1. An empowerment model of health care
Aarogya-Swaraj
An empowerment model of health care
Abhay Bang
SEARCH, Gadchiroli

2. Outline Current challenge of health care.
Data and learning from Gadchiroli.
Alternative model of health care.

3. 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

4. 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

5. The quest for Universal Health Care
How to provide UHC? *

6. The US medical care cost :
$ 6000 per capita/year

7. Cost of Health Care US 17 % 37 % 97% Europe 10 % 25 % 60% % of GDP
US % % 97%
Europe % % %

8. The medical care models from the West are wasteful*
UHC = MEGs
A Medical Employment Guarantee Scheme

9. Medical Nemesis
Health care of ventilators
What is the alternative?

10. SEARCH
Society for Education, Action & Research in Community Health

11. India
New Delhi
Maharashtra
Bombay
Gadchiroli

18. Laboratory of 86 villages
SEARCH, Gadchiroli

19. What are the health care needs of the people?
1. Ask them
2. Population based data
3. Hospital data
SEARCH, Gadchiroli

22. 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

23. * 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. *

24. 1month – 5 years Causes of death in children ( 0-5 Year) Neonatal :
Govt. Program area ( ) ( 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

25. In age group above 15 years
Causes of death
In age group above 15 years
(SEARCH 86 villages )
( person years : 520,162 , Total deaths : 5003 )
Cause specific mort. rate per popul.

26. 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

27. 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

28. 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

29. Population based morbidity studies in Gadchiroli
Expected cases / village of 1000
D) Population
8) Prevalence of tobacco consumption -
Tobacco consumption : %
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 ) : % 8
156

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

33. “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”

35. People’s parliament and people’s prohibition

37. Government of Maharashtra accepted the demand
Introduced prohibition in Gadchiroli District in 1993.

39. Private expenditure on tobacco versus the Government’s annual expenditure on three national schemes in the Gadchiroli district ( ,Rs Crore)
Crore Rs.
NREGA- National Rural Employment Guarantee Act Scheme
ICDS- Integrated Child Development Services
NRHM – National Rural Health Mission

40. Social Determinants of Health (e.g. alcohol, sanitation )
- Policy change
- Regulation
- People’s education through
public campaign
- Corrective measures

41. What type of health care do people need ?
What Next ?
What type of health care do people need ?

45. 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

47. Newborn and Child Deaths

48. 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

51. SEARCH, Gadchiroli

55. Neonatal mortality rate (1993 to 2003) (intervention and control area)
Intervention area
Baseline
Training & visiting
Interventions
Full Interventions
Continuation of care

56. 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

58. *

59. SEARCH, Gadchiroli

60. SEARCH, Gadchiroli

61. 11th & 12th Five Year Plan of India
Gadchiroli model to be the main strategy to reduce IMR in India.
SEARCH, Gadchiroli

62. 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

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

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

65. 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. *

66. 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.

67. 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

68. 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

69. 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)

70. (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,.

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

72. 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

73. Universal Health Coverage
Health for All
Alma-ata (1978)
Universal Health Coverage

74. UHC needs to be conceived and designed more radically*
Dependence is a political disease

75. 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

76. ‘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

77. ‘swa-stha’ *
The concept of health, in India, is inalienably linked with autonomy

78. The promise of universal health care itself should not produce universal disease of health care dependence.

79. 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 ?

80. 2. People identified their health priorities correctly*
Question 2 :
What are the limitations of this approach ?

81. Question 3:
How can the People’s Health Assemblies be made an operational reality from the village, block to the national level ?

82. The community Health Workers were feasible and very effective.
Question 4: *
How can such model be operationalzed on a large scale?

83. How can such model be financed ?
Question 5:
How can such model be financed ?

84. 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 !

85. Aarogya - Swaraj