What A Four-Hour Trek Reveals About Jharkhand’s Healthcare Access

On November 30, 26-year-old Amarmuni Nagesia gave birth to a girl child at home, with the help of her neighbours, in Gwalkhar village of Jharkhand’s Latehar district. The nearest health centre is a four-hour trek away in Mahuadanr, and there wasn’t enough time to take her there. In inclement weather such as rains, the journey is even riskier. For postnatal care, she only received iron and folic acid tablets three days after delivery.

“It is particularly important that all births are attended by skilled health professionals, as timely management and treatment can make the difference between life and death for the women as well as for the newborns,” according to the World Health Organization (WHO).

“In the absence of health care services and lack of transportation, vulnerable tribes are deprived of timely health care facilities,” according to a 2017 report by the Comptroller and Auditor General (CAG) of India, as IndiaSpend reported in September 2019.

Jharkhand’s Scheduled Tribes population is 8.6 million, which is 26% of the state’s population--three times the national figure of 8.6%. Tribal groups--that are more vulnerable to disease and malnutrition than the rest of the population--have to cover a distance of five to 80 km to reach a community or district health centre, the 2017 CAG report said. Across India, people have to cover an average distance of 13.55 km to reach a community health centre, we had reported. This forces women like Amarmuni with little to no care in critical situations, putting their lives at risk.

The treacherous trail to care

Six weeks before Amarmuni gave birth, this reporter joined her for an antenatal check-up. Preparations had begun hours before the actual journey. Her father Sukhdev, with help of neighbours put together a makeshift palanquin for Amarmuni using a wooden basket tied to a bamboo stick. Over seven months pregnant and mother to a two-year-old, she was preparing for the arduous journey.

“The situation is common across Jharkhand, where health centres remain out of reach for forest-dwelling communities,” says Pyari Nageisa, a health worker. In May 2023, the 46-year-old recounted, a woman delivered a child at home and was bleeding heavily. She was rushed to the block hospital in Mahuadanr, then referred to the district hospital in Latehar about 90 km away. But she died in the hospital due to heavy blood loss.

“Three years ago, another woman suffered severe pain during transit and had to give birth in the forest with the help of village women,” Pyari, who accompanied Amarmuni on this slippery, hilly stretch, said.

Villagers carry pregnant Amarmuni Nagesia from Gwalkhar village of Jharkhand's Latehar district on their shoulders, walking for four hours to reach the hospital.

These challenges are not confined to Jharkhand. On September 27, a pregnant woman from Pinjarikonda village in Andhra Pradesh was carried through a stream from an overflowing dam to reach a hospital.

Gwalkhar is about 178 km from state capital Ranchi. The majority of over 1,500 people in the village belong to the Kisan, Korwa and Birija tribes. “It’s bad here,” Sukhdev says. “The rain last night made the path even more slippery. If anyone slips, who knows what’ll happen to the mother and child.”

“The lack of a road has always been the problem. We’ve asked for help, but nothing changes,” said Sukhdev. “People die because of it—three or four children already from our village. In 2021, my wife was paralysed. We didn’t have the money for treatment, and she died too. What can we do?”

After about four hours of walking, Sukhdev, the villagers, and the health worker reached the nearest road, where an ambulance was waiting. Amarmuni’s blood pressure was checked, and the ambulance took the father-daughter duo to the hospital. The villagers continued walking--they couldn’t afford to hire an auto and were denied a seat in the ambulance.

Amarmuni needed an ultrasound, but the hospital lacked the equipment. A private hospital was charging Rs 1,000, which the family could not afford. So after basic checkups, they set about to return.

By 4 p.m., Sukhdev and four others from the village carried Amarmuni back in the bamboo palanquin, hoping to reach the village before nightfall. In their haste, they had forgotten to bring a torch—an oversight that could have made the journey even more treacherous.

On October 17, 2024, villagers and family members carried Amarmuni Nagesia on their shoulders for four hours, walking to the hospital for her final antenatal check-up.

Pregnancy care inadequate

Antenatal care (ANC) constitutes healthcare for pregnant women to monitor for signs of complications, detect and treat hypertension and diabetes, provide iron and folic acid tablets and counsel on preventive care, diet during pregnancy, delivery care, postnatal care etc. ANC is provided by a skilled healthcare provider such as a doctor, auxiliary nurse midwife or other health professionals.

“None of this is readily available to pregnant women in forest villages,” said Pyari.

