Rural Health Care System Research Articles

Mortality Rate of COVID-19 With Comorbid Pneumonia in a Rural Area.

A myriad of risk factors and comorbidities have been determined to influence COVID-19 mortality rates; among these is pneumonia. This study considers pneumonia as a risk factor for increased mortality in patients admitted with COVID-19 in a rural healthcare system. We predicted that the presence of pneumonia of any kind would increase mortality rates in patients admitted with COVID-19. A retrospective observational study was conducted using data collected from hospitals in the Freeman Health System (FHS) located in Joplin and Neosho, Missouri. Data were collected between April 1, 2020, and December 31, 2021. Using International Classification of Diseases, Tenth Revision (ICD-10) codes, the investigators identified five distinct patient populations: patients with COVID-19 and pneumonia due to COVID-19 (P1); patients with COVID-19 but without pneumonia due to COVID-19 (P2); patients with COVID-19 and any type of pneumonia (P3); patients with COVID-19 but without any type of pneumonia (P4); and patients without COVID-19 and with any type of pneumonia (P5). In order to understand how pneumonia influences COVID-19 outcomes, the investigators used Wald's method and a two-sample proportion summary hypothesis test to determine the confidence interval and to compare the mortality rates between these populations, respectively. The population of patients with COVID-19 and any type of pneumonia (P3) and the population of patients with COVID-19 and pneumonia due to COVID-19 (P1) showed the highest mortality rates. The population of patients with COVID-19 but without any type of pneumonia (P4) had the lowest mortality rate. The data revealed that having pneumonia combined with COVID-19 in any patient population led to a higher mortality rate than COVID-19 alone. Mortality rates were higher among COVID-19 patients with pneumonia compared to COVID-19 patients without pneumonia. Additionally, pneumonia, by itself, was found to have a higher mortality rate compared to COVID-19 alone.

Factors Influencing Time to Definitive Care in Hip Fracture Patients in a Rural Health System.

Current literature has not adequately addressed factors affecting wait times for hip fracture surgery in the rural setting. This study aims to assess the factors affecting admission, transit, and preoperative wait times that impact the timeliness of hip fracture surgery within a rural health system. A single-center retrospective cross-sectional study was conducted in a rural community comprising five community hospitals and two receiving hospitals. A trauma registry study included all hip fracture cases from 2019. Mean, standard deviation, median, and interquartile range were calculated for admission wait times, transit times to the receiving hospitals, and preoperative wait times in hours. Metrics based on means or medians were developed for these wait times. A total of 163 patients met the inclusion criteria. The emergency department wait times before and after admission to the community hospitals were 1 hour and 2.5hours, respectively. The transit times from the community hospitals, ranging from shorter to farther distances, to receiving hospitals were 40minutes and 1 hour, respectively. The preoperative wait time for admitted and transferred patients was 12hours. Our study outlines a methodology for establishing wait time metrics that impact surgical timeliness for hip fracture patients within a rural healthcare system. We recommend conducting comparable studies with larger sample sizes across different healthcare systems.

Patient Practices, Perceptions, and Barriers to Self-measurement of Blood Pressure in a Rural Health System.

Self-measurement of blood pressure (SMBP) is endorsed by current guidelines for diagnosing and managing hypertension (HTN). We surveyed individuals in a rural healthcare system on practices and attitudes related to SMBP that could guide future practice. Survey questions were sent via an online patient portal to a random sample of 56,275 patients with either BP > 140/90 mm Hg or cardiovascular care in the system. Questions addressed home blood pressure (BP) monitor ownership, use, willingness to purchase, desire to share data with providers, perceptions of patient education, and patient-centeredness of care. Multivariable logistic regression was used to examine patient characteristics associated with SMBP behaviors. The overall response rate was 12%, and 8.4% completed all questions. Most respondents, 60.9%, owned a BP monitor, while 51.5% reported checking their BP at home the month prior. Among device owners, 45.1% reported receiving instructions on SMBP technique, frequency, and reading interpretation. Only 29.2% reported sharing readings with providers in the last 6 months, whereas 57.9% said they would be willing to do so regularly. Older age, female sex, and higher income were associated with a higher likelihood of device ownership. Younger age, lower income, and Medicaid insurance were associated with a greater willingness to share SMBP results with providers regularly. While a significant proportion of respondents performed SMBP regularly, many reported insufficient education on SMBP, and few shared their home BP readings with providers. Patient-centered interventions and telemedicine-based care are opportunities that emerged in our survey that could enhance future HTN care.

