The State of Himachal Pradesh in India has primarily a hilly terrain with an overall population of 6 million (60,77,900₁). Around nine-tenth (90.2%) of the population is rural with very limited accessibility to modern health services. There is a wide disparity in the State in relation to various population and health related accessibility indicators. As per the 2001 Census, population density of the state is 109/ sq. km which are far below All-India average of 325/ sq. km. Even with-in the State, the density of the population varies between 2/ sq. km (Dist. Lahaul Spiti, which covers around one fourth of State area) and 12/ sq. km (Dist. Kinnaur, which covers around one eighth of State area) to 298/ sq. km (Dist. Una). One sub-center covers a population of around 2838 which also varies between 974 (Dist. Lahaul Spiti) to 3421 (Dist. Una). On an average, area covered by one sub-center in the State is around 26.9 sq. km. which also varies between 11.7 sq. km/ sub-center (Dist. Una) to 395 sq. km/ sub-center (Dist. Lahaul Spiti). One sub-center covers around 8.46 villages₂.

The sub-center is a peripheral outpost of existing health care delivery system in rural area, which are established for every 5000 population in general and every 3000 population in hilly, tribal and backward areas₃. In view of the hilly terrain, one health worker needed to walk two to seven hours to travel the distance between two villages in some remote hilly districts. In such a difficult terrain, as the Medical officers (MOs) put it, a month's time was not sufficient to cover all the villages under a SC by one ANM. Due to hilly terrain and scattered population, it was difficult for a health worker to visit even 5 km distance in a day and cover the scattered population.

It was seen that some health sub-centers located near to town areas were over-staffed whereas those located at remote places were under-staffed. Further, health workers posted at remote areas don't reside at their place of posting. This imbalance in posting of staff had affected the performance of the health centers in rural areas of the state. Although government accommodations were available at most of the places of posting but it was not found optimally utilized. There was a negligible sharing of resources between the districts, PHCs and SCs as far as infrastructural facilities (equipment, vehicles, communication instruments, supply of material etc) and manpower is concerned.

It was observed during face-to-face interviews and focus group discussions with the health workers and medical officers of different areas that no. of houses visited per month varies from 100 to 1000 per month in remote inaccessible and comparatively accessible areas of Himachal Pradesh. Average distance traveled by one health worker per day also varies from 15 meters to 2 KMs in inaccessible and accessible areas. Energy spent per day to perform house visit was also comparatively more in hilly terrain as compared to plain areas. To add to this, lesser time is available to health worker of hilly areas in winter/ snowy and rainy seasons as compared to time available to health worker of plain areas (Table-1).

The norms set by the government were not suitable in terms of population covered. It needed revision in view of the scattered population, wide inter-state and inter-district disparity. In my opinion, comparing norms of absolute population of plain and hilly areas should not be advisable as there is a very wide inter and intra-state disparity in terms of area and population covered by a sub-center, difficult terrains, and poor communication. The population norm of 3000 per sub-center for hilly areas is not just 60% of norms of plain areas (5000 per sub-center)

Figure 1

Table 1: Comparative Work Assessment of Health Worker in Plain vs. Hilly Areas

Correspondence to

Dr Sonu Goel, Assistant Professor
Dept. of Community Medicine
Dr RP Govt. Medical College,
Kangra at Tanda, Himachal Pradesh, India
Ph-91-9418039835