Skip to main content

India home to acclaimed home-grown models of community healthcare

Dr Abhay and Rani Bang
By Moin Qazi*
Women are not dying because of diseases we cannot treat…They are dying because societies have yet to make the decision that their lives are worth saving. – Mahmoud Fathalla, Chair of the WHO Advisory Committee on Health Research
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 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”. In fact it is much less expensive to produce healthy children than to keep repairing ill born ones.
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 October 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 strong 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 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 an 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: Increasing burden of non-communicable diseases (NCDs) and certain infectious diseases; robust growth of the healthcare industry; high incidence of catastrophic healthcare spending by households; and 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.
There is a massive shortage of healthcare professionals in the country and their supply must therefore be expanded rapidly if we want to fulfill our commitments in this sector. Country-wise availability of doctors per million people (World Bank Report) Cuba: 7519, Russia: 3975, China: 3625, UK: 2825, US: 2568, Brazil: 1852, Pakistan: 978, Sri Lanka: 881, South Africa: 818, India: 758, World Average: 1857.
All these point to a need for more local community-owned and community-designed model of healthcare which also incorporates the experience of traditional health systems. In the third century BC, emperor Ashoka is believed to have said, “I am going to propagate medicinal herbs throughout my kingdom to ensure complete accessibility to all my subjects as it is my ethical responsibility to provide good health to all people.” The country has 750,000 medical practitioners of the traditional medical systems of Siddha, Unani, Ayurveda, and Homeopathy (AYUSH). They receive five and a half years of medical training, and about 70 percent are legally permitted to prescribe allopathic medicines. While most are based in rural areas (unlike their MBBS counterparts), there are few professional options for them and there has been no concerted effort to integrate AYUSH practitioners into the primary care level, which could fill the gap of doctors practicing in these areas.
One of the obvious reasons is the strong resistance from the allopathic practitioners particularly bodies like Indian Medical Council which would not allow dilution of its standards. Several areas continue to be serviced by quacks and faith healers’ wisdom demands that we work out a an acceptable model of healthcare that combines the best features of all systems and is at the same time safe and affordable.
India has been home to several internationally acclaimed home-grown models of community healthcare. The earliest innovators were two doctor couples in Maharashtra: 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 needs. In 1972, the World Health Organisation 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 new-born 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 new-borns.
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 health kit 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), which 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. Along with a mobile tablet, they visit rural women door-to-door to conduct basic medical tests.
The sakhis charge a nominal fee of Rs 150 from each individual, which includes cost of generation of rep-ort, 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 Rs 50 to Rs 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. They present a unique human resource to be deployed to helping people with both physical and mental disorders.
SSP was awarded the sixth Billionth South Asia Award 2015 in M-Health category for this technology enabled-project 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. Co-designing co-creating, and co-owning health services is an increasingly effective and scalable path to inclusive health. Putting people and communities in charge of their own healthcare leads to better outcomes and increased productivity by leveraging traditional knowledge and local healing plant material.
