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Uttarakhand’shills districts have long faced four fundamental challenges—education, healthcare, infrastructure and employment. These are not independent problems. They reinforce one another and, together, contribute significantly to migration from the hills.A family is unlikely to remain in a remote village if its children have to leave for quality education, a seriously ill family member has to be carried several kilometres before reaching a functional health facility, roads and transport remain uncertain, and employment opportunities are scarce.Recent news of women carrying an ill aged man for 04 kms on makeshift stretcher and long delay in transport took his life. One more incident of person dying with cardiac issues due to non-availability of oxygen and a specialist doctor speaks volumes about the access to medical facilities in the hills. Thus, if Uttarakhand genuinely wants to arrest outmigration and encourage reverse migration, healthcare must be regarded as an essential component of the strategy rather than merely another item in the welfare budget.The State’s own experience shows that migration is no longer confined to young men leaving temporarily for employment. Increasingly, entire families move towards towns and cities in search of better livelihoods and quality of life. Studies on Uttarakhand have identified inadequate local livelihood opportunities, education and public services among the factors associated with this transformation.A functional health facility in a mountain village can therefore have an economic value far greater than the cost of running that facility.
The health centre at the end of the road
The Primary Health Centre (PHC) is often the first formal point of contact between a villager and the healthcare system.On paper, the system appears reasonably structured:Sub-Centre → PHC → CHC/SDH → District Hospital → Medical College/Tertiary Hospital. On the ground, however, the situation can be very different.A building may exist without adequate staff. A doctor may be posted but unavailable. A pharmacy may exist without medicines. A diagnostic facility may exist without trained personnel. An ambulance may be available but the patient may still have to travel considerable distances over difficult mountain roads.The result is that a patient who should have received treatment at the primary level is referred to a higher centre.For a person living in the plains, a referral may mean a short journey.For a villager in the Himalayas, it may mean several hours of travel, considerable expenditure, loss of wages for accompanying family members and, in emergencies, potentially a life-threatening delay. The problem is particularly serious for pregnant women, children, elderly people, trauma victims and patients requiring immediate intervention.An unnecessary referral with a relatively uncomplicated medical condition can cause humongous administrative and economic problem.If the local facility can diagnose and treat the patient, the family may spend a few hundred rupees and return home the same day.If the facility is unable to provide treatment, the same patient may have to travel to the block headquarters or district hospital, arrange transport, spend money on accommodation and food, lose a day’s work and possibly pay for private consultation.In the far flung areas without road connectivity, villagers walk through treacherous terrains, cross dangerous rivulets and forests to take their patient to road heads. For poorer families, healthcare becomes an economic shock.
The pharmacy officer and the forgotten first responder
The demand of the Pharmacy Association of Uttarakhand to make medical sub-centres operational with appropriate deployment of pharmacy officers (erstwhile pharmacists) deserves serious consideration, though such deployment must operate within clearly defined legal scopes of practice, clinical protocols and referral systems.The author has personal experience of the healthcare environment of the hills during the 1980s and 1990s. At that time, when qualified MBBS doctors were not always available in remote locations, pharmacists and other health personnel often became the most accessible healthcare providers for villagers.Their role sometimes extended far beyond the formal expectations of their designation.The author recalls instances where pharmacist provided basic consultation, managed minor injuries and even undertook procedures because there was nobody else available.Whatever one’s view of such practices from the standpoint of modern medical regulation, one fact is undeniable:A trained health worker who is physically present in a remote village is immensely more valuable than an authorised position that remains vacant.However, the lesson from the past should not be interpreted as a justification for unqualified practice.Instead, Uttarakhand should create a legally defined, competency-based hill healthcare cadre, supported by telemedicine, standard treatment protocols, emergency training and rapid referral.The objective should be to eliminate the vacuum between the patient’s home and the doctor.
