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

2 million new cases of TB annually 55% women anemic 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 US 17 % 37 % 97% Europe 10 % 25 % 60% % 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

India New Delhi Maharashtra 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) Communicable diseases (diarrhea, malaria, TB, filariasis) Respiratory problems (cough and breathlessness.) Back-ache and musculo-skeletal pains Sexual, reproductive and uro-genital problems. Weakness – (anemia, malnutrition ?) Blood pressure and stroke Alcohol and tobacco 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. *

1month – 5 years Causes of death in children ( 0-5 Year) Neonatal : Govt. Program area ( 2004-2010) ( Deaths : 314 , Live births : 5146) Cause Specific Mortality Rate per 1000 Live Births Causes 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 Pneumonia 14.4 Malnutrition 6.8 Encephalitis/ Meningnitis / cerebral malaria 5.2

In age group above 15 years Causes of death In age group above 15 years (SEARCH 86 villages 2002-2009) ( person years : 520,162 , Total deaths : 5003 ) 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 2) Childhood ARI - Acute Respiratory Infections in children - Incidence of cough and cold - Incidence of Pneumonia 74 % 15 6 episodes per child / year 600 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 morbidities- Gynecological and sexual morbidities prevalence ( n=650) : 92 % 340 5) Prevalence of anemia in women - Anemia in women ( n= 2019) - During pregnancy : 59% - non pregnant women : 43 % 12 159

Population based morbidity studies in Gadchiroli Expected cases / village of 1000 C) Men 6) Prevalence of health complaints in males - - Non-reproductive symptoms : 70 % - Reproductive, urogenital, sexual : 68 % 259 252 7) Prevalence of Alcohol consumption - Prevalence of alcohol consumption - Prevalence of alcohol consumption : 36 % - Prevalence of daily alcohol consumption : 4 % 133 15

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 % Heterozygous ( A – S ) : 15.60 % 8 156

The health care needs of population are enormous in magnitude, multiple, and are often chronic.( 2600) Health care must be designed appropriately

“Now we know why are we poor” 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. 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 type of health care do people need ? 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

Newborn health care must visit where the neonates are. 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) Intervention area Baseline Training & visiting Interventions Full Interventions Continuation of care

Reduction in IMR = 6 points per year The Infant Mortality Rate in Gadchiroli (1988 – 2003) 39 intervention villages Infant Mortality Rate 140 120 Pneumonia case management Home-based newborn care 100 80 60 40 Linear regression trend in IMR 20 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 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 ICMR Study: Government of India, five states. 4 countries 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 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 100,000 Villages 100 Village Health Work units (6 / village) x 100 600 Village Health and Sanitation Committees Health Centres (1/5,000 pop) 20 Primary Health Centers (1/30,000) 3 Community Health Centre (50 bed hospital) 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 49 Communicable disease control & sanitation 60 Chronic diseases Mental health , health promotion 8 activities

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,.

Annual budget Rs. 2 million Functions Clinical services at health center. Outreach services in 5 villages Training Supervision Coordination * Annual budget Rs. 2 million

Aarogya-Swaraj Health care Health empowerment Social Health Hospitals Community based care Health empowerment Individual and family : Behavior and capacity to care Social determinants : Policies , Development, Culture Social Health

Universal Health Coverage 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 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?

How can such model be financed ? 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