Attitudes, knowledge, and risk perceptions of patients who received elective genomic testing as a clinical service

PurposeElective genomic testing (EGT) is increasingly available clinically. Limited real-world evidence exists about attitudes and knowledge of EGT recipients. MethodsAfter web-based education, patients who enrolled in an EGT program at a rural nonprofit health care system completed a survey that assessed attitudes, knowledge, and risk perceptions. ResultsFrom August 2020 to April 2022, 5920 patients completed the survey and received testing. Patients most frequently cited interest in learning their personal disease risks as their primary motivation. Patients most often expected results to guide medication management (74.0%), prevent future disease (70.4%), and provide information about risks to offspring (65.4%). Patients were “very concerned” most frequently about the privacy of genetic information (19.8%) and how well testing predicted disease risks (18.0%). On average, patients answered 6.7 of 11 knowledge items correctly (61.3%). They more often rated their risks for colon and breast cancers as lower rather than higher than the average person but more often rated their risk for a heart attack as higher rather than lower than the average person (all P < .001). ConclusionPatients pursued EGT because of the utility expectations but often misunderstood the test’s capabilities.

Evaluation of Secondary Overtriage at a Rural Level 1 Trauma Center.

To retrospectively assess the prevalence of secondary overtriage (SO) within a rural regional Appalachian health care system. Trauma registry data was extracted for all trauma activation transfer patients from 2017 to 2022. Transferred patients were then stratified into two groups, non-secondary overtriage (non-SO) or SO. Patients were considered SO if they met three criteria following transfer: an Injury Severity Score (ISS) of less than 15, no required operative intervention, and discharge within 48hours of arrival. Descriptive statistics were compared for age, length of stay (LOS), ICU LOS, and ISS. Surgical subspecialty consultations were compared between the two groups. Patients in the SO group were further assessed by body region of injury and Abbreviated Injury Score (AIS). Among 3,291 trauma activation transfer patients, 43% (1,407) were considered SO transfers. Patients in the SO group were significantly younger, had shorter average hospital and ICU LOS, and lower ISS compared to the non-SO group. Additionally, 25.7% of patients in the SO group had injuries to the head or neck of which 8.96% have an AIS ≥3. 21% of patients had injuries to the face, with 0.14% having an AIS ≥3. 43% of transfer patients in this study met our definition of SO. Although no optimal rate of SO has been universally established, limiting SO stands to benefit both patients and trauma systems. This study highlights how institutional analysis of transfer patients may help inform transfer protocols to reduce secondary overtriage and overutilization of scarce resources.

Future Possible Changes in Medically Underserved Areas in Japan: A Geographic Information System-Based Simulation Study.

A decrease in populations could affect healthcare access and systems, particularly in medically underserved areas (MUAs) where depopulation is becoming more prevalent. This study aimed to simulate the future population and land areas of MUAs in Japan. This study covered 380,948 1 km meshes, 87,942 clinics, and 8354 hospitals throughout Japan as of 2020. The areas outside a 4 km radius of medical institutions were considered as MUAs, based on the measure of areas in the current Japanese Medical Care Act. Based on the population estimate for a 1 km mesh, the population of mesh numbers of MUAs was predicted for every 10 years from 2020 to 2050 using geographic information system analysis. If the population within a 4 km radius from a medical institution fell below 1000, the institution was operationally assumed to be closed. The number of MUAs was predicted to decrease from 964,310 (0.77% of the total Japanese population) in 2020 to 763,410 (0.75%) by 2050. By 2050, 48,105 meshes (13% of the total meshes in Japan) were predicted to be new MUAs, indicating a 31% increase in MUAs from 2020 to 2050. By 2050, 1601 medical institutions were tentatively estimated to be in close proximity. In Japan, the population of MUAs will decrease, while the land area of MUAs will increase. Such changes may reform rural healthcare policy and systems.

