Aarogya-Swaraj

An empowerment model of health care

Abhay Bang

SEARCH, Gadchiroli

Outline• Current challenge of health care.

• Data and learning from Gadchiroli.

• Alternative model of health care.

Health Care cost in India

Health care cost : 5% of the GDP

$ 100 per capita per year (at ppp)

20% by the public sector

80% by the private sector

Health status of the people in India

• 2 million new cases of TB annually

• 55% women anemic

• 43% children underweight

• 1.5 million child deaths each year

The quest for

Universal Health Care

* How to provide UHC?

The US medical care cost :

$ 6000 per capita/year

2010 2050 2100

US 17 % 37 % 97%

Europe 10 % 25 % 60%

% of GDP

Cost of Health Care

The medical care models from the West are wasteful

A Medical Employment Guarantee Scheme

*UHC = MEGs

Medical Nemesis

Health care of ventilators

What is the alternative?

SEARCHSociety for Education, Action & Research in Community Health

Bombay

New Delhi

Maharashtra

Gadchiroli

SEARCH, Gadchiroli

Laboratory of 86 villages

SEARCH, Gadchiroli

What are the health care needs of the people?

1. Ask them

2. Population based data

3. Hospital data

The priorities expressed by the people (not

in any order of ranking)

1. Communicable diseases (diarrhea, malaria, TB,

filariasis)

2. Respiratory problems (cough and

breathlessness.)

3. Back-ache and musculo-skeletal pains

4. Sexual, reproductive and uro-genital problems.

5. Weakness – (anemia, malnutrition ?)

6. Blood pressure and stroke

7. Alcohol and tobacco

8. Anxiety

Interestingly, missing were the national vertical program priorities such as the Maternal Mortality, Family Planning, Polio, HIV.

Universal Health Care must move beyond the few vertical programs and incorporate people’s priorities.

*

Causes of death in children ( 0-5 Year) Govt. Program area ( 2004-2010) ( Deaths : 314 , Live births : 5146)

Neonatal :

1 Birth Injury / Asphyxia 29.3

2 Prematurity 20.6

3 Neonatal sepsis 13.4

4 Low birth weight 11.7

1month – 5 years 1 Pneumonia 14.4

2 Malnutrition 6.8

3 Encephalitis/ Meningnitis / cerebral malaria

5.2

Causes Cause Specific Mortality Rate per 1000 Live Births

0 50 100 150 200

Pneumonia /Ac. Bronchitis

Unexplained fever

Stroke

Asthma / COPD

Diarrhoea

TB

Accident or poisoning

Cancer

Malaria

Heart disease

Suicide

Cause specific mort. rate per 100000 popul.

Causes of death In age group above 15 years

(SEARCH 86 villages 2002-2009)( person years : 520,162 , Total deaths : 5003 )

1) Newborn morbidities -

Incidence of morbidities in newborns

2) Childhood ARI - Acute Respiratory Infections in children

- Incidence of cough and cold

- Incidence of Pneumonia

Population based morbidity studies in Gadchiroli

A) Newborns and Children

74 %

6 episodes per child / year

13 % of children / year

Expected cases / village of 1000

15

600

13

3) Maternal morbidities -

Population based morbidity studies in Gadchiroli

B) Women

4) Gyneacological morbidities-

Incidence of Maternal morbidities during

- pregnancy, delivery , post partum : 59 %

- Emergency Morbidities : 13 %

Gynecological and sexual morbidities

prevalence ( n=650) : 92 %

Expected cases / village

of 1000

12

3

340

5) Prevalence of anemia in women - Anemia in women ( n= 2019)

- During pregnancy : 59%

- non pregnant women : 43 %

12

159

6) Prevalence of health complaints in males -

Population based morbidity studies in Gadchiroli

C) Men

7) Prevalence of Alcohol consumption -

- Non-reproductive symptoms : 70 %

- Reproductive, urogenital, sexual : 68 %

Prevalence of alcohol consumption

- Prevalence of alcohol consumption : 36 %

- Prevalence of daily alcohol consumption : 4 %

Expected cases / village of

1000

259

252

133

15

8) Prevalence of tobacco consumption -

Population based morbidity studies in Gadchiroli

D) Population

9) Prevalence of hypertension - Tobacco consumption : 50.4 %

Hypertension (n= 879)

in Males : 6.5%

in females : 13.5 %

10) Prevalence of sickle cell gene - Prevalence of sickle cell gene

Homozygous ( S – S ) : 0.80 %

Heterozygous ( A – S ) : 15.60 %

Expected cases / village

of 1000

504

24

50

8

156

The health care needs of population are enormous in magnitude, multiple, and are often chronic.( 2600)

Health care must be designed appropriately

Rs. 140 million District Development plan

Rs. 200 million spent on alcohol

“Now we know why are we poor”*

People’s parliament and people’s prohibition

Government of Maharashtra accepted the demand

Introduced prohibition in Gadchiroli District in 1993.

10.4

73.4

2214.9

0102030405060708090

100

Tobacco NREGA ICDS NRHM

Crore Rs.

