Before I left for US for my study abroad, my dad had cited a husband and wife team who returned from US to serve rural villagers of Southern Gujarat. Their names – Dr. Anil and Dr. Lata Desai– were always engrained in my brain with vague images of small rural town. Fast forward 30 years, Bhupenbhai, a past president of ICA suggested that I must visit SEWA Rural before we send ICA Ambassadors for summer internship.
With a scope of 1500 surrounding villages with 1.71 lac population, this was no small town operation that my brain had imagined since my teenage days. Within hour of my visit I was impressed to see their operation focused on social service, scientific approach and spiritual outlook. Overnight humming sound of ambulances leaving every few minutes and next day visit to tribal villages opened my eyes about scope of their operations.
Though it would be unjust to give you all the details about their operation, for some who is specifically learning about SEWA-Rural, I highly recommend visiting their website. However, I thought readers might find useful to learn from my personal observation about such unique operations, challenges and key issues facing rural healthcare delivery in India.
As noted earlier Dr. Anil Desai and Dr. Lata Desai along with unique team of doctors and local field professionals started this team with a dedication and what it sets apart is amazing teamwork still in action after 30 years. Most of the core team still intact has managed to keep take an approach of healthcare at maximum potential. A student of rural healthcare development will immediately notice that you cannot just deliver healthcare without overall integrated development approach. The main campus with a focus on Kasturba hospital has emphasis on gynecology, vision care and rehabilitation for the blind and primary care (OPD). At the same time, the limits of healthcare are also clearly evident such a lack of support for advance care including orthopedic surgery, radiology, anesthesiologist and cancer. Only during this visit you realize, difficulty of attracting competent doctors to serve truly the most poor and needy persons. What sets apart SEWA Rural is not – what they don’t have, but what they do well in unique way, i.e. community health. This will become only apparent if you visit tribal around in 50 km surrounding them.
Background of villagers
It was a difficult for me to believe that as I was stepping out of a bus, the first thing I saw was road to all the villages, water on center chowk, electricity and even solar street lights and satellite dishes. I was pleasantly surprised. You must thank Gujarat government for this. However, reality settled in for me as soon as I stepped out to meet various tribal families. Our group objective was to meet as many pregnant women to detect anemic conditions in them, convince them for a better nutrition and agree to deliver a baby at the hospital. Reality starts setting as soon as you meet these tribal mother and family regarding their Antenatal Care (ANC). In Gujarat, which comes right in middle of most mother and child health indicators, only 57% of women are taking 3 ANC checkups. I suspect that these women were not one of them.
So now let’s just see how our team did with all three expected outputs.
Anemic condition: I was shocked that best mechanism to check the anemic condition was to examine a hand of women, a totally un-scientific way of doing this. Why are they not measuring hemoglobin right there? A light bulb: why not have a hemoglobin tester which doesn’t require you to transfer blood. It turns out later I found that CIIE at IIM-A is already working on it.
Nutrition: It was a Mamta day and mother who delivered a baby were advised to visit village center where better balanced and local nutritional food was on display and female worker would give supplementary medication and nutrition to mother and vaccination to child. Even if they received free service for medicine, I was wondering how this mother of 4 children and other family member can afford to cook this food for someone earning 50 Rs per day. Needless to say many in tribal are known to be drinking afternoon (and extramarital affair – more common tribal than racially mixed villages). I later confirmed when I saw a palace like building and asked someone who owned the house! It wasn’t really a “sarpanch” who are frequently tainted but it was a liquor lord supplying illegal liquor to entire area.
I was horrified to see that school meal program only spends 1 Rs per child. Most children had only rice and daal in their dish.
Delivery to hospital: Our group entered one of the selected pregnant women’s home. As you enter their house first thing you notice is a delivery date. This is where it gets hairy and perhaps too complex for me to understand as they were not speaking their tribal language. It seemed to me that these dates were mainly for “sakhi” (or ASHA worker in government jurisdiction heath worker area). It seems that many women are not encouraged to deliver at home, a very risky proposition. I left unconvinced about family’s intention for pregnancy though they said that they will send her to her mother’s home which is close to hospital. When training leader raised issue of doing birth control operation after pregnancy, we got strange reasons for other 4 skeleton looking children. Mother-in-law said that they will all do ‘majoori’ as a field labor as if they are assets of family. Father-in-law was worried that many of them die.