Development of a Proof-of-Concept Multi-Method Computer Simulation to Support Rural Healthcare Disaster Preparedness Planning

Due to a lack of resources, rural communities often face challenges when planning catastrophic events. This project involved applying systems thinking and model-based systems engineering to develop a proof-of-concept, multi-method computer simulation and then determining whether the simulation could be used to assess the efficacy of disaster planning approaches on health outcomes in rural communities, as a function of primary healthcare. The project focus was a rural or non-urban healthcare system experiencing a natural hazard. Both system dynamics and discrete event models were incorporated to represent subsystem operations, crucial disaster responses, as well as three key response systems: public health, emergency management, and healthcare. The subsystem models included several components: policies/procedures, communications, resources, exercises/drills/training, healthcare space and staff, and the flow of affected people into and through the system. The combined simulation can serve as a first step to a more comprehensive approach to helping rural communities achieve more efficient and effective healthcare planning for disaster responses.

66. Implementing a Pediatric Gynecology Curriculum in a Rural Healthcare System

66. Implementing a Pediatric Gynecology Curriculum in a Rural Healthcare System

48. Establishing the Need for a Pediatric Gynecology Curriculum in a Rural Healthcare System

48. Establishing the Need for a Pediatric Gynecology Curriculum in a Rural Healthcare System

Reduced burden on urban hospitals by strengthening rural health facilities: Perspective from India.

In India, rural-urban health disparities have been persisting over a period. Migration of patients from rural to urban is an integral part of population dynamics thereby creating an additional burden on urban hospitals. Over the decade, India has made significant advances in health in reducing the rural-urban gap. The article highlights how the strengthening of rural healthcare facilities has reduced the burden of urban hospitals. Secondary data on the usage of public and private healthcare facilities from two rounds of the National Family Health Survey (NFHS) conducted in 2016 and 2021 and the Rural Health Statistics 2021-2022 were analyzed. The proportion of beneficiaries seeking care from public health facilities has increased from 41.9% to 45.7% in rural areas and 31% to 35.3% in urban areas between 2014 to 2017. The institutional deliveries have increased from 56% to 69.2% in rural areas and from 42% to 48.3% in urban areas. The State and local level interventions such as the upgradation of existing physical infrastructure, human resources, regular supply of medicines and consumables, development of referral linkages, patient transportation, and enhancing community participation have strengthened the rural healthcare system. Adequate utilization of the resources is crucial to addressing the lag and alleviating the rural-urban divide.

IJCM_204A: A qualitative research to identify the barriers and facilitating factors in the utilization of healthcare services by a Particularly Vulnerable Tribal Group (PVTG) in Udupi District

Background: Udupi district hosts two major Particularly Vulnerable Tribal Groups (PVTG) namely Malaikudiya and Koraga. Koraga tribes are declining in number and deprived of availability of healthcare services and accessibility to healthcare facilities. There are a lot of barriers such as lack of awareness and social stigma amalgamate the existing conditions of Koraga tribes in Udupi district. Research studies pertaining to this problem has been seldom done. Objective: We aim to explore the barriers and facilitating factors in accessing healthcare services by a Particularly Vulnerable Tribal Group (PVTG) in Udupi district. Methodology: We conducted qualitative research through 8 in-depth interviews with AMOs from PHC and CHC, ITDP staff and NGO workers, and 3 focus group discussions with community health nurses, ASHA workers, and Koraga community leaders from Udupi district. We explored the major facilitators and barriers that influence the utilization of health care services by the PVTG. Results: On the beneficiaries’ point of view, lack of awareness, distance to health facilities, poor public transportation, perceived negative behavior of hospital staff, lack of infrastructure, unwelcoming neighbourhood approaches, and economic instability were the main barriers to utilizing healthcare facilities. On the stakeholders (providers) point of view, availability of healthcare facilities, government policies and schemes and NGO activities are the facilitating factors. Conclusion: Our study highlights the barriers to utilizing health facilities; these are not always driven by factors linked to the PVTG members’ socio- economic status but also depend significantly on the quality of the health services and other contextual factors. Although the government has made efforts to improve the rural healthcare system through national-level programs, our qualitative study shows that there are a number of barriers which lessens the effectiveness of the programs to enhance the utilization of healthcare facilities by the PVTG in the study area.

