Tuesday October 23, 2018

Why More than 580 Million People in India Have Poor Healthcare?

The maternal mortality ratio -- deaths of mothers per 100,000 births -- in these states is 32 per cent higher (244) than the national average (167)

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Healthcare in India. Pixabay
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  • India’s average spending on health, as a proportion of GDP, is already the lowest among BRICS nations
  • It accounts for 70 percent of the country’s infant deaths, 75 percent of under-five deaths and 62 per cent of maternal deaths

July 07, 2017: Nine of India’s poorest states — home to 581 million or 48 percent of the population — account for 70 percent of the country’s infant deaths, 75 percent of under-five deaths and 62 per cent of maternal deaths, but do not spend even the money they have set aside for healthcare, according to an IndiaSpend analysis of 2017 Reserve Bank of India data on state budgets.

The data also reveal:

— The maternal mortality ratio — deaths of mothers per 100,000 births — in these states is 32 percent higher (244) than the national average (167).

— 38 per cent and 40 per cent children in these states are underweight (low weight-for-age) and stunted (low height-for-age), respectively, higher than the national average of 36 per cent and 38 per cent, respectively, according to 2015-16 national health data, the latest available.

— Uttar Pradesh, Bihar, Madhya Pradesh and Rajasthan — with 372 million people, more than the combined populations of US, Australia, Sweden, and Greece –together contribute to about 58 percent of all child deaths in India.

The nine poorest large states — in official jargon called “high-focus”, a term that implies they need special attention — spent an average of 4.7 percent of their social sector expenditure on public health care and family welfare annually, marginally less than the national average of 4.8 percent. Social sector expenditure includes water supply and sanitation, housing and urban development.

India’s average spending on health, as a proportion of GDP, is already the lowest among BRICS nations.

The “high-focus” states are Bihar, Chhattisgarh, Jharkhand, Madhya Pradesh, Odisha, Rajasthan, Uttarakhand, Uttar Pradesh and Assam.

“In 2005, it was observed by (the) Government of India that some states were performing poorly in various indicators,” Avani Kapur, Senior Researcher, Accountability Initiative, an advocacy, told IndiaSpend. “So, these states were clubbed together as high-focus states and additional resources were given to improve those indicators.”

ALSO READ: “Dual-Disease Burden”? India’s Great Healthcare Challenge and Opportunity 

Of the nine poorest states, Rajasthan spent the highest (5.6 percent) and Bihar the lowest (3.8 percent) proportion of aggregate expenditure on public health care and family welfare, according to the RBI data on 2014-15 actual spending, lower than the budgeted 4.1 percent for Bihar and 6.6 per cent for Rajasthan.

Seven of the nine “high-focus” states report such underspending.

“High focus states allocate large amounts to social sector to improve their indicators but in reality, they spend only a small amount, compared to what is allotted,” Kapur said. “Hence, it is necessary to consider actual accounts in order to know the proper outcomes.”

So, while some “high-focus” states spent less money than set aside by their budgets, other states outspent — by proportion as ratio to aggregate expenditure — other larger states on healthcare and family welfare, but that had no relation to their healthcare indicators.

For instance, Rajasthan (68.6 million people) reported an MMR of 244 deaths per 100,000 births in 2011-13, the second lowest in India and worse off than Bangladesh and Nepal, both poorer countries, by per capita income. In contrast, Andhra Pradesh (84.6 million people), another big state, spent 4.1 per cent of total expenditure on public healthcare and family welfare but reported an MMR of 92, according to government data.

Since 2008, Rajasthan increased its spending by 0.8 per cent and its MMR decreased 23 per cent while Andhra Pradesh’s spending increased by 0.5 per cent and MMR decreased 31 per cent.

Assam, which spends 4.2 per cent of its total expenditure on health and has 31.2 million people, has an MMR of 300 deaths per 100,000 births — comparable to Rwanda and Sudan — while Kerala, which spends 5.3 per cent on 33.4 million, reported an MMR of 61, comparable to Sri Lanka and Poland.

Madhya Pradesh, which reported an infant mortality rate (IMR) — deaths per 1,000 live births — of 51 in 2015-16, spends 4.3 per cent of total expenditure on healthcare (against the budgeted 5 per cent) and is worse off than some of the world’s poorest countries, such as the Gambia and Ethiopia.

In the nine “high-focus” states, 72.6 per cent of all births were in healthcare institutions, a steady improvement but below the national average of 78.9 per cent, according to the 2015-16 National Family Health Survey (NFHS-4) data, the latest available.

Promoting community-based education on improved maternal and newborn care, and home-based treatment for newborn infections could enhance child survival in the “high- focus” states “significantly”, said a 2012 PLOS-ONE study. (IANS)

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How Auxillary Nurse Midwives (ANMs) in Remote Tribal Belts of Andhra Pradesh in India have brought down Maternal Deaths to Zero

With 4,000 employees in just its health vertical, Piramal Swasthya is prehaps the largest NGO in India, implementing 29 healthcare projects in 16 states.

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Akaru women, MATERNAL DEATHS
Midwifing change: How maternity deaths were reduced to zero in remote tribal hamlets. Flickr

The scenic beauty of Araku Valley in Andhra Pradesh is in stark contrast to the lives of indigenous tribespeople inhabiting the region. Living in virtual destitution, these tribals — like their counterparts scattered in remote locations across the rest of India — lack access to basic amenities like safe drinking water, healthcare and education. Till a few years ago, some of these habitations were not even covered in the national census and nobody knew they even existed.

But efforts of a leading NGO over the last seven years have yielded results in 181 habitations around Araku. This is testified by the fact that no maternal deaths have been reported here over the last two years — a giant step forward for a place where maternal mortality was double the national average.

