Aarogya-Swaraj An empowerment model of health care
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Transcript of Aarogya-Swaraj An empowerment model of health care
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