According to National Health Mission (NHM) guidelines, pregnant women are advised to receive a tetanus toxoid injection, take folic acid tablets for 100 days, and consume milk products and green vegetables. However, due to the lack of these essentials, complications arise, often leading to prolonged labour and sometimes even risky home deliveries.

UNICEF advises pregnant women to eat three nutritious, home-cooked meals a day, along with one or two nutritious snacks and three to five servings of fruits and vegetables. A diet rich in whole grains (like whole wheat, brown rice, and oats), protein (eggs, fish, chicken, lentils, soy), and green leafy vegetables is essential, along with plenty of clean water for hydration.

”Forget about reaching healthcare facilities to get mandatory checkups,” said Pyari, “when it rains heavily, reaching the village with essential supplies for pregnant women like folic acid becomes a tough task. This can have an impact on the child in the womb.”

To reach the road from Gwalkhar village in Jharkhand's Latehar district, tribals have to walk through the forests on treacherous paths. They are constantly under the threat of animal attacks.

The NHM guidelines say pregnant women should get four ANC visits–the first when pregnancy is suspected, the second around 26 weeks, the third around 32 weeks, and the fourth at 36-40 weeks. Across India, only 58.5% pregnant women received four or more ANC visits, NFHS data show. In Jharkhand, this drops to 38.7%--third lowest in the country.

Jasinta Korvain, another health worker for Gwalkhar village, said that blood pressure, sugar, and blood testing equipment have been damaged for four years. “Funds for buying new equipment were sanctioned by the state government in October 2024 but due to the lack of KYC it could not be procured yet," Korvain said.

The result is that antenatal checkups, which should occur at least three times during pregnancy, are only done once or twice at most. The scarcity of basic health resources is compounded by the lack of clean water. "We drink from the Chuan (water stored in pits from mountain streams)," Jasinta explains.

Korvain, who lives two villages away, learned about Amarmuni’s delivery two days later–the villages do not have mobile phone connectivity. An hour’s trek through forested hills with no roads or infrastructure separates the villages. She then provided the mother with iron and folic acid tablets.

India’s healthiest children are in states that provide the best maternal healthcare, IndiaSpend reported in January 2016. Further, the poor quality of health infrastructure, antenatal care, maternal health and postnatal care jeopardise the lives of children, we reported in January 2020.

About 36% of children under the age of five across India are stunted, or short for their age, NFHS-5 data show. Jharkhand has the country’s fourth highest rate–nearly 40% of children are stunted.

“Stunting is a proxy for overall cognitive and physical underdevelopment,” according to a September 2017 report by the Bill and Melinda Gates Foundation, as IndiaSpend reported in January 2018. “Stunted children will be less healthy and productive for the rest of their lives, and countries with high rates of stunting will be less prosperous.”

Adults who were stunted at age two spent nearly one year less in school than non-stunted individuals, according to this study conducted by University of Atlanta in 2010, as IndiaSpend reported in July 2016.

Similarly, a study of Guatemalan adults found that those stunted as children had less schooling, lower test performances, lower household per capita expenditure and a greater likelihood of being poor. For women, stunting in early life was associated with a lower age at first birth and more pregnancies and children, according to this 2008 World Bank study.

A 1% loss in adult height due to childhood stunting is associated with a 1.4% loss in economic productivity, according to World Bank estimates. Stunted children earn 20% less as adults compared to non-stunted individuals, we had reported.

Further, experts say that early childhood malnutrition increases the risk of developing non-communicable diseases such as hypertension, diabetes and heart disease in adult life, as IndiaSpend reported in October 2019.

On October 17, before heading to the Mahuadanr Community Health Centre for a check-up, Amarmuni Nagesia fed her child and got ready for the journey.

Roadblocks to lifelines

India has approximately 650,000 villages, with 170,000 located near forests, the environment ministry told Parliament in December 2023. Around 300 million people depend on forests for their livelihood.

Of 117,064 villages with more than 25% tribal population for which data were available, one-third did not have access to an all-weather road and three in four did not have a health centre, the government told the Lok Sabha in November 2019. For nearly a third of the villages without a health centre, the distance to the nearest facility was more than 10 km, while another 28% villages were 5-10 km away from the nearest health centre.

“If people have to walk four hours to get to a hospital, that’s a catastrophic failure,” Thiagarajan Sundararaman, global coordinator of Jan Swasthya Abhiyaan, says. “It’s the responsibility of both central and state governments to ensure that every person has access to an all-weather road within a kilometre of their village. Back in 2011-12, a mapping of these remote areas was done in Jharkhand to ensure pregnant women could reach hospitals within an hour. But action has been delayed—likely due to funding issues and the government’s lack of commitment.”

