Clinical Accessibility to Neurotechnological Devices in Rural India

The setting: a three-tier system with a hollow base

India’s public health system is designed as a three-tier pyramid in rural areas:

• Sub-centres (SCs) – the most peripheral contact point, staffed mainly by ANMs and multipurpose workers.

• Primary Health Centres (PHCs) – first level with a doctor, serving as referral units for several sub-centres.

• Community Health Centres (CHCs) – 30-bed facilities meant to provide basic specialist care and serve as referral centres for PHCs (MoHFW, 2012).

In 2020, rural India had about 155,404 sub-centres, 24,918 PHCs, and 5,183 CHCs (Statistics Division, MoHFW, 2021). More recent figures for 2022 show similar orders of magnitude—over 157,000 rural sub-centres, nearly 25,000 rural PHCs, and 5,480 rural CHCs (Statistics Division, MoHFW, 2023).

On paper, this looks like dense coverage. But from a neurotechnology perspective, the pyramid has a very thin layer of actual diagnostic hardware.

• Sub-centres are not expected to have any imaging or electrodiagnostic equipment.

• PHCs are small units with a doctor, a lab technician, and a few beds—but no requirement for X-ray, CT, MRI, or EEG in the national norms.

• CHCs, by contrast, are supposed to have one X-ray unit and a radiographer, along with a lab and operating theatre (MoHFW, 2012).

That means the entire front line of rural care (SCs + PHCs) is structurally designed without neurodiagnostic tools. And even at the CHC level, reality often falls short of the norms.

Who is actually providing care? The rural–urban workforce gap

India is officially classified as a country facing a major human resources for health (HRH) shortage. WHO’s minimum benchmark is 44.5 doctors, nurses, and midwives per 10,000 people; India’s national density is around 20.6 per 10,000, with huge variation between regions (Karan et al., 2021; DocBox, 2023).

The distribution is deeply skewed:

• Only about 27% of India’s population lives in urban areas, but roughly 75% of healthcare infrastructure is located there (DocBox, 2023).

• Urban areas have about four times the doctor density of rural regions (DocBox, 2023).

Rural residents nonetheless generate the bulk of service demand. A classic analysis noted that nearly 86% of all medical visits in India are made by ruralites, with 70–80% of health spending paid out-of-pocket (Singh & Chokshi, 2014).

So:

Rural India sends most of the patients, but gets a minority of the doctors, facilities, and equipment.

For neurology, the picture is even more stark. A mapping of 3,666 neurologists and neurosurgeons found that:

• 30.1% live in the four major metros,

• 29.5% in state capitals,

• 30.6% in tier-2 cities,

• 7.1% in tier-3 cities, and

• only 2.67% live in rural areas, serving about 84.6 million people (Ganapathy, 2015). 

In other words, almost the entire rural population has no resident neurologist or neurosurgeon; specialist neuro-care is essentially an urban service.

Neurological disease burden: big numbers, thin coverage

The India State-Level Disease Burden Initiative estimated that in 2019, neurological disorders contributed substantially to disability and mortality across all states. The largest contributors to neurological DALYs were:

• Stroke – 37.9% of neurological DALYs

• Headache disorders – 17.5%

• Epilepsy – 11.3%

• Cerebral palsy – 5.7%

• Encephalitis – 5.3%

(India State-Level Disease Burden Initiative Neurological Disorders Collaborators, 2021). 

Many of these conditions—stroke, epilepsy, infections, structural brain lesions—depend heavily on timely access to neuroimaging or EEG for diagnosis and triage. But that’s precisely where rural India runs into a wall.

Where are the machines? X-ray, CT, MRI, PET, EEG

At the level of CHCs

National norms specify that a CHC should have X-ray and lab facilities, but not CT or MRI; those are expected at district and tertiary hospitals (MoHFW, 2012).

A Planning Commission–commissioned study of 31 sample CHCs in several states found that:

• 26 had an operating theatre,

• 19 had a pathology lab, and

• only 20 had X-ray machines (about two-thirds of the sample) (Development Monitoring and Evaluation Office, 2015). 

So even at the first level where X-ray is supposed to exist, access is patchy. And at the vast network of sub-centres and PHCs below that level, there is essentially no radiology or neurotech by design.

District hospitals and above

Neuroimaging becomes more visible at district hospitals and medical colleges, but availability is still uneven:

• A 2016 report from Delhi described one MRI machine being shared by 34 government hospitals, leading to long queues and week-long waits even for in-patients needing scans (Hindustan Times, 2016).

• A study on PET/CT capacity noted that India had a much smaller installed base of PET/PET-CT systems relative to CT and MRI, with machines concentrated in large cities and cancer centres (Khan et al., 2016).

While overall CT and MRI numbers have grown, they remain heavily clustered in urban centres and private hospitals. Government documents and market studies show that district hospitals and diagnostic centres are the primary users of CT and MRI, with rural public facilities often relying on PPP contracts or referrals to private centres (Competition Commission of India, 2021).

