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
Cost of Health Care
% of GDP
2010
2050
2100
US
17 %
37 %
97%
Europe
10 %
25 %
60%
The medical care models from
the West are wasteful
*
UHC = MEGs
A Medical Employment
Guarantee Scheme
Medical Nemesis
Health care of ventilators
What is the alternative?
SEARCH
Society for Education, Action & Research in Community Health
New Delhi
Bombay
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
SEARCH, Gadchiroli
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)
Causes
Neonatal :
( Deaths : 314 , Live births : 5146)
Cause Specific Mortality
Rate per 1000 Live Births
1 Birth Injury / Asphyxia
2 Prematurity
3 Neonatal sepsis
4 Low birth weight
29.3
20.6
13.4
11.7
1month – 5 years
1 Pneumonia
2 Malnutrition
3 Encephalitis/ Meningnitis /
cerebral malaria
14.4
6.8
5.2
Causes of death
In age group above 15 years
(SEARCH 86 villages 2002-2009)
( person years : 520,162 , Total deaths : 5003 )
Suicide
Heart disease
Malaria
Cancer
Accident or poisoning
TB
Diarrhoea
Asthma / COPD
Stroke
Unexplained fever
Pneumonia /Ac. Bronchitis
0
50
100
150
200
Cause specific mort. rate per 100000 popul.
Population based morbidity studies in
Gadchiroli
A) Newborns and Children
Expected cases
/ village of 1000
1) Newborn morbidities Incidence of morbidities in newborns 74 %
15
2) Childhood ARI Acute Respiratory Infections in children
- Incidence of cough and cold
6 episodes per child / year
600
- Incidence of Pneumonia
13 % of children / year
13
Population based morbidity studies in
Gadchiroli
Expected
cases / village
of 1000
B) Women
3) Maternal morbidities Incidence of Maternal morbidities during
- pregnancy, delivery , post partum : 59 %
- Emergency Morbidities
: 13 %
12
3
4) Gyneacological morbiditiesGynecological and sexual morbidities
prevalence ( n=650)
: 92 %
340
5) Prevalence of anemia in women Anemia in women ( n= 2019)
: 59%
12
- non pregnant women : 43 %
159
- During pregnancy
Population based morbidity studies in
Gadchiroli
Expected cases
/ village of
1000
C) Men
6) Prevalence of health complaints in males - Non-reproductive symptoms
: 70 %
259
- Reproductive, urogenital, sexual : 68 %
252
7) Prevalence of Alcohol consumption Prevalence of alcohol consumption
: 36 %
133
- Prevalence of daily alcohol consumption : 4 %
15
- Prevalence of alcohol consumption
Population based morbidity studies in
Gadchiroli
Expected cases
/ village of 1000
D) Population
8) Prevalence of tobacco consumption Tobacco consumption : 50.4 %
504
9) Prevalence of hypertension Hypertension (n= 879)
in Males
: 6.5%
in females : 13.5 %
24
50
10) Prevalence of sickle cell gene Prevalence of sickle cell gene
Homozygous ( S – S ) : 0.80 %
8
Heterozygous ( A – S ) : 15.60 %
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.
Private expenditure on tobacco versus the Government’s
annual expenditure on three national schemes in the
Gadchiroli district (2008-09,Rs Crore)
Crore Rs.
100
90
80
70
60
50
40
30
20
10
0
73.4
22
14.9
Tobacco
NREGA
ICDS
10.4
NRHM
NREGA- National Rural Employment Guarantee Act Scheme
ICDS- Integrated Child Development Services
NRHM – National Rural Health Mission
Social Determinants of Health
(e.g. alcohol, sanitation )
- Policy change
- Regulation
- People’s education through
public campaign
- Corrective measures
What Next ?
What type of health
care do people need ?
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)
Neonatal mortality rate
80.0
70.0
Control area
60.0
50.0
40.0
30.0
Intervention area
20.0
10.0
0.0
1993-95
1995-96
Baseline
Training
& visiting
1996-97
1997-98
1998-01
2001-03
Interventions Full
Continuation of care
Interventions
The Infant Mortality Rate in Gadchiroli (1988 – 2003)
39 intervention villages
Infant Mortality Rate
140
120
100
Pneumonia case management
Home-based newborn care
80
60
40
Linear regression trend in IMR
20
0
Year
Reduction in IMR = 6 points per year
*
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
HBMNC Scaling up
SEARCH, Gadchiroli
ANKUR Project in Mahatashtra
Africa
4 countries
ICMR Study: Government of India, five states.
23 States in India
Other Countries
State ASHA training centers
SEARCH, Gadchiroli
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.
Universal Health Care must include :
• 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.
Suggested Health Care in a Block
Public health system
Population
Villages
Village Health Work units
(6 / village) x 100
Village Health and Sanitation
Committees
Health Centres (1/5,000 pop)
Primary Health Centers (1/30,000)
Community Health Centre
(50 bed hospital)
100,000
100
600
100
20
3
1
Health care activities in the village
Hours / 1000 popl /month
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
Chronic diseases
5 activities
Mental health , health promotion
8 activities
60
60
60
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
Hospitals
Health care
Community
based care
Individual and family :
Behavior and capacity to
care
Health
empowerment
Social determinants :
Policies , Development, Culture
Social Health
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.
Evidence from Gadchiroli
1. People actively campaigned to control
social determinants of ill health, such
as alcohol.
*
Question 1 :
Can this mobilization approach be
applied to other determinants of ill
health ?
2. People identified their health priorities
correctly
*
Question 2 :
What are the limitations of this
approach ?
Question 3:
How can the People’s Health
Assemblies be made an operational
reality from the village, block to the
national level ?
The community Health Workers
were feasible and very effective.
* Question 4:
How can such model be
operationalzed on a large scale?
Question 5:
How can such model be financed ?
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