A dangerous vacuum must not be filled by quackery
A particularly disturbing situation arises when neither doctors nor appropriately trained pharmacy officers are available and other support staffbegins advising patients, prescribing medicines or distributing drugs.This is neither safe nor acceptable.It is especially dangerous in the case of antibiotics.Indiscriminate or inappropriate antibiotic use contributes to antimicrobial resistance (AMR), which the World Health Organization (WHO) recognises as one of the major threats to global public health.The answer is not to leave hills communities without treatment.The answer is to provide them with competent, protocol-based primary healthcare.Every hills health facility should therefore have:a clearly identified responsible healthcare professional;essential medicines;standard treatment guidelines;teleconsultation;emergency stabilisation capability;diagnostic support;electronic patient records wherever feasible andantibiotic stewardship protocols.
The uncomfortable problem of transfers
Recent transfer postings in government departments, including the health sector, have again highlighted the difficulty of ensuring that doctors and other personnel actually serve at their designated hill postings.A hills posting must not become a punishment.At the same time, government service cannot function if employees can indefinitely avoid difficult postings through repeated leave, influence or administrative manoeuvring.The solution should be a combination of:Incentives + accountability + better working conditions + transparent transfer policy.Doctors serving in remote hills areas should receive meaningful incentives such as:additional remuneration;preferential consideration for postgraduate training;additional points in promotion;accommodation;hardship allowance;children’s education support where feasible;assured tenure;adequate security;professional development opportunities etc.Remote hills service should become a career advantage, not a career disadvantage.
A three-tier Hills healthcare model
Uttarakhand requires a special healthcare model suited to its geography.The conventional plains-based model cannot simply be transplanted to the mountains.
Tier I: The Mountain Primary Health Centre for providing comprehensive primary care.Every strategically located village cluster should have access to a functional health facility providing:general OPD;maternal and child healthcare;immunisation;management of common infections;non-communicable disease screening;minor emergency care;wound management;essential diagnostics;essential medicines;telemedicine;health education; and referral coordination.The concept of “time to care” is particularly relevant for hilly and difficult areas. The National Health Mission has itself recognised the importance of strengthening sub-health centres in hilly states according to the time required to reach care.This principle should become the foundation of Uttarakhand’shills health planning.
Tier II: Stronger Block and Community Health Centres (CHCs) for providing access to medicine;surgery;obstetrics and gynaecology;paediatrics;anaesthesia;emergency care;laboratory services;radiology;blood storage where required and ambulance services.The purpose should be to prevent unnecessary movement of patients from the hills to Dehradun, Haldwani or other tertiary centres.The State should identify a limited number of Hills Emergency Hubs strategically located along major population and pilgrimage corridors.
Tier III: Tertiaryand telemedicine networkstoconnect district hospitals and medical colleges with remote hillsPHCs.Telemedicinehas enormous potential in Uttarakhand because geographical distance is one of the principal barriers to specialist consultation.A doctor in a remote PHC should be able to electronically consult specialists in:medicine;paediatrics;cardiology;dermatology;psychiatry;orthopaedics;gynaecology and radiology. The model should be:Village → PHC → Telemedicine → District Hospital → Medical Collegerather than:Village → PHC → unnecessary referral → District Hospital → Medical College. It is worthmentioning that AIIMS Rishikesh is offering yeoman’s service in telemedicine.
A Hills Medical Service for Uttarakhand
One innovative possibility is the creation of a dedicated Hills Medical Service (HMS).These doctors could be recruited and trained specifically for primary and emergency care in remote areas.TheseHMS doctors could receive focused training in:emergency medicine;trauma stabilisation;obstetric emergencies;neonatal care;common infectious diseases;hypertension and diabetes;basic mental-health care;snakebite and animal-bite management; hills-related emergencies;disaster response;rational use of antibiotics and early stage diagnosis of cancer.A structured three-year HMS could become an important bridge between medical education and specialist practice.Alternatively, regular MBBS doctors posted to difficult hills PHCs could be required to serve three to five years as an essential component of public service, with suitable incentives and career benefits.This would need to be designed carefully with professional councils and recruitment authorities, but the underlying principle is sound:Doctors serving the people who finance the public health system should also experience the realities of hills and remote areas termed as priority areas.
