Showing posts sorted by relevance for query health. Sort by date Show all posts
Showing posts sorted by relevance for query health. Sort by date Show all posts

Saturday, February 22, 2014

Environment: Industrial Safety Thrown Norms To The Winds

By Sirajuddin Shaik | INNLIVE

In view of the violation of the norms for the health and safety of workers in thermal plants, the Supreme Court directs the High Courts to examine whether adequate health delivery systems are in place. 

The Supreme Court judgment in Occupational Health and Safety Association vs Union of India, delivered by Justice K.S. Radhakrishnan on January 31, has brought to the fore the serious health hazards faced by workers in coal-based thermal power plants across the country. 

A protracted legal struggle that began in 2005 has only culminated in the apex court giving directions to the High Courts to examine whether there are adequate and effective health delivery systems in place and to evaluate the occupational health status of workers in thermal power plants.

Tuesday, May 21, 2013


By Soumya Parekh / Hyderabad

Delivering health care to a billion-plus population is very complex. And, like eating a Reese’s, there’s no right way to do it. In the past, Indian entrepreneurs have innovated on several business models that range from frugal to world-class luxury care. A testimony to its success is the fact that citizens spent Rs 1,650 billion, or 3.16 percent of the GDP (in 2011-12), on health care, whereas the government spent only 1.04 percent. In other words, a family of four spends nearly Rs 10,000 per year on health care. 

Friday, March 13, 2015

'Perfect Health Insurance Is An Effective Tax-Saving Tool'

SPONSORED: The end of each financial year sends each of us into a tizzy. One all-important question lingers on everyone’s lips: ‘Have I invested in enough tax-saving instruments this year?’ As 31 March approaches, there is a mad rush to save more tax, be it through fixed deposits, pension funds, home loans or life insurance.

The selection of a tax-saving instrument is governed by two factors: (a) the amount of tax that it helps save and (b) the returns that it promises.

Saturday, March 14, 2015

Religare Care Health Insurance 'Criticare': How Good It Is?

SPONSORED: Specialized Health Insurance companies have brought tremendous innovation, and choice to the market. In fact, this morning I was thinking how the choice and convenience would have been if we did not have these players, and only depended on the “general” General Insurance companies.

Now, the fourth specialized health insurance company in India, Religare Health Insurance recently launched its first product – “Care”, an indemnity benefit health insurance policy, with a series of benefits.

Monday, May 15, 2017

Violence in hospitals: Three steps towards mending doctor-patient relationships

Delhi’s mohalla clinics and Mumbai’s Swasth clinics have the right idea – make primary healthcare better.

Even after repeated protests, mass leaves and assurances from authorities of better security, incidents of violence against doctors continue unabated. Last week, a man whose critically ill father died at Sion Hospital manhandled a resident doctor, even though several security personnel had been deployed at the hospital since April.

Thursday, October 13, 2011

Beyond Bureaucracy Challenge: How do Organizations Conquer Bureaucracy?

By M H Ahssan

To sustain high performance, organizations must build the capacity to learn and keep changing over time.

If you’re like most senior executives, you want your organization to be exemplary. But if you’re honest with yourself, you also know that it’s not and that, in fact, you’re not even sure what exemplary means or how you’ll ever get there. Most management writing won’t help: despite the multitude of volumes written on organizational excellence, nothing we’re aware of combines a view on the “steady state” of high, sustainable organizational performance with a dynamic perspective on how companies can transform themselves to achieve it.

We’ve tried to fill that gap with our forthcoming book, Beyond Performance: How Great Organizations Build Ultimate Competitive Advantage (Wiley, June 2011), from which this article is adapted. Our central message is that focusing on organizational health—the ability of your organization to align, execute, and renew itself faster than your competitors can—is just as important as focusing on the traditional drivers of business performance. Organizational health is about adapting to the present and shaping the future faster and better than the competition. Healthy organizations don’t merely learn to adjust themselves to their current context or to challenges that lie just ahead; they create a capacity to learn and keep changing over time. This, we believe, is where ultimate competitive advantage lies.

Getting and staying healthy involves tending to the people-oriented aspects of leading an organization, so it may sound “fluffy” to hard-nosed executives raised on managing by the numbers. But make no mistake: cultivating health is hard work. And it shouldn’t be confused with other people-related management concepts, such as employee satisfaction or employee engagement.