The government too has embraced the lessons from these grassroots initiatives and the public health programmes are modeled round them. The community health worker, including cadre such as the ASHA worker and the Auxiliary Nurse Midwife, are indeed the foundation of our public health care system. They have played a central role in the success of our public health programmes which substantially reduced maternal and child mortality.
An ASHA (Accredited Social Health Activist) is a community worker who is appointed to assist pregnant women to avail themselves of their health entitlements. There is one ASHA for every 1,000 women. Her job is to spread awareness about antenatal care, ensure that women go to hospitals for deliveries, and receive proper care during childbirth and the postpartum period. Many ASHAs accompany women to a health facility for antenatal check-ups, delivery and postnatal check-ups.
Baby Fakira Sidame is an ASHA worker, or frontline health worker in villages in the Yavatmal district of Maharashtra. Chosen by her village as their health representative, Baby mobilizes her community to bring their children for routine immunizations, and provides counselling to pregnant women and new mothers about breastfeeding, vaccinations, hand-washing, and other basic health needs. She also runs a day care centre for young children in the community, providing basic education and lunch.
“Drastic changes have occurred. No one used to do family planning. Many children suffered from polio, many of whom died or were not able to walk. But over the last five years that I have been working, I have been able to reach out to these families through home visits, through meeting them and informing them about better health practices and vaccination. Now there are a lot of changes happening in these communities. People are adopting family planning and coming for vaccination and keeping good hygiene practices. We are trying to do our best and continue to improve our results. Immunization is very important. It is like holy water. It will save children from polio, diphtheria, pertussis, tetanus, and measles. If a child gets immunized, then my community becomes healthier.
“And similarly, my country will also become healthy. When a hungry child gets fed at my centre, I take great pleasure in seeing that that child is full. Also when a child comes to my centre and gets a vaccination on time. Seeing those cheers on the faces of the children brings me great happiness. That’s what motivates me,” says Baby. A highly laudable vision.
Corporate India too has been quite alive to these indigenous models and has been replicating it through either their CSR or social business programmes. Through ‘Aarogya’, the health initiative under its CSR programme, Tata Motors operates mobile health clinics for remote tribal community outreach, offering last-mile aid. Aarogya also focuses on maternal and child health, with a holistic and balanced approach towards preventive healthcare and curative healthcare interventions. The Company has tied up with nutrition rehabilitation centres across India to raise awareness on the health of children, pregnant women and lactating mother.
Arogya Parivar, another successful community-centric health model, is a sustainable social business initiative by Swiss drug maker Novartis, and not a Corporate Social Responsibility project. Social business is a for-profit model whereas CSR is not-for-profit. The awareness generated in remote villages by the Aarogya Parivar animators is followed-up with a doctor close by or by connecting via the internet to a doctor at a larger hospital who helps with diagnosis. Given the magnitude of the healthcare challenge in India, philanthropy is not enough. We also need scalable business models that take into account the needs of society.
At present about 24% of the total spend on CSR is focused on healthcare. However, much of the spending tends to be focused on health camps and building hospitals or donating to hospitals for upkeep of facilities. Health camps tend to have a short-term orientation and are number driven. Setting up and running hospitals are often poorly targeted. There is a need to focus on primary care rather than tertiary care. The local youth could be trained to advice residents on simple treatments. Community health works, supported under CSR, could help with basic diagnostics like blood pressure, pulse, and sugar testing.
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.
*Development expert