A Study on Assessment of Rural Health Care System in India: Schemes and Implications

India’s rural healthcare system plays a pivotal role in ensuring access to quality healthcare for a significant portion of the population. This study aims to shed light on the state of rural healthcare infrastructure, the effectiveness of government healthcare initiatives, and the far-reaching implications for rural communities. Rural India presents unique healthcare challenges characterized by disparities in healthcare infrastructure, limited access to medical services, and varying health outcomes. The government of India has launched several healthcare schemes and initiatives over the years, such as the National Rural Health Mission (NRHM) and Ayushman Bharat, to address these challenges. Understanding the impact of these schemes and their consequences is essential to inform future healthcare strategies and policies. This study provides a holistic view of the primary healthcare infrastructure in rural India, offering insights into the effectiveness of government schemes and their implications for the health and well-being of rural populations. Its findings serve as a valuable resource for policymakers, stakeholders, and healthcare professionals working toward the improvement of rural healthcare in India.

Mycobacterial tissue culture positivity in the work-up of suspected cutaneous infection in a rural dermatology patient population.

Dermatologists may be over-ordering mycobacterial tissue cultures when performing the broad work-up of skin infection. The objective of this study was to determine mycobacterial tissue culture positivity in the work-up of suspected skin infection. This was a retrospective cohort study including patients biopsied for mycobacterial tissue cultures performed by dermatology providers from 2006 to 2020 in a large Midwestern US rural healthcare system. Main outcomes and measures were mycobacterial tissue culture positivity rates by body location, immunocompromised status, clinical setting, and exposure history. There were 552 mycobacterial tissue culture results from 515 patients, resulting in mycobacterial culture positivity in 13 cases (2.4%). Of these, 12 (92.3%) were outpatients, 9 occurred in immunocompromised patients (69.2%, P = 0.02), and 8 (61.5%) were from upper extremity lesion biopsies (P = 0.007). Lower extremity lesions were significantly associated with decreased mycobacterial culture positivity (P = 0.038). Trauma and environmental water exposures were not associated with mycobacterial tissue culture positivity. The rate of mycobacterial tissue culture positivity is low. Mycobacterial tissue cultures should particularly be targeted in patients who are immunocompromised and patients with upper extremity lesions. Automatic inclusion of mycobacterial tissue culture for skin infection work-up may not be necessary.

Measure Twice, Change Once: Using Simulation to Support Change Management in Rural Healthcare Delivery.

Barriers to adequate healthcare in rural areas remain a grand challenge for local healthcare systems. In addition to patients' travel burdens, lack of health insurance, and lower health literacy, rural healthcare systems also experience significant resource shortages, as well as issues with recruitment and retention of healthcare providers, particularly specialists. These factors combined result in complex change management-focused challenges for rural healthcare systems. Change management initiatives are often resource intensive, and in rural health organizations already strapped for resources, it may be particularly risky to embark on change initiatives. One way to address these change management concerns is by leveraging socio-technical simulation models to estimate techno-economic feasibility (e.g., is it technologically feasible, and is it economical?) as well as socio-utility feasibility (e.g., how will the changes be utilized?). We present a framework for how healthcare systems can integrate modeling and simulation techniques from systems engineering into a change management process. Modeling and simulation are particularly useful for investigating the amount of uncertainty about potential outcomes, guiding decision-making that considers different scenarios, and validating theories to determine if they accurately reflect real-life processes. The results of these simulations can be integrated into critical change management recommendations related to developing readiness for change and addressing resistance to change. As part of our integration, we present a case study showcasing how simulation modeling has been used to determine feasibility and potential resistance to change considerations for implementing a mobile radiation oncology unit. Recommendations and implications are discussed.

Comparative Study on the Satisfaction of Healthcare Service Providers with the Synergistic Development of Rural Healthcare Systems in China: Medical Alliance Counties vs. Non-Medical Alliance Counties.