Uttarakhand’s health budget: an opportunity and a challenge
The Uttarakhand Budget 2026–27 provides ₹4,916 crore for Health and Family Welfare, compared with ₹4,862 crore in the revised estimates for 2025–26. Health accounts for approximately 5.9% of the State’s total expenditure, compared with an average of about 6.2% across states in the comparable Policy Research Studies (PRS) analysis.The allocation therefore represents a substantial public commitment, but the hills-specific requirement deserves greater attention.If the State is serious about using healthcare as an instrument of regional development, a larger proportion of the health budget should be explicitly earmarked for:hills health infrastructure + human resources + emergency transport + diagnostics + telemedicine.The author’s suggestion of moving towards 10% of total State expenditure on health may be debated from a fiscal perspective, but the underlying argument—that healthcare deserves a substantially higher priority—is compelling.A more practical approach would be to establish a multi-year Hills Health Mission with protected funding rather than relying exclusively on annual budget increases.
Visible improvement in extension of medical facilities in hills and challenges
The case for reform should not ignore the progress Uttarakhand has made.National Family Health Survey (NFHS-6), conducted in 2023–24 and released in 2026, shows considerable improvement in several maternal and child-health indicators.In Uttarakhand:institutional deliveries increased from 83.2% to 88.9%;births attended by skilled health personnel increased from 83.7% to 90.3%;antenatal-care coverage increased from 91.8% to 98.3% and first-trimester pregnancy registration increased from 68.8% to 80.6%.Health-financing coverage has also improved considerably. NFHS-6 reports that households with at least one member covered by a health insurance or financing scheme rose from 62.5% in NFHS-5 to 79.5% in NFHS-6 in Uttarakhand.These are important achievements.But they also reveal an important distinction of coverage and accessibility. A family may possess an insurance card but still struggle to reach an empanelled hospital.A woman may be entitled to free treatment but still have difficulty arranging transport.A PHC may officially exist but not have the personnel or medicines required.Therefore, the next phase of health reform must move from coverage to effective access.The expansion of Ayushman Bharat and other health-financing schemes has the potential to protect families from catastrophic medical expenditure.However, the card must translate into actual treatment.Denial of an eligible patient’s treatment merely because of administrative inconvenience, lack of awareness or reluctance of an empanelled institution should be dealt with firmly.The State should establish:“Ayushman Access Cells”at district and block levels to monitor:rejected claims;denial of eligible treatment;hospital availability;beneficiary complaints;referral patterns and unnecessary out-of-pocket expenditure.The objective should be simple:No eligible person should be denied medically necessary care merely because the system is difficult to navigate.
A Hills Health Index
Uttarakhand should consider developing a Hills Health Index for every district and block.The index could measure:Doctor availability; nurse availability; availability of pharmacy officers; essential medicine availability; diagnostic availability; ambulance response time; average travel time to PHC; average travel time to CHC; telemedicine utilisation; referral rate; unnecessary referral rate; maternal-health indicators; infant-health indicators; non communicable diseases (NCD) screening; Ayushman utilisation; patient satisfaction; staff absenteeism and facility functionality. Every district could then be ranked annually.This exercise will help managing healthcare in better way in the hills.