EEG and other neurotech

Compared to CT/MRI, EEG availability is even less systematically documented. In practice:

• EEG services are mostly provided by neurology departments at medical colleges and tertiary hospitals.

• Many district hospitals lack neurology departments altogether, let alone EEG labs.

• For rural patients with seizures, diagnosis is often clinical, with limited access to video-EEG or advanced epilepsy work-up (Bhardwaj et al., 2018).

So the typical rural care pathway for neurological symptoms is:

sub-centre → PHC (no imaging) → CHC (X-ray if you’re lucky) → district/tertiary hospital (possible CT/MRI/EEG, if present and affordable).

Each step adds travel, time, and out-of-pocket costs.

What this looks like for a rural patient

Put it together, and a pattern emerges:

1. Most doctors and nearly all neurologists are in cities. Only 2.67% of neurologists/neurosurgeons live in rural areas, covering 84.6 million people (Ganapathy, 2015).

2. Rural people still make most visits and pay mostly out-of-pocket. 86% of medical visits are made by rural residents; 70–80% of costs are OOP (Singh & Chokshi, 2014).

3. Local facilities lack neurotech. SCs and PHCs are not equipped with X-ray, CT, MRI, or EEG; CHCs are supposed to have X-ray but many do not (MoHFW, 2012; Development Monitoring and Evaluation Office, 2015).

4. Neurological conditions are common and disabling. Stroke, epilepsy, headache, cerebral palsy, and encephalitis together account for the majority of neurological DALYs (India State-Level Disease Burden Initiative Neurological Disorders Collaborators, 2021).

The human translation:

• A villager with sudden weakness may be told to travel tens or hundreds of kilometres to reach a CT-capable centre—often after the optimal thrombolysis window has closed.

• A child with recurrent seizures may never reach an EEG lab; treatment is based on intermittent generalist visits.

• A person with progressive cognitive decline might never get basic brain imaging or formal cognitive testing, and the condition may be dismissed as “old age.”

Neurotechnology exists—just not where the majority of patients live.

Telemedicine & teleradiology: partial bridges

India has been a global early adopter of teleradiology and tele-neurology.

• As early as 2009, teleradiology pioneers were transmitting radiological images from remote hospitals to specialists in cities, specifically to bridge rural radiologist shortages (Burute & Jankharia, 2009).

• Ganapathy (2015, 2018) has argued that given the extreme concentration of neurologists in urban centres, “additional virtual neurological care” is the only realistic way to offset workforce maldistribution, describing tele-stroke, tele-epilepsy, and other tele-neuroscience initiatives in India (Ganapathy, 2015, 2018).

• Tamil Nadu’s government created a statewide teleradiology network linking 58 CT and 18 MRI machines in public hospitals to a central reading hub, explicitly to compensate for radiologist shortages and expand access (Ramakrishnan, 2018).

More recently, reviews and commentaries emphasise that:

• Teleradiology is now indispensable in India’s imaging ecosystem, with companies partnering with government programmes and rural health missions to provide reporting services to remote facilities (Kalyanpur, 2023). 

• Technology innovations—cloud PACS, AI-assisted triage, mobile networks—can help bring imaging interpretation closer to primary care, even if scanners remain centralized (Chandramohan et al., 2023). 

For neurology, tele-solutions now support:

• Tele-stroke consults, where CT images from district hospitals are reviewed by neurologists in urban hubs.

• Tele-epilepsy clinics that adjust treatment remotely when EEG and imaging data can be uploaded.

• Tele-neuro-ICU monitoring in some tertiary hospitals.

However, these innovations have prerequisites: working scanners, connectivity, and at least some trained staff at the sending site. Many rural districts still don’t clear that bar.

So what would “accessible neurotechnology” actually mean in rural India?

Given this landscape, “clinical accessibility to neurotechnological devices” has to be defined realistically. It probably doesn’t mean putting a 3-Tesla MRI or a PET-CT in every PHC. Instead, a plausible equity-focused design might look like this:

Fix the basics at the periphery

• Ensure sub-centres and PHCs are fully functional according to IPHS norms—a 2020 analysis found only 3.4% of 155,000+ sub-centres met IPHS standards as of March 2020 (Ugargol et al., 2023, summarizing Rural Health Statistics 2019–20).

• Invest in training and decision-support tools so PHC doctors can take thorough histories, perform focused neurological exams, and recognize “red flag” symptoms requiring urgent imaging.

Guarantee core neurodiagnostics at the district level

• Treat district hospitals as the minimum guaranteed point for CT, basic MRI, and EEG in every district, with clear protocols for acute stroke, epilepsy, and CNS infections.

• Use public–private partnerships carefully to expand scanner availability while keeping fees affordable and transparent.

