The public health service in India is poor. Besides this, regional imbalances in the distribution of healthcare facilities are immense. Human health has been a prime factor in the sustainable development of the society, irrespective of the developmental status. Like other developing countries, India struggles to provide adequate health care services and ensure their optimum utilization to the whole population. Many of the healthcare facilities, or for that matter, Primary Health Centre (PHC) are underused because of the poor services they provide, lack of accessibility, and willingness.
The population is considered very dynamic in terms of its spatial arrangement and distribution in the space along with its cultural and behavioural characteristics. Thus, accessibility to health can be expressed as people’s ability to use health services when they are in need, and the reachability of the healthcare services comes under the supply side variables such as population pressure and distance from the facility. Quick access to primary care can prevent the extraneous cost of health services as traveling time is the easiest measure of accessibility when public transport facilities are available. Keeping these facts in mind, the National Rural Health Mission (NRHM), as per the 12th Plan of the Planning Commission of India, aims to provide superior healthcare to the rural population, especially to the remote and most disadvantaged groups.
Most of the rural Indian population are from the low economic group and it is difficult for them to afford private healthcare services, therefore, most rural individuals travel to PHCs to meet their health needs. The use of GIS has provided researchers with the ability to employ varied methodological options to measure accessibility. In India, despite economic development, child and maternal morbidity remains a major concern. The Indian rural healthcare infrastructure is designed as a three-tier system, center (SC), primary health center (PHC), and community health center (CHC) (Ministry of Health and Family Welfare, 2012). SC being the most peripheral unit, is limited with minimal healthcare facilities, and therefore, people tend to turn to the PHC.
Institutional delivery is a necessary intervention to reduce delivery-related avoidable maternal and infant mortality (Moyer et al., 2013). Between 1990 and 2015, more than 10 million women died globally due to pregnancy and childbirth-related complications (Alkema et al., 2015). Globally, 2.6 million new-borns died in 2016, approximately 7,000 per day, and almost all (99%) of these potentially preventable deaths occurred in low- and middle-income countries (LMICs) (WHO 1990–2016). Pregnancy-related complications that lead to maternal mortality may occur during or shortly after childbirth. In LMICs, direct obstetric complications during childbirth were responsible for 70% of maternal deaths. Timely access to facility-based births saves the lives of many mothers and newborns (Ronsmans et al., 2002). In high-income countries, maternal mortality can be further reduced with increased rates of institutional delivery. The low usage of institutional delivery services in many low- and middle-income countries (LMICs) can be attributed to cultural concerns and geographical limitations that prevent women from obtaining services. As a result, women are more likely to give birth at home.
To ensure equitable and accessible institutional delivery services, identifying vulnerable groups and populations within countries is crucial so that customized interventions can be developed and delivered (Koblinsky et al., 1999).
Table 1
Data regarding Place of Delivery according to National Health & Family Survey 5 (2019-21).
Districts | Place of Delivery |
Non- Institutional | Institutional |
Dehradun | 3.44 | 96.56 |
Almora | 8.24 | 91.76 |
Uttarkashi | 11.15 | 88.85 |
Rudraprayag | 11.41 | 88.59 |
Tehri garhwal | 11.45 | 88.55 |
Pithoragarh | 11.65 | 88.35 |
Udham Singh nagar | 12.07 | 87.93 |
Garhwal | 16.03 | 83.97 |
Nainital | 17.38 | 82.62 |
Champawat | 17.58 | 82.42 |
Bageshwar | 17.66 | 82.34 |
Haridwar | 28.29 | 71.71 |
Chamoli | 29.03 | 70.97 |
Total | 15.48 | 84.52 |
However, we can figure out from the NFHS 5 data that Chamoli witnessed one of the lowest institutional delivery in Uttarakhand while Rudraprayag performed better although being a neighboring district and hilly in terrain. If compared with NFHS-4 data regarding Institutional delivery the dependency on private facilities has decreased significantly in both districts but a higher difference is seen in the Rudraprayag district. Both districts share a similar proportion of deliveries held in private institutions.
