Leave no one behind

Dr Carolyn Kavita Tauro - CNS
Recently, Ahmedabad was host to an International Conference on Inequity in Maternal and Child Health organized by the Indian Institute of Public Health (IIPH) Gandhinagar and Public Health Foundation of India (PHFI). It brought together national and international public health professionals to discuss about various issues affecting an equitable delivery of health care to mothers and children in India.

The programme focussed on solutions rather than the problems alone. It was recognized that there exists a great divide between the health services available to the wealthy and the poor. With India having an average lifetime risk of maternal death as 1 in every 170 mothers, neonatal mortality rate of 32 (per 1000 live births) and an infant mortality rate of 48 (per 1000 live births), it was felt that though reaching Millennium Development Goals by 2015 seemed bleak, there was no reason to sit back but to keep striving for it.

What is pulling India back?

Insufficient human resource in the medical field is the biggest challenge. The conference highlighted how most doctors today preferred to be in urban areas rather than rural or tribal ones, despite offers of competitive salaries. The reason perhaps is the lack of development in these areas. If priority is given to building good roads, a convenient transport system, electricity and education, the number of doctors prepared to work in these areas would increase.

Meanwhile, the government of Gujarat has invested in better transport with its link up with the 108 emergency vehicles which have in the past year transported expectant mothers to the hospitals of their choice. Drop back facility has also been initiated to ensure that mother and child are safely brought back home.

Currently less than 1.7 % of the health budget of India is spent on medical education. This results in inadequate institutions, faculty fleeing, and insufficient and inefficient investment. It is time now to go to a competency driven method, with better communication between the Education and Health Ministries.

While the government has introduced various health programmes/schemes across India, the effectiveness of these programmes is debatable. Many are introduced without a pilot study and no programme evaluation is carried out either periodically or on one-time basis to see how effective an intervention is. Thus an increase in the number of institutional deliveries did not necessarily mean a lower maternal mortality rate (MMR) as the poor medical attention given at some health facilities that lacked doctors, drugs, equipment and infection control methods contributed towards high MMRs.

How can inequity be tackled?

“Constant monitoring is important. It is essential to record and analyse outcomes, according to social classes. An infant mortality rate of a particular class can help make interventions targeted toward these classes”, said Professor Dileep Mavalankar, Director of IIPH, and member of the Steering Group on Health for the 12th Five Year Plan of the Planning Commission of India.

The World Health Organisation makes policies for 193 countries, but this one size fits all model does not work for a vast and diverse country like India. The importance of more local and tailor-made policies suited to individual needs of states was stressed upon.

“It is not enough to have equity in health unless income and wealth equity is addressed”, said Dr. Paul Bissel, Professor of Public Health and Director of Public Health Section at School of Health and Related Research (ScHARR) University of Sheffield, UK. “Whilst setting up a robust health system is crucially important, if material and social inequity continue to exist, the desired outcomes may not be achieved. India, along with other countries, faces a triple burden of diseases – communicable diseases, non-communicable diseases and those arising out of socio-cultural issues. Even in the United Kingdom, which has a public funded health system in place, a strong social gradient in mortality and morbidity still exists”.

“Some of the other issues that India needs to consider while addressing health are corruption, greed and non-compassion,” said Dr. Vinod Diwan, Professor and Director of the Centre of Global Health at Karolinska Institute, Sweden. “There are those who are very wealthy and there are those who are extremely poor with a variety of classes in between. Those doing better than the others fear contributing (monetarily) towards the needy due to the insecurity they face – they do not want to go a class lower. Unless India works on bringing the extremely poor to even one class higher, the rich will not feel secure or compassionate enough to contribute towards the health of the those actually in need”.

Dr. Dinesh Biswal, Deputy Commissioner of the Ministry of Health and Family Welfare, presented the Central Government’s plan to address inequities in maternal and child health. He said that contrary to the annual plans submitted by each state so far, a three-year plan would now have to be submitted with full information (displayed online) about the state’s facilities, human resources, service delivery data, equipment, transportation, number of non-governmental organisations (NGOs) and Public-Private partnership (PPP) details.

The plans will get a positive feedback in terms of financial support--if a state government has good ‘responsiveness, transparency and accountability’, the Central Government would then support the state with 8% of the contribution made. Likewise, quality assurance would attract 3% contribution. Further increased incentives could also be given contributing more than 10% to their annual health budget.

While existing key programmes like the Janani Suraksha Yojana (JSY), Janani–Shishu Suraksha Karyakram (JSSK) and operational facilities for Basic Emergency Obstetric and New born Care (BEMONC) and Comprehensive Emergency Obstetric and New born (CEMONC) are in place, the Mother and Child Tracking System (MCTS) for early registration of Ante-natal care (ANC) will soon be put in practice. Maternal death reviews, comprehensive abortion care, Life Skills Anesthesia (18 weeks training to medical officers to equip them to handle Anesthesia during Caesarean sections) and BEMONC training (16 weeks training to medical officers to conduct Caesarean sections) are planned. A more integrated approach called Reproductive Maternal, Neonatal and Child Health plus Adolescent (RMNCH+A) will be set up to address the reproductive and sexual health and nutritive needs of adolescents.

Professor Sreekumaran Nair, Professor of Biostatistics and Head Department of Statistics at Manipal University, presented The Public Health Evidence South Asia (PHESA), an initiative in collaboration with Cochrane Review. This initiative has been made to address the inequity in terms of accessible data from the West in comparison to data available from the South Asia region. Researchers were encouraged to help collate evidence-based papers that can contribute towards data pertaining to the region of South Asia.

Good governance plays a crucial role in overcoming social determinants of health that influence maternal and child health as this sector is usually the first one to be deprived off when a cut in budget is required. Good health at low cost, tax-based health insurance and taking care of macroeconomics were also highlighted at the meet.

Dr Carolyn Kavita Tauro, Citizen News Service - CNS
December 2013