Build tele-neurology and tele-radiology as default

• Network all CT/MRI scanners in the public sector (like Tamil Nadu did) so every rural district can access 24/7 radiology reporting (Ramakrishnan, 2018; Burute & Jankharia, 2009).

• Develop regional tele-neurology hubs that can read EEGs, review imaging, and provide specialist opinions to district and select CHC facilities (Ganapathy, 2015, 2018).

Deploy ultra-portable and low-cost devices intentionally

• Encourage pilot deployment of portable EEG, low-field MRI, and handheld ultrasound for neuro-relevant use cases (e.g., neonatal brain imaging, carotid scans) in selected rural hospitals, paired with strong tele-support.

• Combine such devices with AI-based decision support, making it easier for non-neurologists to interpret basic findings safely.

Align financing with equity, not volume

• Move away from pure fee-for-service incentives that push high-volume scanning in cities while rural areas wait in line.

• Experiment with bundled payments and performance metrics that reward early diagnosis, reduced disability, and equitable access across urban and rural populations (Karan et al., 2021; Ugargol et al., 2023).

Conclusion: Designing for rural brains, not just urban machines

In India, neurotechnology has grown impressively—but mostly upwards and inwards: upwards to tertiary centres, and inwards toward metros and large private hospitals. Meanwhile:

• Rural India still makes most of the medical visits and shoulders heavy out-of-pocket costs (Singh & Chokshi, 2014).

• Only a tiny fraction of neurologists live in rural areas (Ganapathy, 2015).

• Local facilities lack scanners and EEG, and even CHCs often operate below equipment norms (MoHFW, 2012; Development Monitoring and Evaluation Office, 2015).

• Neurological disorders remain a major, state-wide burden (India State-Level Disease Burden Initiative Neurological Disorders Collaborators, 2021).

True accessibility to neurotechnological devices in rural India isn’t only a story of buying more machines. It’s a design problem that spans:

• where machines are placed,

• who can operate and interpret them,

• how patients travel through the system, and

• how the system pays for and rewards care.

Until those pieces are redesigned with rural patients at the centre, neurotechnology will remain something most villagers hear about, rather than something that actually changes their neurological outcomes.

References

Bhardwaj, A., et al. (2018). Profile of patients from a neurology registry in resource-limited rural north-west India. Annals of Indian Academy of Neurology, 21(3), 193–198.

Burute, N., & Jankharia, B. (2009). Teleradiology: The Indian perspective. Indian Journal of Radiology and Imaging, 19(4), 259–262.

Chandramohan, A., Krothapalli, V., Augustin, A., et al. (2023). Teleradiology and technology innovations in radiology: Status in India and its role in increasing access to primary health care. Lancet Regional Health – Southeast Asia, 23, 100195.

Competition Commission of India. (2021). Market study of diagnostic medical imaging equipment industry in India.

DocBox. (2023). Healthcare access in rural India.

Development Monitoring and Evaluation Office. (2015). Functioning of Community Health Centres (CHCs). NITI Aayog, Government of India.

Ganapathy, K. (2015). Distribution of neurologists and neurosurgeons in India and its relevance to the adoption of telemedicine. Neurology India, 63(2), 142–154.

Ganapathy, K. (2018). Telemedicine and neurosciences. Neurology India, 66(6), 1733–1738.

Hindustan Times. (2016, July 23). Need an MRI scan in a Delhi government hospital? Come back in 2018.

India State-Level Disease Burden Initiative Neurological Disorders Collaborators. (2021). The burden of neurological disorders across the states of India: The Global Burden of Disease Study 1990–2019. The Lancet Global Health, 9(8), e1129–e1144.

Karan, A., Negandhi, H., Hussain, S., Zapata, T., & Zodpey, S. (2021). Size, composition and distribution of health workforce in India: Why, and where to invest? Human Resources for Health, 19, 39.

Khan, S. H., Navalkissoor, S., & Jha, A. (2016). Cancer and positron emission tomography imaging in India: The past, present and future. World Journal of Nuclear Medicine, 15(1), 2–7.

Ministry of Health and Family Welfare. (2012). Rural health care system in India. Government of India.

Singh, S., & Chokshi, M. (2014). Health care in rural India: A lack between need and feed. Journal of Family Medicine and Primary Care, 3(3), 187–189.

Statistics Division, Ministry of Health and Family Welfare. (2021). Rural Health Statistics 2019–20. Government of India.

Statistics Division, Ministry of Health and Family Welfare. (2023). Rural Health Statistics 2021–22. Government of India.

Ugargol, A. P., et al. (2023). In search of a fix to the primary health care chasm in India: Can institutionalizing a public health cadre and inducting family physicians be the answer? Journal of Family Medicine and Primary Care, 12(5), 857–863.

Ramakrishnan, R. (2018, June 27). Tamil Nadu networks all CT, MRI machines in public hospitals. The Hindu – Science Chronicle.