Application of a bottom-up approach to reduce healthcare disparity between the urban and rural areas




Barriers to Healthcare, Rural Healthcare, Antenatal Care, Child Malnutrition, Bottom-up approach, ASHWINI


Disparity in access to healthcare between rural and urban regions occurs world-wide, both in higher and lower income countries. To offset poor health outcomes a number of approaches to structuring healthcare services can be used. Several factors have been identified to play a role, however there are differing degrees of severity in how they contribute to the healthcare gap - depending on whether a higher or lower income country is being evaluated. Traditionally, healthcare systems worldwide adopt a top-down approach which is initiated by large institutions providing resources required for large scale projects along with centralisation of efforts. Although it does lead to change, the results can be short-lived. The authors discuss the bottom-up approach used in ASHWINI organisation in Gudalur, India which allowed for the development of accessible and sustainable healthcare system managed by the community. Other projects, based in part on the principles of a bottom-up approach, have been applied in other countries to reduce healthcare disparities. When designed to deliver geographically-accessible, locally managed, culturally appropriate care, the bottom-up approach can provide sustainable results and being universal in nature, it could be applied in other setting with similar set up.


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Douthit N, Kiv S, Dwolatzky T, Biswas S. Exposing some important barriers to health care access in the rural USA. Public Health [Internet]. 2015 [cited 6 July 2021];129(6):611-620. Available from:

Debate: Rural Health Care [Internet]. Royal College of Nursing. 2019 [cited 2 July 2021]. Available from:

Weisgrau S. Issues in Rural Health: Access, Hospitals, and Reform. Health Care Financing Review [Internet]. 1995 [cited 10 July 2021];17(1). Available from:

Peprah P, Abalo E, Agyemang-Duah W, Budu H, Appiah-Brempong E, Morgan A et al. Lessening barriers to healthcare in rural Ghana: providers and users’ perspectives on the role of mHealth technology. A qualitative exploration. BMC Medical Informatics and Decision Making [Internet]. 2020 [cited 3 July 2021];20(1). Available from:

Mohan P, Kumar R. Strengthening primary care in rural India: Lessons from Indian and global evidence and experience. Journal of Family Medicine and Primary Care [Internet]. 2019 [cited 5 July 2021];8(7). Available from:

Zhu A, Tang S, Thu N, Supheap L, Liu X. Analysis of strategies to attract and retain rural health workers in Cambodia, China, and Vietnam and context influencing their outcomes. Human Resources for Health [Internet]. 2019 [cited 17 October 2021];17(1). Available from:

Ogunlayi F, Britton P. Achieving a ‘top-down’ change agenda by driving and supporting a collaborative ‘bottom-up’ process: case study of a large-scale enhanced recovery programme. BMJ Open Quality [Internet]. 2017 [cited 20 June 2021];6(2). Available from:

World Bank Country and Lending Groups [Internet]. The World Bank | Working for a World Free of Poverty. [cited 22 July 2021]. Available from:

The World Factbook. India [Internet]. [cited 16 June 2021]. Available from:

Gupta I, Patel N, Tikkanen R, Osborn R, Mossialos E, Djordjevic A et al. International Health Care System Profiles. India [Internet]. The Commonwealth Fund. 2020 [cited 21 June 2021]. Available from:

ASHWINI (Association for health welfare in the Nilgiris) A health program for the people by the people [Internet]. ASHWINI. [cited 21 June 2021]. Available from:

Rajpal S, Joe W, Subramanyam M, Sankar R, Sharma S, Kumar A et al. Utilization of Integrated Child Development Services in India: Programmatic Insights from National Family Health Survey, 2016. International Journal of Environmental Research and Public Health [Internet]. 2020 [cited 22 June 2021];17(9). Available from:

Annual Report- April 2017-March 2018 [Internet]. ASHWINI. [cited 21 June 2021]. Available from:

The Economist Intelligence Unit. Democracy Index 2020 In sickness and in health? [Internet]. The Economist Intelligence Unit; 2021. Available from:

Murthy N. Decentralized Health Planning: Lessons from Two Districts in India. Journal of Health & Population in Developing Countries [Internet]. 1998 [cited 12 October 2021];. Available from:

Björkman M, Svensson J. Power to the People: Evidence from a Randomized Field Experiment on Community-Based Monitoring in Uganda*. Quarterly Journal of Economics [Internet]. 2009 [cited 31 October 2021];124(2):735-769. Available from:

Gill Z, Bailey P. Bottom up and top down: A comprehensive approach to improve care and strengthen the health system. Journal of the Pakistan Medical Association [Internet]. 2010 [cited 13 October 2021];. Available from:

The Health Foundation. What’s getting in the way? Barriers to improvement in the NHS [Internet]. The Health Foundation; 2015. Available from:’s-getting-in-the-way-barriers-to-improvement-in-the-nhs.

Top down or bottom up? [Internet]. 2007 [cited 14 October 2021]. Available from:

Mcdermott A, Hamel L, Steel D, Flood P, Mkee L. Hybrid healthcare governance for improvement? Combining top-down and bottom-up approaches to public sector regulation. Public Administration [Internet]. 2015 [cited 13 October 2021];93(2):324-344. Available from:

How to Cite

Malicka A, George N. Application of a bottom-up approach to reduce healthcare disparity between the urban and rural areas . JMS [Internet]. 2021 Nov. 26 [cited 2023 Jun. 1];90(4):e568. Available from:



Original Papers
Received 2021-09-14
Accepted 2021-11-02
Published 2021-11-26