This study aimed to explore whether the establishment of county medical alliances can improve satisfaction with the vertical integration of healthcare systems among rural medical and healthcare service provider managers and service providers. Our study also sought to provide recommendations for the sustainable development of vertical integration in healthcare systems. A semi-structured interview with 30 healthcare service providers was employed in this research, and Nvivo software was utilized to analyze factors that influence vertical integration. From April to July 2021, a multi-stage random sampling method was used to select participants. The sample included two leading hospitals in medical consortia, 15 member units (healthcare service providers and medical staff), two county-level hospitals, and 15 township health centers/community healthcare service centers from non-medical consortia. Questionnaire surveys were conducted with these groups. Factor analysis was used to calculate satisfaction scores for healthcare service providers with the cross-institutional synergistic development of healthcare systems in both medical and non-medical consortia (denoted as M(IQR)). Propensity score matching was employed to reduce confounding factors between groups. The Mann-Whitney U test was used to compare satisfaction differences between groups. The overall satisfaction scores for lead-county hospital managers, member institution managers, medical staff at the lead-county hospital, and medical staff at member institutions were 4.80 (1.00), 4.17 (1.17), 4.00 (1.38), and 4.00 (1.12), respectively. Lead-county hospital managers' satisfaction with cross-institutional collaboration, development capacity enhancement, and structure and resource integration in the Medical Alliance group showed higher satisfaction than the Non-Medical Alliance. Similarly, lead-county hospital medical staff in the Medical Alliance group reported greater satisfaction with collaboration efforts, supportive environment, and development capacity enhancement. Notably, while the Medical Alliance group's satisfaction scores were higher, the differences between the two groups were not statistically significant for lead-county hospital managers and medical staff. The Medical Alliance group did show statistically significant differences in member institution managers' satisfaction with collaboration, development capacity enhancement, and structure and resource integration. Additionally, medical staff of member institutions in the Medical Alliance group reported statistically significant higher satisfaction with collaboration, supportive environment, development capacity enhancement, healthcare service integration, and human resource development. To facilitate the establishment of county medical alliances, managers of leading county-level hospitals should adopt a healthcare system integration strategy. This strategy involves evolution from being a member of a single institution to a coordinator of cross-institutional vertical integration of medical and healthcare services. Additionally, revamping remuneration and appraisal systems for members of county medical alliances is necessary. This will encourage cooperation among healthcare institutions within the three-tiered system and their medical staff, ultimately facilitating the provision of integrated services.

Impact of Urban-Rural Resident Basic Medical Insurance integration on individual social fairness perceptions: evidence from rural China.

Achieving universal health insurance coverage has become a fundamental policy for improving the accessibility and equity of healthcare services. China's Urban-Rural Resident Basic Medical Insurance (URRBMI) is a crucial component of the social security system, aimed at promoting social equity and enhancing public welfare. However, the effectiveness of this policy in improving rural residents' social fairness perceptions (SFP) remains to be tested. To examine the impact of the urban-rural resident basic medical insurance (URRBMI) on rural residents' social fairness perception (SFP) in China. The study utilizes city-level and national micro-survey (CGSS) datasets, applying a time-varying difference-in-difference (DID) approach to analyze the equity effects of URRBMI. Excluding urban samples, the final dataset consists of 20,800 rural respondents from 2010, 2011, 2013, and 2015, covering 89 cities. Key findings reveal that URRBMI has a significant negative effect on SFP. The impact varies depending on the integration model and intensifies over time. Additionally, the negative effect shows heterogeneity based on income, age, health, and region. This study highlights the complexities and impacts of integrating China's urban and rural healthcare systems. It provides a detailed understanding of the role of URRBMI in rural China, emphasizing the need for targeted approaches to improve rural residents' perceptions of social fairness. The research offers specific policy recommendations, such as establishing differentiated contribution standards, implementing welfare policies favoring rural residents, and adopting varied reimbursement rates for different diseases.

Treatment Patterns and Persistent Disease Activity in Patients With Eosinophilic Esophagitis: A Retrospective Cohort Study

Limited real-world nontertiary care evidence on the patient therapeutic journey and disease burden of eosinophilic esophagitis (EoE) exists. The aim was to collect real-world data on the EoE patient journey across different age groups. This retrospective, real-world, cohort study used electronic medical records and claims data provided by a rural integrated US healthcare system. Eligibility criteria included ≥ 2 diagnoses of EoE (2009-2018), ≥ 1 endoscopy, and ≥ 12 months of data before and after the index date (the first endoscopy date during the 180 days before and the 365 days after the first EoE diagnosis). Clinical findings, all-cause healthcare resource utilization, specialists consulted, therapies, and markers of disease progression were analyzed. Overall, 613 patients were enrolled: 0-11 (children, n= 182), 12-17 (adolescents, n= 146), 18-54 (adults, n= 244), and ≥ 55 years old (older adults, n= 41). Post index, the prevalence of signs and symptoms increased. At baseline, most endoscopies were abnormal (80.5%) and most peak eosinophil counts were > 15 eosinophils/high-power field (87.9%); post index, all age groups had endoscopic and histologic improvements. However, 3 years post index, abnormal endoscopic appearance (62.3%) and histologic activity (51.2%) were observed. Patients of all ages exhibited considerable all-cause healthcare resource utilization. During follow-up, 86.3% of patients consulted a specialist. Before and after index, proton pump inhibitors and corticosteroids were the most commonly used pharmacological therapies; 44.0% of patients discontinued their first treatment post index. Disease progression occurred in 13.9% of patients post index. In this setting, patients with EoE irrespective of age face difficult therapeutic journeys with substantial disease burden.