Comments

TRENDING

Sorry state of Indian academics: why was I thrown out of Delhi varsity interview room?

By Dr. Abhay Kumar*  The interview for the post of political science (Guest) was scheduled on Saturday afternoon, September 10, 2022. Given my previous experience, I was not willing to appear for it. But friends persuaded me to go and fight for our rights. I reached the college well before the time. When my turn came and I entered the room. The first question was asked about my experience. I said that I had taught for four semesters at NCWEB. I mentioned that I had taught ”Comparative politics”, “International Relations”, “Comparative Political Thoughts” and “Indian Government and Politics”. I said that as a teacher I had taught all the articles listed in the syllabus of the same Delhi University and the expert could ask anything about any reading or ideas. Friends, the first question asked by a female member, perhaps she is the principal of the college if I am not wrong, to give the full form of NCWEB! The second question asked by a male expert, perhaps he is the political science dep

Musician and follower of Dr Ambedkar? A top voilinist has this rare combination!

Some time back, a human rights defender, Vidya Bhushan Rawat, who frequently writes for Counterview, forwarded to me a video interview with Guru Prabhakar Dhakade, calling him one of India's well known violinists.  Dhakade is based in Nagpur and has devoted his life for the Hindustani classical music. A number of his disciples have now been part of Hindi cinema world in Mumbai, says Rawat. He has performed live in various parts of the country as well as abroad. What however attracted me was Dhakade's assertions in video about Dr BR Ambedkar, India's undisputed Dalit icon. Recorded several years back at his residence and music school in Nagpur, Dhakade not only speaks candidly about issues he faced, but that he is a believer in Dr Ambedkar's philosophy. It is in this context that Dhakade narrates his problems, even as stating that he is determined to achieve his goal. A violinist and a follower of Ambedkar? This was new to me. Rarely do musicians are found to take a

Tokens, symbols or incipient feminists? : First generation women sociologists in India

By IMPRI Team  The online event on the theme ‘Tokens, Symbols or Incipient Feminists? : The first Generation of Women Sociologists in India’ was held as an initiative of Gender Impact Studies Center (GISC), IMPRI Impact and Policy Research Institute, New Delhi under the #WebPolicyTalk series of The State of Gender Equality – #GenderGaps. Inaugurating the session, Zubiya Moin welcomed the speaker and participants to the program, followed by an introduction to the eminent panelists. Commencing the program, Prof Vibhuti Patel made her opening remarks welcoming Prof Kamla Ganesh, Feminist Sociologists and then greeted Prof Ratna Naidu and the editors of book ‘Reimaging Sociology in India: Feminist Perspective’, Dr Gita Chadha and Dr. Joseph M.T. along with Prof Arvinder Ansari and also welcomed all participants. She set up the stage by making us familiar with women sociologists and their works. Dr Gita Chadha, Editor of the book ‘Reimaging Sociology in India: Feminist Perspective’ After th

Omission of duty by BSF and police: Hindu forcefully kidnapped, taken to Bangladesh

Kirity Roy, Secretary, Banglar Manabadhikar Suraksha Mancha (MASUM), & National Convenor, Programme Against Custodial Torture & Impunity (PACTI) writes to the Chairman, National Human Rights Commission: *** I am writing this to focus on the life and situation of the poor and marginalized villagers living alongside the Indo-Bangladesh border of West Bengal. Through the several complaints we made throughout the years to your good office, it is now evident that the people of this border are living in an acute crisis, not only from a financial perspective but also in terrible distress. The people of the border are devoid of their basic rights and are subjected to immense torture, harassment and restrictions mostly enacted by the Border Security Force personnel, who are supposed to be posted at the international borders with intentions to protect the Indian citizenry. However, on the contrary, incidents of victimizing Indian citizens are being witnessed at large by the BSF. 130 Bhot

Emerging dimensions of India’s foreign policy in the context of global politics

By IMPRI Team  The three-day course took place recently, providing participants with an understanding of the development of Indian foreign policy, the complexity of geopolitics, and its flexibility to adjust to and even shape global outcomes. Many distinguished academics, senior scholars, former Indian diplomats, and journalists who are skilled observers and commentators of India’s foreign policy will serve as instructors for this course. Day 1 The three-day immersive online certificate training on “Emerging Dimensions of India’s Foreign Policy and Global Politics”, an initiative by the Center for International Relations and Strategic Studies (CIRSS) at IMPRI Impact and Policy Research Institute (IMPRI), began on July 14th, 2022 at 5:00 PM (IST) on Zoom platform. Dr Souravie Ghimiray served as the emcee throughout the 3 days of the event and welcomed the distinguished speakers of Day 1. The esteemed panel on Day 1 consisted of, Dr Soumita Basu, Associate Professor, Department of Intern

Demographic parameters of India@75: resource allocation, political representation

By IMPRI Team  As per UN Population Prospects 2022, India is going to be the most populous country in the world. In this regard, IMPRI Impact and Policy Research Institute, New Delhi with #IMPRI Center for Human Dignity and Development (CHDD) , organized a panel discussion, #WebPolicyTalk, as part of the series The State of Population Development- #PopulationAnd Development on India@75: Most Populous Country? The moderator of the event was Mr Devender Singh, Global Studies Programme, University of Freiburg and a Visiting Senior Fellow at IMPRI. The panellists for the event were Prof P.M Kulkarni, Demographer, Retired Professor of Population Studies, Jawaharlal Nehru University(JNU) , New Delhi; Dr U.V Somayajulu, Co-Founder, CEO and Executive Director, Sigma Research and Consulting ; Dr Sonia George, General Secretary, Self Employed Women’s Association (SEWA), Kerala; Prof K.S James, Director and Senior Professor, International Institute for Population Sciences (IIPS), Mumbai. Th