Nor should you study what other companies do and then apply their approach. While you can always learn helpful things from others, we have found that the recipe for excellence in a particular organization is specific to its history, external environment, and aspirations, as well as the passions and capabilities of its people. Creating and sustaining your own recipe—one uniquely suited to these factors—delivers results in a way that your competitors simply can’t copy.
Why health?
The case for health starts with an understanding of how it relates to performance. Performance is what an enterprise delivers to stakeholders in financial and operational terms. It is evaluated through such measures as net operating profit, return on capital employed, total returns to shareholders, net operating costs, and stock turns. Health is the ability of an organization to align, execute, and renew itself faster than the competition to sustain exceptional performance over time. It comprises core organizational skills and capabilities, such as leadership, coordination, or external orientation, that traditional metrics don’t capture.

More than a decade of research and even more of experience have led us to believe strongly that health propels performance—and that, in fact, at least 50 percent of any organization’s long-term success is driven by its health.
Statistical evidence
We have developed a survey to measure organizational health and administered it to over 600,000 employees at more than 500 organizations across the globe. The survey’s immediate purpose has been helping organizations to measure their health and then to improve in areas of weakness.

But the data we’ve collected over the years have also enabled us to study the relationship between organizational health and performance. And there’s a strong positive correlation. Companies in the top quartile of organizational health are 2.2 times more likely than lower-quartile companies to have an above-median EBITDA margin, 2.0 times more likely to have above-median growth in enterprise value to book value, and 1.5 times more likely to have above-median growth in net income to sales.

The results within individual organizations mirror the results from our large sample of companies. At a multinational oil corporation, for example, we analyzed correlations between performance and organizational health across 16 refineries. We found that health accounted for 54 percent of the variation in performance (Exhibit 2).

‘Experimental’ evidence
We’d be the first to admit that correlations should be treated with caution. But the case for health doesn’t rely solely on them. We’ve also tested our hypotheses at real organizations trying to improve the way they work.

At a large financial-services institution, for example, we selected an experimental and a control group that were comparable and representative of the wider organization by criteria such as net profit before taxes, customer economics, and branch staff characteristics. The two groups then implemented a sales stimulation program over an 18-month period—one using fairly traditional performance-focused methods, the other following a more balanced approach emphasizing performance and health.

The results were striking. In business banking, the traditional approach yielded improvements in value of 8 percent, the more balanced approach 19 percent. In retail banking, the traditional approach delivered a 7 percent improvement, compared with 12 percent for one emphasizing performance and health. Similar studies in other industries yielded similar results (Exhibit 3).

Evidence from transformation efforts
Finally, we’ve surveyed thousands of executives who have been through organizational-change programs. Data from one survey, on why change programs fail, showed that what we might see as “the usual suspects”—inadequate resources, poor planning, bad ideas, unforeseen external events—account for less than a third of the failures. More than 70 percent resulted from poor organizational health, manifested in symptoms such as negative employee attitudes and unproductive management behavior. Furthermore, our 2010 survey of executives at companies undergoing transformations revealed that organizations focusing on both performance and health rated themselves as nearly twice as successful as those focusing on health alone and nearly three times as successful as those focusing on performance alone.
Working toward ‘and’
The link between health and performance is good news. Unlike many of the key factors that influence performance—changes in customer behavior, competitors’ moves, government actions—your health is something you can control. It’s a bit like our personal lives. We may not be able to avoid being hit by a car speeding around a bend, but by eating properly and exercising regularly we are far more likely to live a longer, fuller life.

Of course, that doesn’t make the pursuit of performance and health any easier. Most companies know how to keep a close eye on performance, but health often suffers from neglect. We asked more than 2,000 executives to name the areas where they wished they had better information to help them design and lead transformation programs, for example. Only 16 percent chose near-term performance. More than 65 percent chose the company’s health for the longer term.

What’s more, even when companies do understand both performance and health, many pursue them separately. The result can be HR-led “people programs” that bear little relationship to a company’s strategic and operational imperatives, performance-improvement initiatives that cut more muscle than fat, or both.

In our experience, building health and achieving its accompanying performance benefits generally require transformational change. The approach we’ve found most effective for pursuing it consists of five stages, which we refer to as the five frames of performance and health. For each stage, you must answer a basic question that applies to both performance and health and then address a related performance- or health-specific imperative.

While no two change programs are alike, we believe that the five frames contain the key ingredients for an organization-wide transformation that delivers performance and health in almost all circumstances. In what follows, we offer examples from companies that have excelled in one stage or another to highlight what’s required to tackle both aspects of a transformation—with an emphasis on health, since pursuing it as an explicit goal is less familiar to most organizations. Although we firmly believe that each organization must find its own way through the five frames, these examples of companies that have made significant and lasting improvements in both performance and health offer some inspiration, as well as guidance on tactics we’ve seen work well.
The importance of setting aspirations that emphasize health as well as performance came through loud and clear in one of our surveys: change programs with well-defined aspirations for both, we found, were 4.4 times more likely to be rated extremely successful than those with clear aspirations for performance alone.