Jharkhand's health minister Irfan Ansari, who recently took charge of the department, told IndiaSpend, "I have decided that I will give doctors postings in their home districts and also increase their pay. This way, doctors will be available everywhere in the state, even the remotest areas. Also, now that the condition of Mahuadanr hospital has come to my attention, I promise I will transform it into a better hospital.”

A 2021 joint survey by the Jharkhand Van Adhikar Manch (JVAM), a platform of 17 small and big voluntary organisations working for forest and tribal rights, and the Indian School of Business found that Jharkhand is home to 14,850 villages in forest areas.

According to JVAM’s convenor Sudhir Pal, even with a conservative estimate of 100 people per village, around 1.48 million people live in these remote areas, and many of them are forced to rely on makeshift transport like cots to reach hospitals in emergencies.

According to a 2021 reply, in the parliament there were 142 positions of doctors lying vacant in the PHCs across tribal areas of Jharkhand. In Union Budget 2023-24, an amount of Rs 117,944 crore has been allocated as Development Action Plan for Scheduled Tribes (DAPST funds out of the total scheme budgetary allocation of 42 Ministries/Departments.

In response to their isolation, many boycott elections, protesting the government’s failure to provide basic infrastructure. During the 2024 elections to the state’s legislative assembly, for instance, residents of Bamanabad village in Bokaro’s Tundi constituency and Taratand block in Giridih’s Bengabad block announced their decision to boycott.

Political promises in Jharkhand’s manifestos, from both the Jharkhand Mukti Morcha and the Bharatiya Janata Party, offered solutions like one ambulance per 5,000 families and a launching mobile units in tribal dominated districts.

“While these promises sound good on paper, they fail to address the fundamental issue: how to actually reach these remote villages. Without clear plans to build roads or improve infrastructure, these promises remain just that--empty rhetoric,” said Pal.

Ajay Kumar Singh, Jharkhand's health secretary, said mobile medical units can help. “More than 100 such units are working in the entire state,” he said. “It can be said that this is a unit with OPD facilities. But for those areas or villages where roads have not reached, the rural development department will have to take the initiative.”

Reshma, who goes by her first name, the Jharkhand State Trainer of Dhvani Foundation which has been working on women's rights for the past 15 years, said that health-related issues of women and children living in forest areas have been consistently ignored. “Even in this election, no one made any announcements keeping these issues in mind. Now, women benefiting from the state’s Maiya Samman Yojana have voted overwhelmingly in favour of the current government. The government should now give them a return gift in the form of better roads and healthcare facilities,” she said.

“Our government’s primary goal is to serve and ensure the welfare of every Jharkhandi, especially those living in remote areas,” Jharkhand Chief Minister Hemant Soren told IndiaSpend. “Whether they reside in forest villages or other inaccessible regions, providing them with access to healthcare services remains a critical priority.

“We are formulating a comprehensive plan to improve healthcare services, which includes constructing motorable roads in coordination with the health, rural development, and forest departments. Our aim is to ensure that every citizen, no matter how remote their location, can access essential medical facilities without obstacles,” he said.

Speaking about the Mahiya Samman Yojana, Soren said, “This ambitious social welfare scheme focuses on empowering women and their families economically. With monthly financial assistance of Rs 2,500, more than 50 lakh women are benefiting from the programme. It’s not just financial aid—it’s a significant step toward women’s empowerment.”

Health worker Pyari Nagesia (47) works in the Champa Panchayat of Mahuadanr Block in Jharkhand's Latehar district. Gwalkhar village falls under this panchayat.

The Forest Rights Act 2006 allows diversion of forest land up to one hectare for construction of schools, health centres, anganwadi, fair-price shops, utilities such as telecom and electricity, drinking water and roads, provided that the number of trees to be felled are not more than 75. George Monippally of JVAM says with such restrictions, it becomes impossible to build roads to connect villages deep in the forest, often several kilometers from the nearest main road.

Monippally believes the solution lies in a clear, actionable plan. “The state government should create a comprehensive list of areas that need roads, measure the distance, and approach the Central forest ministry for permission.”

“If the government and forest department want, all-weather roads can be built anywhere in the forest,” said Lal Ratnakar Singh, former Jharkhand Principal Chief Conservator of Forests. “Since villages in such places are far apart and few people live there, the government doesn't pay attention to them. The people living here aren't even able to properly communicate their concerns to them.”

IndiaSpend reached out to Union minister for tribal affairs Jual Oram for comment. We will update this story when we receive a response.

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