Tamil Nadu govt claiming to reform Hindu religion, temples. People deserve better

By NS Venkataraman  For the last several decades, there have been hate campaign against Hinduism in Tamil Nadu in a subtle or not so subtle manner. Initially, it was a hate campaign against brahmins and the brahmins were abused, insulted and physically attacked. Fearing such conditions, many brahmin families left Tamil Nadu to settle down in other states in India or have gone abroad. Now, the brahmin population in Tamil Nadu is at microscopic level, for which these hate campaigners against brahmins were responsible. Later on, emboldened by the scenario of scared brahmin families not resisting and running away, the hate campaigners started focusing on Hindus. For some years, when M.G.Ramachandran and Jayalalitha were the chief ministers of the state, the hate Hindu campaigners were not much heard, as both these chief ministers were staunch believers in Hindu philosophy and have been offering prayers in temples in full public view. However, in the last eighteen months in

Bhagawat Gita shows the way for the attitude to life and desirable goal of life

By NS Venkataraman*  When a mother delivers a human body, this body has no identity. Then, parents, relatives, friends consult each other and discuss the alternate appropriate names and arrive at a suitable name for this human body and this body is known and identified by this name. This human body, which steadily grow just like animals, plants and others and after experiencing the pleasures and pains of worldly life alternately for several years, perish one day, for the body to be burnt or buried. This body, bearing a name as it’s identity, comes in to the world and goes away from the world and the name that is the identity for the body also goes away along with the body. This is the scenario for several thousands of years that have gone by. The question: One question that does not seem to be still “convincingly explained” in a way that will appeal to the brain in the human body, is as to whether this human body only consists of flesh, bone and blood with well

Implementing misleading govt order to pollute Hyderabad's 100 year old reservoirs

Senior activists* represent to the Telangana Governor on GO Ms 69 dated 12.4.2022 issued by the Municipal Administration and Urban Development (MA&UD), Government of Telangana: ‘...restrictions imposed under para 3 of said GO Ms 111 dated 8.3.1996 are removed...’: *** Ref: GO Ms 111 dated 8.3.1996: ‘To prohibit polluting industries, major hotels, residential colonies or other establishments that generate pollution in the catchment of the lakes upto 10kms from full tank level as per list in Annexure-I...’ We come to your office with grievance that GO Ms 69 dated 12.4.2022 issued by Government of Telangana not only contains false information issued ‘By Order and in the name of the Governor of Telangana’ , without any scientific or expert reports, but also that implementation of the said GO is detrimental and can be catastrophic to the Hyderabad city as two 100 year old reservoirs Osman Sagar and Himayath Sagar were constructed as dams on river Moosa and river Esa, with the first and

Tattoos and intimidating gestures can't always win cricket matches for India

By Sudhansu R Das  Team India waited with baited breath for the outcome of the Pakistan vs Afghanistan match. Speculation was on about India’s return to the game if Pakistan loses to Afghanistan until Pakistan’s tailender, Naseem hit two massive sixes to win the match for Pakistan. Unfortunately, Afghanistan lost the match after being in a strong position till the last over of the game; two full touch balls in the final over turned the match into Pakistan side. The Afghanistan team would never forget this blunder and shock for a long time. India’s team management should introspect and take tough decision keeping in view of the tough match situation in the world cup matches. India lost two crucial matches in the Asia Cup. It could not defend a big total of 176 against Pakistan due to mediocre bowling attack, sloppy fielding and unimaginative captainship. It failed against Sri Lanka in similar fashion; it could not defend another respectable T 20 total of 171 runs. It was a pat