Wells Fargo offers an example of how to pursue both: setting strategic objectives and then defining related health essentials. When current CEO John Stumpf became president, in August 2005, he brought his top team together in a two-day offsite session to debate Wells Fargo’s aspirations for its next era. The performance goal that emerged was to maintain the company’s track record of double-digit compound annual growth in earnings per share and revenue. To that end, the team doubled down on the bank’s long-term cross-sell aspiration of “going for gr-eight” (eight products per customer), with the medium-term goal of adding at least one product on average to its already industry-leading cross-sell rates. The bank’s leaders also set performance targets related to customer loyalty and customer attrition in all key businesses.

But a broader aspiration also emerged, which the team summed up in the phrase “One Wells Fargo.” This idea grew out of the realization that a huge amount of the value the team sought to create lay in what it called “mining the seams” of the organization: working together more effectively across the company’s lines of business to break down “silo thinking” and give customers a better experience that fulfilled more of their financial needs.

Thinking about the bank as One Wells Fargo helped the senior team focus on changes that would be needed to make the organization healthier: management practices related to customer focus, strategic clarity, and collaborating to share ideas and information were all strong within the lines of business but had to be distinctive across them as well. If One Wells Fargo was the strategy, organizational changes would be needed to support and enable it.
Before you move from goals to actions, it pays to take a hard look in the mirror to understand your company’s readiness to achieve its aspirations. What capabilities matter most to meeting your performance goals, and how strong are they in your company today? What mind-sets about “the way things get done around here” could undermine your quest for health, and what are their root causes? The value of such assessments of a company’s readiness to change can’t be overstated: in our 2010 survey, respondents at companies that diagnosed problematic mind-sets were four times more likely than those that didn’t to rate their transformations as successful.

When Pierre Beaudoin took over the aerospace division at Bombardier, in 2001, for example, he knew that it needed a performance boost to ride out the industry’s post-9/11 downturn. He also wanted the company to become a healthy, self-improving organization. The aspirations he set—Can$500 million in bottom-line savings, along with a continuous improvement in service and products for customers—required lean capabilities that Bombardier lacked at the time, as well as a significant change in mind-sets.

Probing cultural issues wasn’t something that came naturally to a company that prided itself on technical expertise. In Beaudoin’s words, “It was a challenge for me and for my leadership team to explain why we were spending so much time on the ‘soft stuff’ when we could be fixing factories, hardware, airplanes. We had lots of conversations explaining that if we did the soft stuff right, our employees, with our help, would be more able to do what they’re supposed to do, like make our factories efficient and work on engineering problems.”

These conversations and a more formal organizational self-assessment yielded a shortlist of beliefs that limited the value placed on individuals, the role of teamwork, efforts for continuous improvement, and the drive for results. One area where the company urgently needed to change was attitudes toward handling problems. As Beaudoin explains, “Suppose I come to a meeting and hear about four problems, and I slam my fists on the table and say, ‘I don’t want to hear about problems any more; you guys are there to fix them.’ Well, guess what—I’m not going to hear about problems. And that’s how you get yourself in deep trouble.”
Once a company knows where it wants to go and how ready it is to go there, it must work out the way from here to there. Countless leaders have told us that this is the hardest part of changing their organizations. But it’s also the stage in a company’s journey when efforts to improve performance and health start to fuse: they interlock and reinforce one another as a focused portfolio of performance-improvement priorities becomes a vehicle for shifting mind-sets toward health.

To understand what this symbiotic relationship looks like in practice, consider the turnaround A. G. Lafley famously engineered at Procter & Gamble after taking the helm, in June 2000. Lafley established some explicit priorities for P&G: focusing on 10 out of 100 countries, for example, and on four core businesses. Emphasizing these priorities was critical to P&G’s performance improvement. It also built a platform for one of Lafley’s deeper goals: to make P&G a more consumer-driven and externally focused company—a healthier one, in short.

As Lafley was setting priorities, he decided to draw up a not-to-do list. One item on it was P&G’s “skunk works”: experimental technology projects outside the company’s mainstream businesses. These endeavors—which had an annual budget as high as $200 million—reflected technological goals rather than customer needs and culminated in products and services that had to be “pushed” to the market in the hope they would be taken up. All this worked against Lafley’s customer-focused aspiration. And so the not-to-do list was rigorously enforced: “If we caught people doing stuff that we said we were not going to do, we would pull the budget and the people, and we’d get them refocused on what we said we were going to do.”