Before emerging as a tourist destination about a decade ago, Araku, 100 km from the port city of Visakhapatnam, was an area that was the redoubt of Maoist extremists. Politicians and officials used to stay away from this forested area in the Eastern Ghats.

The population in scattered and inaccessible hamlets was suffering from malnutrition, leading to high maternal mortality and neonatal mortality rates. Some traditional practices of the tribals and deliveries at home were also contributing to this situation.

Araku, Maternal Deaths
Araku Valley is a hill station and valley region in the southeastern Indian state of Andhra Pradesh. Flickr

When the NGO Piramal Swasthya, the health vertical of Piramal Foundation, launched the Asara Tribal Health Programme in 2011, maternal mortality in this tribal area was over 400 per 100,000 live births as against the then national average of around 200.

No maternal deaths have been reported over the last two years while the percentage of institutional deliveries has risen from 18 per cent to 68 per cent. The neonatal mortality rate too has come down from 37 to 10 per 100,000 live births, say the officials of Piramal Swasthya.

The agents behind this change are Auxillary Nurse Midwives (ANMs) like P. Padma who toil selflessly to help the pregnant women in these remote hamlets. The 27-year-old has been working with the NGO for six years and has attended about 3,000 women. She has seen the transformation.

“The situation in the tribal hamlets was pathetic as women were reluctant to come to hospitals for delivery. A major reason for this was the superstition among tribals. Piramal Swasthya has removed the superstitions and motivated the women,” Padma told IANS.

Padma travels 12-13 km in a four-wheeler and, when the road ends, she goes on a bike driven by a “pilot”, covering another 11 km. When this narrow path also ends, she hikes across mountains and valleys for another 12-13 km to the last habitation of Araku.

Araku, Native Women, India, maternal deaths
A Native Women From Araku. Flickr

This is what she does every day, explains Vishal Phanse, Chief Executive Officer, Piramal Swasthya.

Once in the habitation, the ANM identifies every pregnant woman, conducts basic tests, provides counselling on healthy practices and fixes an appointment for consultation with a specialist at the telemedicine centre. The next day, a four-wheeler is sent to pick up all pregnant women registered and get them to the telemedicine centre, where an expert gynaecologist sitting in Hyderabad provides the consultation through teleconferencing. Free medication, along with nutrition supplements, is also provided to the expectant mother and she is then dropped back to her habitation.

“If a woman can’t walk we arrange ‘palki’ (a kind of palanquin) to bring her till the four-wheeler to take her to the telemedicine centre,” Padma said. Last month, a woman delivered a baby on the palki in Colliguda village. She helped the woman and later safely transported her and the newborn to the hospital.

ANMs support the women and children through their pregnancy, child birth and neonatal period while keeping the government machinery in the loop.

Piramal Swasthya overcame all odds to achieve its goal of ending preventable deaths in 181 habitations, serving 49,000 pregnant women.

Adding some more interventions like training traditional birth attendants and health education of adolescent girls, it is now expanding the programme across 11 “mandals” or blocks comprising 1,179 habitations in the tribal belt of Visakhapatnam district to reach 2.5 lakh population.

It is currently running six telemedicine centres and plans to add five more. The NGO will also be opening two more community nutrition hubs in addition to existing one, where women are educated about a healthy and nutritious diet and trained in the use of traditional and locally available food items.

Araku ,women, maternal deaths
No maternal deaths have been reported over the last two years while the percentage of institutional deliveries has risen from 18 per cent to 68 per cent. Flickr

Based on the learning in Visakhapatnam, the NGO wants to create something which can be replicated in the entire tribal belt of India. More than 10 percent of India’s population is tribal and among them maternal mortality is two-and-a-half times the national average.

“If what works in Araku, works in Visakhapatnam, then we can replicate it in the entire tribal belt of the country,” said Phanse.

Niti Aayog, India’s policy think-tank, is looking at this model with key interest as to how they can scale it up.

“In fact, a lot of people including the United Nations, governments in states and at the Centre are looking at it. We had a lot of visitors trying to understand how we managed to do this. We ourselves are learning every day. Technology is a great enabler if you have to scale it up at the national level.”

Phanse believes that 80 percent of what worked in Araku can be replicated in tribal areas across the country and 20 percent could be local customisation that they have to work on.

What worked for Piramal Swasthya in Araku? “We have doctors, public health professionals and experts with the youngest aged 26 and the oldest 78. That’s the kind of expertise we have with actual feet on the ground. Our actuality to work with them, for them, staying with them and understanding them is what I think has worked best for us,” said Phanse.

Akaru women, maternal deaths
ANM’s support the women and children through their pregnancy, child birth and neonatal period while keeping the government machinery in the loop. Flickr

“If you want make anything sustainable in healthcare you have to create health seeking behaviour in the community. We were successful because we changed the community,” he added.

Phanse feels that the community engagement and participation in the programme is key to its success.

For Piramal, winning the trust of the local community was the key challenge. As Araku was an extremist stronghold, gaining the trust of locals took time.

Most of the 38 people that work for the organisation are from the local community who are wedded to the cause. Forging the local partnership by using the services of dedicated individuals who can speak the language of the community ensured smooth implementation.

Also Read: The Plight of India’s Homeless Women Increases As Cities Expand

With 4,000 employees in just its health vertical, Piramal Swasthya is prehaps the largest NGO in India, implementing 29 healthcare projects in 16 states.

India ranks 131 among 188 countries on the Human Development Index (HDI) 2016 released by the United Nations Development Programme (UNDP). India was placed behind countries like Gabon (109), Egypt (111), Indonesia (113), South Africa (119) and Iraq (121), among others. The government is working towards improving this rating by creating competition between states to perform better on key social indicators like infant mortality rate, maternal mortality rate and life expectancy. (IANS)