Changing the discourse on health and inclusive growth
◗ India seems to have awakened to the glaring realities of its healthcare system. The National Health Policy 2017, the first comprehensive health policy document after the last policy was issued 15 years ago in 2002.
Inclusive growth is now perhaps the strongest buzzword in development discourse. We have all been talking about growth without understanding that development interventions will not be effectual if they don’t benefit all sections of society. The illusion of trickle- down and ripple-effects of growth had kept us on the wrong track for quite long.
Development programmes have delivered good outcomes for some segments of society, but sadly only marginal or zero sum for many others. It is this realisation that has prompted policy makers to draft strategies that can deliver outcomes that benefit everyone. An important new learning is that health or healthcare is a key component of inclusive growth. It is an important piece in the development ecosystem, in independent India too inclusive health was identified as a hallmark of the country’s policy architecture.
As the Organization for Economic Co- operation and Development ( OECD) puts it: “Adults in good health are more productive; children in good health do better at school. This strengthens economic performance, and also makes economic growth more sustainable and inclusive”.
Healthcare has now become a critical leverage point where government action could have the maximum impact. The government’s development wisdom is now focused on identifying the strategic leverage points where successful action could trigger many supportive reactions rather than fixing everything everywhere.
This year marks the 40th anniversary of an important signpost in the world’s history of healthcare. At a conference on Oct 25– 26 in Almaty, Kazakhstan, the Alma Ata Declaration was adopted by the World Health Organization ( WHO) with a pledge to focus on primary healthcare. The vision was to bring healthcare closer to people, by creating a network of rural dispensaries.
Since then, there have been continuous efforts for establishing str- ong primary care systems in local communities in a bid to achieve universal healthcare ( UHC). The results have not been uniform on account of several policy deficiencies. The pursuit of “vertical” programmes ( targeting a single disease) has resulted in health services functioning in silos, in an uncoordinated manner and being unable to respond to people’s real health needs, which are complex and can be addressed by only by a range of healthcare channels.
India now seems to have awakened to the glaring realities of its healthcare system. The National Health Policy 2017, the first comprehensive health policy document after the last policy was issued 15 years ago in 2002 is evidence of this intent. As Prime Minister Narendra Modi put it, “The National Health Policy marks a historic moment in our endeavour to create a healthy India where everyone has access to quality healthcare.”
The NHP reckons four major contextual changes that perhaps motivated the overall policy approach: ( i) increasing burden of noncommunicable diseases ( NCDs) and certain infectious diseases, ( ii) robust growth of healthcare industry, ( iii) high incidence of catastrophic healthcare spending by households, and ( iv) an enhanced growth-enabled fiscal capacity of India. The 71st National Sample Survey ( NSS) January-June 2014 revealed that out of the total hospitalisation cases in rural areas, 58 per cent were in private clinics and 42 per cent were in public hospitals.
The corresponding figures for urban areas were 68 per cent in private and 32 per cent in public. Of a total of 628,708 government beds, only 196,182 are in rural areas. India is regarded as the world’s pharmacy bowl, but ironically a huge proportion of its population sinks into the poverty pit every year due to highly expensive medicines, mostly for cancer, heart ailments and serious injuries that maim most of the victims. All these point to a need for more local community owned and community — designed model of healthcare. India has been home to several internationally acclaimed homegrown models of community healthcare. The earliest innovators were two doctor couples in Maharashtra: Dr Abhay Bang and his wife, Rani in Gadchiroli and doctor Raj and Mabelle Arole in Jamkhed separated by a distance of 664 kms. The Bangs set up the charity SEARCH ( Society for Education, Action and Research in Community Health) in 1985, whereas the Aroles founded the Comprehensive Rural Health Project, ( CRHP) in 1970. CRHP is a comprehensive approach to primary health care at the community level, mobilising communities to use simple tools, adapted to the local context, to address priority health needst. In 1972, the World Health Organization ( WHO) officially recognised CRHP’s pioneering work in villages, also known in the global health community as the Jamkhed Model. The innovation of this approach lies in involving the communities themselves, especially those who are poor and marginalised, in designing their health and development programmes. Through their “Shodh Gram” hospital, the Bangs operate their home- based newborn care model. This model does not depend upon doctors, nurses, hospitals or expensive equipment. It empowers women to use simple medical knowledge and skills to save their newborns.
Instead of villagers having to walk for miles to get to the nearest hospital, health visitors ( called arogyadoots, which means “health messengers” visit remote locations carrying a small healthkit pack on their back. As more women are trained, they pass on their knowledge to others, and entire communities become empowered.
The insistence that patients must be treated in “techno- centric” hospitals by western- trained physicians is to the minds of Bangs, ridiculous particularly in rural India, where lack of transport and low income levels make modern healthcare inaccessible.
A relatively recent innovation is the Arogya Sakhi model promoted by Prema Gopalan in western Maharashtra who established the acclaimed non- profit Swayam Shikshan Prayog ( SSP). SSP selects and trains women who are landless, but have basic education, are interested in healthcare and community service. These Arogya Sakhis are equipped with health devices such as glucometers, blood pressure machines, etc., along with a mobile tablet, they visit rural women door- to- door to conduct basic medical tests.
The sakhis charge a nominal fee of ` 150 from each individual, which includes cost of generation of report, printing charges, doctor’s fee, conducting tests, and even delivering the reports at door steps. After accounting for all costs, a sakhi is usually able to earn ` 50 to ` 70 per beneficiary. “These women conduct a series of preventive tests using mobile health devices, capture the data by using a tablet and upload the results on the cloud server developed by our technology partner,” says Gopalan. The data is then shared with a doctor, who analyses it and provides a report and prescriptions over the cloud. The Sakhis then guide the patients on the treatment and precautions to be taken. Wherever needed, they are referred to SSP’s partner specialist doctors and hospitals for further treatment.
Since many villages have scarce medical facilities, the Sakhis are also trained to provide medical help related to minor burns, cuts, joint pains and other ailments, for which they charge nominal fees. The movement has now reached deep pockets. There are now 150 Arogya Sakhis who have reached out to more than 500 villages.
SSP was awarded the 6th Billionth South Asia Award 2015in M- Health category for this technology enabledproject implemented in partnership with Sofomo Embed- ded Solutions Pvt. Ltd. Any visitor to villages where these community healthcare models are primary drivers of health awareness will marvel at the ability of these health workers to connect with and explain things to women.
Their lack of education is not a handicap; it is an advantage. They understand how to reach the people who most need reaching: illiterate, vulnerable and poor village women.
They know how they think and live, because they are one of them. India is now a far better placed to make inclusive health a reality. An enormous social capital has been built up over the years. It can be leveraged to support innovations in healthcare for development of new and affordable drugs, therapies or medical devices.
Public policy needs to actively promote those innovations that can accelerate our journey to universal healthcare: increased access, quality and affordability of health care; increased responsiveness of the system to healthcare needs; greater health equity; autonomy in healthcare choices; and above all, improvements in the social determinants of healthcare.