How geography continues to shape health care access in Rajasthan

With India's rising burden of hypertension and diabetes, delayed detection is no longer an option. It is a necessity. Many people are only diagnosed after a stroke, heart attack, or kidney failure: the NPNCD program aimed to tackle this by screening adults closer to their homes, sooner. The aim is to reach the last mile and the last man.

However, ensuring this happens in practice is not just dependent on medical care, but is determined by geography, transport, awareness, and distance to care, especially in large, more rural states such as Rajasthan.

Rajasthan had planned and set up multi-sectoral convergence mechanisms for health, transport, and rural infrastructure departments to ensure timely transport for citizens requiring health care in distant and tough terrains. Yet challenges remain on the ground.

Rajasthan is the largest state in India, and geography determines everything about access to care. Covering 3.4 lakh square kilometres, the state has a population density of 200 people per square kilometre, less than half that of India as a whole. This reflects how scattered people are across the Thar desert, the Aravalli hills, and thousands of remote rural hamlets where basic travel is often a struggle.

In these terrains, where villages are far from one another, the nearest care may be at quite a distance. Large tribal districts in South Rajasthan have hilly and forested remote pockets, quite far from primary health centres, and the desert districts in the western part of Rajasthan see entire settlements often 20-30 kilometers from the nearest sub-centre.

For this reason, even though national guidelines mandate one PHC per 30,000 population (and one per 20,000 population in difficult terrains), in practice, Rajasthan creates PHCs for a population of 10,000-15,000.

Terrain is difficult, hamlets are isolated and far away, there is little transport available, and patients cannot be expected to travel far to receive basic care. In such circumstances, reaching even first contact care may be a long journey.

And yet, even while Rajasthan brings facilities closer to people, the challenge of distance remains. This is revealed in the state’s Community Health Centre (CHC) statistics: while 523 are required, 548 exist on paper, suggesting that they are more than sufficient at a population level.

But this masks the challenge of distribution; despite an overall adequate number of CHCs, in Rajasthan’s most remote areas, they are skewed and lacking. CHC shortages exceed 45 per cent in tribal districts, resulting in complete blocks without a functioning referral facility.

It is in these circumstances that distances traveled become immense: with most specialists posted in urban areas of Rajasthan, gynaecologists, surgeons and physicians may be accessed only after travelling 100-150 kilometres.

Even increasing the number of facilities, therefore, cannot overcome the challenge of distance when the terrain is so difficult and the distribution so skewed.

As difficult as Rajasthan’s geography is, the social terrain is just as challenging. Low literacy, especially among women, makes it even more difficult to reach care in time, since awareness, decision-making, and the courage to present at a facility depend heavily on education.

When health warning signs are not recognised, or when families do not know where to take a person with a certain health issue, care is delayed until a case becomes very serious. Moreover, women in most districts are hesitant to travel far alone, and families prefer to consult with lady doctors for female patients. Such awareness gaps are particularly concerning in the context of Rajasthan’s broken roads and transport networks.

And even if they are due to reach a tertiary centre within Rajasthan, rumors complicate the decision, simply, “Ahmedabad has better treatment,” and families that have pooled money to afford travel will bypass multiple closer tertiary hospitals.

Indeed, in Rajasthan’s referral hospitals, many patients are shifted out not because this is clinically necessary, but because fear and rumours trump faith in the public sector facility. These long journeys to reach care are determined by roads, rumors, and inequality. Hypertension cannot be prevented if the nearest facility is a day’s travel away.

Rajasthan has taken important steps to expand facilities and prioritise early NCD detection, indicating that the policy direction is sound. The next priority must be ensuring last-mile delivery through better distribution, transport, and community awareness.

(The author serves as additional professor of community medicine & family medicine at AIIMS Jodhpur, coordinator of the School of Public Health, and joint editor of the Indian Journal of Community Medicine)

The opinions expressed in this article are those of the author and do not purport to reflect the opinions or views of THE WEEK.