10/10/2018 Approaching the Unreached through Mobile Medical Units

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Approaching the Unreached through Mobile Medical Units

Achla Khanna ,  Achla Khanna, Scientist, Technology Information, Forecasting and Assessment Council (TIFAC),
Department of Science and Technology

India’s healthcare system could be bettered with an increase in expenditure on healthcare,

human resources and innovative interventions. Currently, rural areas in India have limited
access to healthcare facilities. In order to combat this, Mobile Medical Units (MMUs) were
introduced. Factors which need to considered when deciding whether to use MMUs are
geographic-demographic facts and whether MMUs will be compatible with healthcare needs
in the area. Should MMUs be determined to be useful, studies should be conducted to assess
the cost-bene t ratio. Studies should also be conducted to analyse the impacts of existing
MMUs.

Background

Although India’s healthcare system has gradually improved over the past few decades, there still remains scope to
bring it at par with neighbouring countries which have a better healthcare system in terms of accessibility,
affordability and quality. The poor state of healthcare in India is attributed to the heavy burden of patients, lack of
medicines and equipment and not so enough of government funding of healthcare initiatives, leading to high out
of pocket expenditure. As recommended by World Health Organization (WHO)(1)  the accepted norm for public
spending on healthcare is 2.5-5.0 per cent of GDP, whereas India’s public healthcare funding remains at 1.2 per
cent of GDP in the year 2017-18. In fact the National Health Policy, 2017 of India has one of its objective to
enhance health expenditure by government to 2.5 percentage of GDP by 2025.

However, there is yet another aspect which needs to be further investigated. There are many low income
countries, such as Bangladesh, that have lower Infant Mortality Rates (IMR) than India does, despite their lower
public spending on healthcare, which indicates that it’s not merely the number which matters. Government
healthcare spending in India could be more effective if larger fund allocation for healthcare are supplemented
with effective and innovative interventions which aim to accomplish global standards speci cally in rural and
inaccessible areas.

Rural Healthcare system in India

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An astounding 70 per cent or nearly two-thirds of the population in India still resides in rural areas and has no
access or limited access to hospitals or clinics. Around 80 per cent of specialists serve in urban areas.The national
norms for a three level rural primary healthcare system (Figure 1) consisting of the Sub-Centre (SC), Primary
Health Centre (PHC) and the Community Health Centre (CHC) had evolved during the Sixth Five Year Plan and as
a result, major expansion of rural healthcare infrastructure was seen during the Sixth and the Seventh Plans.The
Eighth Plan focused on strengthening existing healthcare infrastructure to better the quality and  the outreach
services and the Ninth Plan improved upon the availability of primary healthcare facilities.

Inspite of a continual increase in the number of medical institutions in the country, there still remains a severe
shortage of sub-centers, primary health centers, and community health centers.

Figure 1: Structure of Rural Healthcare system

National Rural Health Mission under the Umbrella of National Health Mission (NHM):

The issues of infrastructure, human resources and inadequate public investment in healthcare are some of the
governing factors for the present unsatisfactory performance of the Indian Public Health System. As a solution,
the planners came up with a comprehensive mission oriented approach to revamp the rural healthcare delivery
system called National Rural Health Mission (NRHM) in 2005 aiming to provide accessible, affordable, effective,
accountable and reliable healthcare to all citizens and in particular to the more poor and vulnerable portions of
the population.This was in accordance with the outcomes envisioned in the Millennium Development Goals
(MDGs) of the United Nations as well.

Provision of  the Mobile Medical Unit (MMU) in every district across the country was one of the key strategies
employed to strengthen healthcare facilities and take healthcare to the doorstep of the public in rural areas. The
states were, however, expected to ensure the adoption of the most suitable and sustainable model of MMU based
on their local requirements.

Under NHM alone, about 1107 MMUs in 333 districts are being run in order to  deliver healthcare services to
dif cult areas besides the Emergency Response Vehicles and ambulances for referral transport services in
eighteen states of our country(2). These MMUs were related to select reproductive and child health services and
to the national disease control programmes and not to the wider range of healthcare services that were needed.
Besides Government initiatives, there is a good variety of MMUs currently being implemented by charitable
organizations or NGOs too.

The Concept of Mobile Medical Units

Despite notable gains in coverage, speci cally when India is moving ahead towards achieving Universal Health
Coverage, reaching populations in the most remoteareas remains a constant challenge. Rural areas are
characterized by low population density, which implies relatively great distances between people. This
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10/10/2018 Approaching the Unreached through Mobile Medical Units

geographical fact itself multiplies the barriers to healthcare services many fold. In addition to the distance
problem, one witnesses the lack of healthcare manpower in rural areas, a factor that cannot be xed with money.
So, even though we recognise a great need for healthcare in rural areas, simply pouring money into these regions
is not the complete answer. Therefore, a system of medical care needs to be implemented large scale which can
ef ciently produce a positive effect within the available resources. Lack of services through xed structures is a
crucial issue that should be addressed as a matter of priority. MMUs can be a key service strategy to reach the
vulnerable and marginalised populations living in remote, dif cult areas as well as  for communities that are cut off
from mainstream services on account of climatic conditions and geography. Not to mention that they have played
a signi cant role in the delivery of health services to uninsured or under insured populations.