There are many important lessons that collaborates my discussion with a soft spoken Dr. Pankaj Shah and down to earth Bankimbhai Sheth. There are severe challenges to healthcare delivery system. Some are totally beyond a control of a private citizen.
Factors that Government can control
Complex politics of central, state and district level limits the ability to recruit qualified doctors. Even new “rural doctor” program is in a mess due to greedy private doctors lobby who fears losing their higher fees.
One of the known NRHM evaluation and recommendation to combine mother and child agency and ASHA is still tangled in a political mess due to a nature that they are in different ministry. Hence, the frequently roles of ASHA worker and community level role of sub-centers, PHC, and CHCs are misaligned. Even incentives, training and targets for ASHA workers are misaligned.
Finally, one aspect that is extremely worrisome to Bankimbhai is that steady influx of corrupted NGOs who are slave driver of government. In fact, new generation corrupt NGOs and their illicit relationship with government have created a poisonous environment. Bankimbhai is really worried that a real trust fabric of rural village is going to be broken if it continues this way. This has reached a point that even Gujarat government is unwilling to own-up NGOs creating anti-NGO climate, a bad omen for new generation of good SEWA-Rural like NGO.
Factors that Indian and International Development agency can control
However, I would like readers of this article who are perhaps in development from private side, to learn following key things. India specific development and international development agencies can perhaps look few things that can be very valuable from what I saw and what was collaborated by few from SEWA-Rural. Health agencies across India can perhaps improve if they seriously think about various interventions in the order noted here.
Social Intervention: SEWA Rural over the course have seen a biggest bank for buck from this example. If you see “delivery to hospital” issue, tribal women’s family is likely to bus her to hospital if anyone is incentivized to drive her to hospital in return they are guaranteed to be reimbursed within 24 hours.
And yes, I witnessed use of 108 service as well.
Medical Intervention: You must understand a rural context to see that many of the drugs are simply not available in rural villages. Rural world is full of local, herbal and voodoo medicines. In fact, they simply do not understand even basics of vitamins or other supplements. Affordability acceptability for the allopathic medicine is low, it is important that local level nutritional knowledge, local medicine with a valid verified medicinal technique be disbursed through a local groups. One such grass root effort that I have observed is through a SRISTI is commendable, though overall results are not measured.
Organization like SEWA-Rural can certainly benefit from services from international volunteer specialist like anesthesiology, orthopedic surgeon, dentist or other advance care doctor. Frequently all it takes a year of service to start building their sustaining service in their respective field like they did for ophthalmology department. Volunteer’s prior understanding of their role and length of role ensures volunteer self-development goal and benefit to organization.
mHealth is clearly a new burgeoning and developing discipline in west. mHealth application developer should develop application with urban, rural and tribal context in mind. Organizations such as SEWA-Rural are very much open about benefit of mHealth application, they need to be deployed in the local context and limited resources. Smart phone application given to field worker that collects specific condition of pre-natal and post-natal condition, gives immediate recommendation and sends details status back to central server for doctor’s review can be very valuable. In addition, ICA’s partner ARMMAN’s mMitra platform which provide voice & animation over mobile voice messaging and animalized film service can be very beneficial for providing culturally appropriate comprehensive information on preventive care and simple interventions in the case of emergencies during pregnancy and childhood.
Non-intrusive, acceptable testing innovation such as hemoglobin test kit which doesn’t need an extensive reliance blood testing in lab could be big blessing.
I certainly hope that through my short experience with SEWA-Rural. It is possible that I was judgmental especially when I was spending short time. My basic messaging remains the same for someone who want to understand an approach for development from outside.
I sincerely thank Dr. Shrey Desai, Dr. Anil and Dr. Lata Desai, Dr. Pankaj Shah and Shri. Bankimbhai Sheth for their one-on-time and entire staff to give a true picture of rural health care delivery.
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