It takes a village
Under a blazing sun, in a poor tribal area in Madhya Pradesh, I try to get Kamla to speak. Barely 20, face covered by a frayed pallu, she presses Gopi, her one-year-old, to her chest. Severely malnourished, he can be saved only at a government facility two hours away. Kamla’s mother-in-law listens in. Kishore, her husband, looks away. Ram Babu, the patriarch, generously moustached, mildly inebriated, pronounces: “What God takes away, God gives back. If one child dies, there will be another”. His face darkens—“No bahu of mine will go to the city, it’s not safe. She has to cook, and to earn here.” It takes some doing, but we prevail upon him.
This episode encapsulates India’s health challenges. Gopi was simply left out of the harried village health worker’s cumbersome registers. The facility was too far to access. Gender inequity, and social and cultural norms took away Kamla’s voice. Policies and programmes to support women and prevent malnutrition never reached Gopi.
15 years ago, I made a great leap from business to public health. Since then, I have been working primarily at the grassroots, more recently in maternal and child health in the villages of Rajasthan. I’ve met many Kamlas in many states.
The goal of any public health system is universal healthcare, where every citizen is assured of quality health services, both preventive and curative. We seem far away from meeting that goal. In this first column for Mint, I would like to share what I have learned about the public health system in India, and despite all the gaps, why I am still an optimist. In later columns, I will dive deeper into specific issues. The data is mostly from public, government sources.
I think of India’s public health as an ecosystem with inter-linked components, necessary to achieve the goal of universal healthcare.
Government spending is inadequate: Public health spending was a dismal 1.2% of GDP in 2016-17. India ranked 15 places from the bottom of 188 countries where figures were available as per 2014 World Health Organization (WHO) data. Why eight poor states in 2016 did not spend more than 40% of their National Rural Health Mission allocation is another story. Consequently, for every rupee received from government, the poor end up spending two rupees of their own money on health.
Medical insurance cover is insufficient: The Rashtriya Swasthya Bima Yojana initiative provides hospitalization coverage of up to Rs30,000 annually for individuals below the poverty line. It’s a positive step, but so far not very effective. 40% of eligible households hadn’t taken up the scheme, and of those who did, out-of-pocket health expenses hadn’t reduced, according to a 2017 study by Social Science Medicine.
National programmes are well-conceived: Here, we can be more positive. India has more than 20 well-conceived national health programmes, across preventive and treatment services. For example, the Integrated Child Development Service programme is designed to meet the nutrition needs of pre-school children and pregnant/lactating mothers in every village. The National Rural Health Mission seeks to provide quality health care to rural populations. Swachh Bharat is a major declaration of intent by the government in tackling foundational issues of water and sanitation.
Infrastructure is deficient: India has a health infrastructure that reaches down to the village level. It is a pyramid structure of sub-centres (SCs), primary health centres (PHCs), and community health centres (CHCs) feeding into a tertiary centre, the district hospital. Nationally, there is a shortfall of 19% in SCs, 22% in PHCs, and 30%in CHCs. Of the functioning SCs, 20% don’t get regular water, and 24% get no electricity. Only 37% of PHCs have operation theatres, and 69% have a labour room. Among CHCs, 60% don’t have a stabilisation unit for new-borns, and 44% don’t have a functional X-Ray machine. Facilities need staffing. There is an 82% shortage of specialised staff at CHCs. Only 26% of PHCs have lady doctors, and 64% have lab technicians.
Empowered frontline workers can achieve great results
There are three government frontline workers. There is the ASHA (accredited social health activist), who goes house-to-house to spot critical health cases. The anganwadi worker (AWW) looks out for malnourished kids, and provides supplementary food rations to pregnant and lactating mothers. The auxiliary nurse midwife (ANM) provides medical services and refers the case upward if needed.
We have found in Rajasthan that if you enable these three workers to share data, they can target the most needy cases such as high-risk pregnancies, and work together to prevent a tragedy. We do this through two pioneering innovations. The first is “village mapping” where the three frontline workers meet, create a large map, share information, placing bindis to locate high-risk cases, and develop a joint intervention plan. The second is a first of its kind “AAA-App” that enables the three women to share this same data digitally, in real time. The state government is currently expanding both initiatives.
Community awareness is vital: Even women as marginalised as Kamla can become part of a larger community of aware and engaged consumers of health facilities. The Ekjut program in Jharkhand demonstrated this. We are finding that adolescent girls can play a crucial community role in Rajasthan.
Two of every three births are from villages. Most health problems related to maternal and child health have known solutions and can be managed at the village level itself. If Kamla had received regular ante-natal check-ups, if her anaemia was addressed, if she knew she had to keep her new-born warm and feed Gopi only breast milk, chances are that he would have been a well-nourished baby. And if Swachh Bharat truly brings clean drinking water and sanitation, fewer kids would need to be taken to ill-equipped and understaffed PHCs and CHCs.
There are three issues that have to be tackled at the village level. They are the supply side (AAA effectiveness), the demand side (community mobilization) and positive advocacy to address barriers. Government, corporate entities, non-government organisations, philanthropists, and the public at large, all need to provide support.
Thus, several components and entities need to work together for the Indian public health system to realize its potential.
In the past 15 years, I have found time and again that the solutions are at the base of the pyramid. And that is why I am optimistic.
Ashok Alexander is founder-director, Antara Foundation