Interconnection between health, local employment and migration
Migration from the hills cannot be stopped merely by announcing new schemes.People return when the village provides a reasonable quality of life.That means:School + Hospital + Road + Internet + Employment + Water + Electricity + Market. Healthcare is therefore one of the pillars of reverse migration.A young family contemplating a return to its ancestral village may tolerate limited shopping facilities.It may tolerate a longer journey to a railway station.It may even accept fewer entertainment options.But it is unlikely to accept a situation where a medical emergency requires a journey of several hours.Thus, a functional health centre can become an important anchor institution for rural repopulation.Expansion of rural healthcare itself creates employment.Each functioning health facility requires:doctors;nurses;pharmacy officers;laboratory technicians;radiographers;ambulance staff;administrative personnel;sanitation workers;maintenance staff and data-entry and digital-health personnel.Local recruitment, wherever feasible, can improve retention.A person born in a mountain village is more likely to understand its geography, language, culture and practical difficulties.Local youth should therefore be trained to become the human resource backbone of mountain healthcare.Mobile medical units will cater to the additional needs of scattered population in the hills.Mobile services can include:OPD;maternal care;vaccination;NCD screening;laboratory testing;medicines and teleconsultation.The mobile unit should not be an occasional publicity exercise.It should become a scheduled extension of the permanent healthcare system.If Government seriously thinks about such measure in the hills then need of extending freebies will itself die out.
Bolstering Emergency care and curative medicine
Hills geography creates special emergencies:road accidents;landslides;falls;snakebite;cardiac emergencies;pregnancy-related complications;hypothermia;altitude-related illness and disasters and mass-casualty events.Every strategically located PHC should therefore be equipped for stabilisation before referral.The first objective should not always be to transport the patient immediately.It should be:Stabilise → Communicate → Decide → Transportrather than:Refer → Transport → Hope.The State should not spend the entire health budget on hospitals.Preventive healthcare is cheaper than hospitalisation.Village-level programmes should focus on:hypertension;diabetes;cancer screening;tobacco and alcohol-related disease;mental health;maternal health;nutrition;sanitation and elderly care.The changing disease profile of Uttarakhand makes this particularly important. NFHS-6 has also highlighted the continuing importance of lifestyle-related diseases among adults.
Planning forthe extension of medical facilities in the hills
A practical roadmap could be divided into three phases.Within one year: Identify every non-functional or partially functional PHC and sub-centre; publish district-wise vacancies; fill critical vacancies on priority; ensure essential medicines; establish telemedicine at all strategically located remote facilities; introduce standardised emergency kits; establish a transparent remote-posting incentive system and audit ambulance response times.Within three years: Establish a Hills Medical Service; strengthen CHCs as Hills Emergency Hubs; establish district-level diagnostic networks; create accommodation for health personnel; introduce digital health records; expand mobile medical units; create district-level Ayushman Access Cells and develop a Hills Health Index.
Conclusion
The health of a population is not merely a social-sector issue.It is an economic investment.A healthy population:works more efficiently;sends children to school;saves more;spends less on avoidable illness;participates in local economic activity and is more capable of creating enterprises.A functioning healthcare system can help keep people in the hills.It can make villages more attractive to retired personnel, professionals, entrepreneurs and families considering reverse migration.Uttarakhand cannot afford to allow its villages to become empty simply because essential services have migrated towards the plains.The State has made significant progress in healthcare. NFHS-6 demonstrates that maternal and child-health indicators have improved substantially, while health-financing coverage has also expanded.The next challenge is more difficult:to take quality healthcare to the last habitation in the mountains.The solution does not necessarily require a large hospital in every village.It requires a carefully designed network:Functional Sub-Centre → Strong PHC → Hills CHC → District Hospital → Medical Collegesupported by:Hills Medical Service + pharmacy officers + nursing officers + diagnostics + telemedicine + ambulances + essential medicines + accountability.The State should also consider a substantially stronger financial commitment to hills healthcare, including a dedicated and protected Hills Health Missionwith an objective that when a villager falls sick, there should be a competent person, essential medicine and appropriate medical advice available within reasonable reach.If Uttarakhand succeeds in achieving this, healthcare will do more than save lives; it will strengthen villages; it will create employment; it will reduce the economic burden of illness;it will increase confidence among rural hills families and, perhaps most importantly, it can become one of the instruments through which Uttarakhandhills transform outmigration into sustainable reverse migration.A healthy village is a living village and keeping the villages of the hills alive must become one of the highest priorities of Uttarakhand’s development policy.
Dr Prashant Thapliyal
Associate Professor
Army Cadet College
IMA Dehradun