Three lessons for rural health care systems from COVID-19.

Three lessons for rural health care systems from COVID-19.

Using the RE‐AIM framework to help implement an educational intervention for improving the care of persons with behavioral and psychological symptoms of dementia in primary care

AbstractApproximately 90% of persons living with dementia (PLWD) experience behavioral and psychological symptoms of dementia (BPSD) over the course of their illness, including aggression, psychosis, and depression. With a growing lack of access to specialty geriatric care, most people with BPSD will receive care from their primary care providers. Many primary care practices lack knowledge, self‐efficacy, and established pathways to expert advice for managing these complex behaviors. We have developed a comprehensive educational intervention for primary care providers and clinical staff to help them better address BPSD. The educational intervention combines two complementary approaches: the academic detailing model and the DICE ApproachTM (DICE). In a recent pilot with two primary‐care integrated memory clinic teams, we noted improvements in provider knowledge and clinical staff self‐efficacy and comfort in BPSD and dementia care after 6‐months of participation in academic detailing and DICE training. In our current study, we use the RE‐AIM framework to guide the implementation planning for our educational intervention for primary care providers and clinical staff to help them better address BPSD. The RE‐AIM framework is a widely used tool for evaluating the implementation of health interventions to ensure they are both effective and sustainable. Twenty semi‐structured interviews will be completed among providers practicing in one of two primary care integrated memory clinics who participated in the pilot program (champions) and among their generalist primary care colleagues with no to minimal program experiences (novices), in one urban and one rural healthcare system. The RE‐AIM framework informed the design of our semi‐structured interviews and will help to frame content analysis for identifying potential barriers to implementation, for scale‐up to generalist primary care teams. Five interviews have been completed to date. Qualitative analyses are also underway, and results will be presented. Findings from this study will be used to develop an implementation plan for a future randomized controlled trial to measure the effectiveness of this intervention on health outcomes in PLWD and BPSD.

Utilisation of Zero Priced Rural Healthcare System in India - A Review

Rural health is an important pillar of rural life for to return economic activity and using their muscle power. In India the rural healthcare system is supplying healthcare services at zero prices. As per the Economic Survey 2022-23, 65 percentages of India’s population lives in the rural areas and 47percentage of the population is dependent on agriculture for livelihood.On 12 April 2005, the Government of India took a major welfare initiative by launching National Rural Health Mission (NRHM) in 18 states with weak public health indicators and infrastructure and extended it across the entire country. Nearly two decades the programme is executing by government in rural healthcare which may be influence the residents positively in their health status. In addition, many government programs have been launched with the aim of improving rural health, the effectiveness of these initiatives is depends upon the utilisation of available healthcare serviceswhenever needed by the rural in habitants. The other side of healthcare system, specifically private sector healthcare is mushrooming as clinic, dispensary, hospital and multispecialty hospital and people are also utilising the services and willing to pay for their health requirements. The research question is, when a service is available at zero prices to access why the people are utilising the priced one healthcare service.Hence, here is an attempt wasconducted to find the utilisation of rural healthcare system by rural population in India from the published articles.The summary of findings of the reviewed articles enlighten the need of increasing the rural healthcare working hours, number of medical personnel, strengthening healthcare infrastructure, ensuring availability of essential medicines, need of palliative care in rural PHC and investing in multispecialty workforce development in rural areas. It’s crystal clear that any programme needs a continuous monitoring, evaluation and adaptation of strategies is essential. This kind of summation of findings from scattered articles about the accessing of healthcare will be an aid to the health policy maker. A concerted effort to raise the health status of rural communities will not only improve their quality of life but also contribute to the overall health and development of the country which is in the hands of rural healthcare system.