Even though the concept of mobile hospital is much older than our imagination, there is less well documented
(limited published literature) in the eld. Past literature on this topic remains largely anecdotal, patchy and
atheoretical. A mobile health service is any form of medical care in which services are brought to the patient
rather than having the patient travel to the services. It can be as simple as a medically-trained person bringing his
talent to the patient's bedroom as opposed to a 50-feet container with lacs of rupees worth of machinery manned
by an entire medical team.

Mobile health units can be classi ed according to the presence or absence of mobile equipment. Travelling
medical personnel carrying only small amounts of supplies are called mobile teams. Mobile services including
equipment in addition to personnel are known as mobile facilities. When speaking in general of mobile personnel,
facilities, or both, the term mobile unit is used. Simple mobile units can be jeeps or cars for the transport of
personnel with basic equipment and drugs. Ambulances with oxygen, stretchers, splints and bandages are a form
of mobile unit. A more complex mobile unit may contain a sink with running water, cabinets, a generator for
electricity, refrigerator, examining table, simple laboratory facilities such as a microscope or centrifuge, x-ray
equipment, dental equipment, and so forth. Of course, as the unit becomes larger, its mobility decreases,
especially on the muddy narrow roads of many underdeveloped countries or hilly terrain. Different types of
mobile units also have different purposes. Some are designed to provide comprehensive primary care to people
who have no access to stationary facilities. Others cater to some speci c aspect of health and provide for more
specialized care e.g. bone density check up, ophthalmic units for eye care, immunization, dental checkups, cardiac
units for coronary care, Cancer screening or multiphase screening etc.

There are multiple factors which need to be considered and examined when deciding whether to bring health
services to the patient rather than requiring the patient to travel to the services. Firstly, the geographic-
demographic facts must be taken into consideration, and these may lead one to the conclusion that mobile units
are necessary for any utilization of health services to take place, or that mobile units are at least one feasible way
of providing services. Second, one must determine whether the type of health service desired is compatible with
the innate qualities of mobile units, i.e., periodicity, simple facilities, mobility and usually simply-trained personnel.
Finally, if on the basis of these considerations, mobile units are a reasonable answer to the health delivery
problem, a cost-bene t study should be done to determine whether a mobile system has a higher bene t-to-cost
ratio than a system of xed services.

Conclusions and Recommendations

Though mobile units have great potential in rural areas, especially in certain aspects of preventive medicine and
emergency care, the concept of MMUs must not be embraced without a thoughtful analysis. Pre-launch studies
for assessing the needs of that particular area or studying the disease pro le are essential for successful
implementation and long term sustainability of the intervention. An assessment of patient satisfaction by seeking
feedback after regular intervals is mandatory from users. In fact, understanding the reasons for non-utilization is
also important to improvise and to get a suf cient framework for policy analysis.

The most important disadvantage of mobile units is the lack of continuous care for patients by medical personnel.
Therefore, it cannot replace the permanent structures. A suitable mix between the stationary and the mobile
policy can ne-tune the healthcare system to the particular needs of a concrete country. It may be preferable to
supplement the stationary hospitals or healthcare stations by some few mobile units providing care even at a
rather low level instead of excluding large parts of the population totally from medical supply. There does not

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seem to be a unanimous agreement upon  telemedicine. Under such an environment, it would be advisable for
stakeholders involved to know the limitations of this technology and work out strategy as appropriate to their
environment. More studies need to be conducted, preferably in a prospective manner based on scienti c
parameters by investigators drawn from diverse background to avoid bias.

The public-private collaboration will continue to engage policy attention and is justi ed on the basis of resource
limitations for expansion to meet the growing demand. There is little evidence to suggest the institutional capacity
of the government agencies to design, negotiate, implement and monitor such partnerships, scope and coverage
of the services for potential partnerships with the private sector. Detailed studies are therefore required to get an
insight of the kind of partnerships and linking them with the results targeted.

At this point of time, when the network of MMUs has been implemented in almost the whole of India, it becomes
very important to take up  research studies to analyse the impact of these MMUs. We need to understand
whether the launching of these MMUs can really play a pivotal role in providing healthcare services to the
unreached people of rural India.Thorough studies aiming to assess the impact are therefore required to be
undertaken to get a ample framework for policy analysis.

1.    WHO Discussion Paper (How Much Should Countries Spend on Health?) Available from:
http://www.who.int/health_ nancing/en/how_much_should_dp_03_2.pdf
2.    Ministry of Health and Family Welfare, Annual Report 2015-16, Department of Health and Family Welfare,
Government of India.

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