing capacity. Another concern while executing pharmacy services is education of patient. Most of rural patient are either illiterate or low educated and often require a proper counselling while dispensing a medication for them. Pharmacist may even confront the situation wherein the needy patient ask him for OTC medicine without a money. In other cases patient do ask medicines effective in diabetes, hypertension, sexual dysfunctioning etc without prescription. Here the role of pharmacist become prominent to educate and counsel them properly about the use of medication. Beside the pharmacist has to keep eye on his business development and financial maintenance for future challenges.

Summary and perspectives
By and large, health care system in the rural areas of Indian state of Maharashtra still remains in infancy and need a strong boost from the governing bodies to cope the current challenges. Different healthcare works faces different challenges and at different levels. The emergence of covid had adversely affected the aleady weakened healthcare systems particularly in rural Maharashtra. This can be witnessed by constant surge in covid cases and mortality rate in the rural Maharashtra over the past few months. Upon meeting with different healthcare workers, it is clear that covid 19 only added to their plight which they were already in while executing health services in rural Maharashtra. The huge vacancies in the health care system actually rendered a tremendous pressure on working health professionals. At point they have to risk their own life while treating a patient. Most of patient from rural Maharashtra are either noneducated or low educated. This further worsen the scenario as such patient remains unresponsive to physician guidelines due to their ignorance or lack of knowledge. Here lies an opportunity to governing bodies to practice a new school of thought by opening up a mobile health informative services especially to rural areas. This will not only aware the patient about his health but also lessen the burden of attending physician. Unemployment in the rural areas is another concern where governing bodies should look up to. Since the socioeconomic of the patient is ultimate determinant of quality of healthcare services he is going to get. Nursing is a noble profession serving humanity. It should receive appreciation for its services. However nursing personals have their own challenges while rendering services. Current covid crisis and shortage of nursing professional has perturbed health care system immensely. To meet the need of hour the nursing professional has to work day in and day out. Moreover while doing their duties they are exposed to huge bioburden and there are chances of opportunistic and nosocomial infection staking their lives. Here there is need to lessen their burden by recruiting more nursing personals and at the same time assuring their life with insurance. Covid crisis has seen a tremendous shortage of blood availability in the blood bank. However, at the blood bank, working persons has their own challenges like counseling, educating and persuading the blood donor. Besides several donor do not reveal their past medication history, surgery, or body tattoo which eventually compels the personal in the blood bank to withdraw his blood. In this regard a proper educational initiatives need to be taken so that the blood donor should aware of the effect of surgery, antibiotics, or any other mediation they recently used. In addition to this there is need to set up a fully functional blood bank to rural areas else the patient from such place has no choice than travelling to nearby city. From the retail pharmacist perspective delivering medicine to older people is often challenging owing to their poor vision & poor capacity of hearing. Economically compromised patient often put pharmacist in dilemma by asking cheap OTC medication for which perception is not needed. In such a situation it's become a duty of pharmacist to educate the patient about the medication given to him. Apart from the daily defies confronted by the healthcare workers an additional burden of covid 19 has inflicted them deeply while executing their services. Moreover, recently Neeti Ayog has warned the Indian government regarding the surge of third wave of covid -19 by the end of September 2021 accounting 4-5 lakh daily cases [9]. It's truly alarming and strongly demands for an adequate manpower, infrastructures, sophisticated primary health centers, availability of oxygen beds, ventilators etc. More care should be executed at rural areas owing to its low literacy rate, different life styles, and a myriad ignorance about the covid implications. In this regard a functional advisory is very crucial. Rural education and training centers need to be set up to impart the villagers with the basic knowledge of health and its maintenance.

Conclusion
This work provides a glimpse of the daily problems faced by the heathcare servants while executing their duties especially in rural Maharashtra. Rural health care system need to be reformed to meet the current expectations of the health workers and the patients. To this to happen local governing bodies should implement certain policies to ensure a robust healthcare system capable of withstanding any future calamities. This may include filling all the vacancies in health care sectors, setting up health clinics and education centers across the state and the rural territory, encouraging the drug manufacturing companies for constant supply of healthcare products, providing the grants to new startups in health sector particularly in rural areas etc. This will not only revolutionize the current healthcare practices but also assist to burden off undue challenges faced by health professionals while executing their duties.

Acknowledgments
Authors wish to acknowledge OpEx Accelerated Pvt. Ltd., Kolhapur for their collaboration for this project under Continuous Improvement Program (Startup Cell).

Disclosure of conflict of interest
The author declares no conflict of interest.

Statement of informed consent
Informed consent was obtained from all individual participants included in the study.