Table 2
Data regarding Place of Delivery according to NFHS 4 & 5 focusing on the deliveries held in public and private facilities.
| NFHS – 5 | NFHS-4 |
Non- Institutional | Institutional | Public | Private | Non- Institutional | Institutional | Public | Private |
Chamoli | 29.03 | 70.97 | 97.43 | 2.57 | 46.7 | 53.3 | 92.73 | 6.71 |
Rudraprayag | 11.41 | 88.59 | 97.03 | 2.97 | 33.49 | 66.51 | 89.88 | 10.12 |
Earlier studies in healthcare coverage and mapping
In the Indian context, there is a dearth of literature on this crucial topic, despite its policy significance.
Nevertheless, studies on equity in healthcare in low- and low-middle-income countries (LMICs) have been reviewed below. According to recent data, a number of these nations have improved healthcare access to lessen disparities in healthcare utilization. Due to expanded insurance coverage and primary healthcare, disparities in the use of inpatient and outpatient care have drastically decreased in China in recent years (Kumar, 2001). Yet another instance of a country where the health system has improved equity is Chile, where the implementation of the "health guarantee" strategy guaranteed citizens' access to healthcare for the majority of illnesses (President et al., 2009). Although the use of hospital care was more concentrated among the wealthier between 2001 and 2005, Thailand, the first non-OECD nation to adopt Universal Health Coverage (UHC), has also seen notable decreases in disparity in outpatient care use (Ã & Qi, 2009). However, a few countries are still lagging in achieving parity in healthcare utilization (Son, 2009) discovered that, despite having almost universal health insurance, the Philippines saw an increase in the disparity in the use of healthcare services from 1998 to 2007. Furthermore, (Mills et al., 2012) observed that while the burden of disease was higher for those with lower incomes, the distribution of healthcare service advantages favored wealthier persons in South Africa, Ghana, and Tanzania. India is not an anomaly. India is no different. According to (Weekly, P & Weekly, P 2016), disparities in healthcare access still exist but have grown more widespread throughout states. According to a different study on mother and child health services, India's use of these services continues to favor the wealthy.
Study area
The districts were selected with consideration for accessibility and spatial position, as both of them encompass a wide range of spatial characteristics, from densely populated areas to sparsely populated areas. The area features highly dispersed plateaus and hills due to the offshoots of hilly tracts covered in vegetation, as well as rugged and undulating terrain. A district in the Indian state of Uttarakhand is called Chamoli. The region is bordered to the north by Tibet, to the east by the districts of Pithoragarh and Bageshwar in Uttarakhand, to the south by Almora, to the southwest by Pauri Garhwal, to the west by Rudraprayag, and the northwest by Uttarkashi. Gopeshwar is home to the Chamoli district's administrative center. The District occupies an area of approximately 7,520 km³ (2,900 sq mi). 49 people are living in the district per square kilometer (130/sq mi). Between 2001 and 2011, its population increased at a pace of 5.6%. Chamoli has an 83.48% literacy rate and a sex ratio of 1021 females for every 1000 males. The populations of Scheduled Castes and Scheduled Tribes are 20.25% and 3.13%, respectively.
In the Indian state of Uttarakhand, the Rudraprayag district includes the cities and municipalities of Rudraprayag. Rudraprayag is the site where the Alaknanda and Mandakini rivers converge, one of the Panch Prayag (five confluences) of the Alaknanda River. Rudraprayag is situated 86 miles away from Kedarnath, a sacred Hindu city. It is 895 meters (2936 feet) above sea level on average. The population of Rudraprayag district is 242,285 (almost equivalent to the population of Vanuatu), according to the 2011 census. As a result, it is ranked 583rd out of 640 in India. 119 people are living in the district per square kilometer (310/sq mi). Between 2001 and 2011, the population growth rate was 4.14%. According to the 2011 census, Rudraprayag has the sixth-highest sex ratio in the nation, with 1120 girls for every 1000 males; the only place higher is Almora, which is also in Uttarakhand. Its literacy rate is 82.09%. The proportions of Scheduled Castes and Scheduled Tribes to the total population are 19.68% and 0.16%, respectively.