Private expenditure on tobacco versus the Government’s annual expenditure on three national schemes in the

Gadchiroli district (2008-09,Rs Crore)

NREGA- National Rural Employment Guarantee Act Scheme

ICDS- Integrated Child Development Services

NRHM – National Rural Health Mission

- Policy change

- Regulation

- People’s education through

public campaign

- Corrective measures

Social Determinants of Health (e.g. alcohol, sanitation )

What type of health care do people need ?

What Next ?

Tribal friendly hospital• 26,000 patients from 1000 villages

• Cerebral malaria

• Snake bites

• 500 major operations

• Spine surgery, Gynec surgery

• Mental Health OPD

• Oral & dental health OPD

Newborn and Child Deaths

Newborns in India

27 million newborns are born each year

30 % born at home

Even the hospital delivered mother and newborns are sent home < 24 hr.

Newborn health care must visit where the neonates are.

*

SEARCH, Gadchiroli

SEARCH, Gadchiroli

Neonatal mortality rate (1993 to 2003)(intervention and control area)

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

80.0

1993-95 1995-96 1996-97 1997-98 1998-01 2001-03Baseline Training

& visiting Interventions Full

InterventionsContinuation of care

Neonatal mortality rate

Control area

Intervention area

0

20

40

60

80

100

120

140

19881989

19901991

19921993

19941995

19961997

19981999

20002001

20022003

Infant Mortality Rate

Pneumonia case management

Home-based newborn care

Year

Reduction in IMR = 6 points per year

Linear regression trend in IMR

The Infant Mortality Rate in Gadchiroli (1988 – 2003)

39 intervention villages

*

SEARCH, Gadchiroli

SEARCH, Gadchiroli

11th & 12th Five Year Plan of India

Gadchiroli model to be the main strategy to reduce IMR in India.

SEARCH, Gadchiroli

SEARCH, Gadchiroli

ANKUR Project in Mahatashtra

HBMNC Scaling up

ICMR Study: Government of India, five states.Africa

Other Countries

SEARCH, Gadchiroli

23 States in India4 countries

State ASHA training centers

Global Policy Statement

Joint statement by the WHO, UNICEF, US-AID and Save the Children , US ( 2009).

How to provide health care to 1.25 billion population living in 1 million villages/ hamlets ?

Universal health care by a medical system may generate dependence, exploitation and astronomical costs.

The best way of providing universal health care to 1.25 billion population is to generate

Universal Capacity to Care for Health. *

• Control of social determinants by regulations and social campaigns.

• Generating pro-health culture through the media and school education.

• Health education for behavior change.

• Training and capacity building for self care, and care of the community.

• Preventive and promotive activities

• Health care in the village or close to village.

• Continuum of care.

Universal Health Care must include :

Suggested Health Care in a BlockPublic health system

Population 100,000Villages 100Village Health Work units

(6 / village) x 100600

Village Health and Sanitation

Committees100

Health Centres (1/5,000 pop) 20

Primary Health Centers (1/30,000) 3Community Health Centre (50 bed hospital)

1

Health care activities in the village

Maternal and Newborn Health

7 activities

62

Sexual health + FP + Urogenital and gynecological problems

5 activities

63

Child health & Nutrition

7 activities

49

Communicable disease control & sanitation

7 activities

60

Chronic diseases

5 activities

60

Mental health , health promotion

8 activities

60

Hours / 1000 popl /month

Village Health Team

The 6 VHW units can be performed by

• 6 different individuals, each working for nearly 2 hour per day

• or two persons working for 6 hrs/day

They can be women (ASHA) and men (ASHOK)

(B) Health Centre

One health centre per 5,000 population (5 villages) is proposed.

In each block (100,000 population) the current 20 sub-centres (1:5000) should be upgraded as Health Centres,.

Functions

1. Clinical services at health center.

2. Outreach services in 5 villages

3. Training

4. Supervision

5. Coordination

Annual budget Rs. 2 million*

Aarogya-Swaraj

Social Health

Health empowerment

Health care Hospitals

Community based care

Individual and family :

Behavior and capacity to care

Social determinants :

Policies , Development, Culture

Health for All

Alma-ata (1978)

Universal Health Coverage

UHC needs to be conceived and designed more radically

Dependence is a political disease

*

Universal Health Care must include the

fundamental freedom to be healthy

(and not freedom to be sick) as well as

universal capacity to care for health

‘Aarogya-Swaraj’ describes this goal

better than a patronizing promise of

access to cash-less medical care mass

produced by a medical industry

whether public or private

‘swa-stha’

The concept of health, in India, is inalienably linked with autonomy

*

The promise of universal health

care itself should not produce

universal disease of health care

dependence.

1. People actively campaigned to control social determinants of ill health, such as alcohol.

Evidence from Gadchiroli

*

Can this mobilization approach be applied to other determinants of ill health ?

Question 1 :

2. People identified their health priorities correctly

What are the limitations of this approach ?

Question 2 :

*

How can the People’s Health Assemblies be made an operational reality from the village, block to the national level ?

Question 3:

The community Health Workers were feasible and very effective.

How can such model be operationalzed on a large scale?

* Question 4:

How can such model be financed ?

Question 5:

Universal Health Care can not be a one more centrally financed and controlled scheme.

It has to become a movement for health, autonomy and freedom !

Aarogya - Swaraj