Often, shifting mind-sets means changing formal systems, structures, processes, and incentives. At P&G, Lafley made sure that planning processes started with an understanding of consumer trends and reframed the organizational structure to give it a stronger consumer orientation. Finally, role modeling, storytelling, and skill development can also play a vital role in shifting mind-sets. Lafley, for instance, set up an in-house college for managers and dedicated a substantial part of his own time to coaching. Although this soft stuff is often overlooked, it’s vital. Senior executives who told us, in one of our surveys, that they’d implemented initiatives to change their employees’ mind-sets and behavior during a transformation were twice as likely as others to report that it had succeeded.
When it’s time to get moving, pilot programs are almost always the right way to start working on performance. If things go well, successes can be replicated elsewhere; if they go awry, you can confine mistakes to a small area. Early results also help to build your employees’ motivation and appetite for change. One key to successful pilots, we’ve found, is conducting them in two stages: first, a standard proof of concept and, second, a proof of feasibility, which will ensure that you have a replicable means of capturing the value you’ve identified across your organization. Too many companies don’t take the second step and find that they can’t build on their initial success.

But even the most carefully constructed pilots aren’t enough. Lasting, healthy change also requires an organization motivated to go the extra mile over and over again as employees carry out their routine, day-to-day tasks while fundamentally rethinking many of them. The whole process can feel like trying to change the wheels of a bike while you’re riding it. Not surprising, most companies find this difficult: one of our surveys found that only some 30 percent of all executives who had been through a transformation thought their companies had been completely or mostly successful at mobilizing energy in it.

CEO Julio Linares took the reins of Spain’s incumbent telecom operator, Telefónica de España, in January 2000, as earnings and cash flow were sliding. He used three methods to create a powerful engine for change as he transformed the company. The first was to help people “understand how the project they were working on would contribute to that year’s targets and, therefore, to the overall transformation program.” With that goal in mind, Linares and his team emphasized growth, competitiveness, and commitment as critical themes. Developing new distribution models and improving customer segmentation came under the heading of growth; adopting lean work processes and enabling online transactions, of competitiveness; and embedding a new set of company values and reorganizing business units, of commitment.

Second, Linares ensured that the whole company felt ownership of the changes. He and his senior team brought the telco’s top 500 executives together every January, for example, to help design the program for the year to come. Beyond this core group, Linares sought to “give relevant people at different levels of the organization an opportunity to participate” in the redesign of the transformation program “and then to complement that with a strong communication program.” Sometimes, companies need to reach out even further to create a shared sense of ownership. When structuring the transformation of India’s Larsen & Toubro, CEO A. M. Naik explained, “We involved one in four employees, about 7,000 people. I visited 38 locations of the company.” He added, “When the vision was finalized” in a document, “everyone could say, ‘That word was mine,’ you know? Maybe that word was in the minds of a thousand people. But the process created a shared vision everyone could believe in.”

Finally, Linares used progress evaluations, which are always important, as a third tactic for maintaining energy. Linares explained the need for them in this way: “The market is going to change constantly, and because of that you need to make a constant effort to adapt your company. Some parts of the program will end, but new ones will come up.”
The final stage is to make the transition from the intensive work and constant upheaval of a transformation to a period of continuous improvement. According to one survey, companies that build a capacity for it into their organizations are 2.6 times more likely to consider their transformation programs a success over the long term.

Continuous improvement can be cultivated during a major transformation effort by building an infrastructure, as you go, that includes knowledge sharing, learning methods, and expertise to help the company continue to improve. For these to be embraced after the initial transformation effort is complete, the right leadership skills and mind-sets must be in place. After the formal end of a transformation program at ANZ Bank, for example, the company trained more than 6,000 leaders in areas such as self-awareness, resilience, and the ability to energize oneself and others. The response was tremendous: participants spoke of the program’s “profound impact” and described the experience as “life changing.” ANZ also held other personal-leadership workshops to develop its employees’ ability to improve continuously, cascading the workshops right through the organization in a process that eventually touched more than 26,000 employees.

These efforts helped ANZ usher in an era of nonstop progress, which included grassroots business initiatives, organizational delayering, bureaucracy busting, internal job markets, and greater diversity. Supporting these endeavors were some 180 “champions” who worked, on top of their regular jobs, to foster continuous improvement in the businesses.

ANZ’s strong financial performance, in the years after its transformation, was accompanied by striking evidence of organizational health: it had the highest level of staff engagement of all peer organizations in Australia and New Zealand, and the share of employees who agreed that “we live our values” and “are earning the trust of the community” was 85 percent and 81 percent, respectively.

If you want to change your organization for the better and to make the changes stick, you must focus on its long-term health even as you push for higher performance now. We hope our research has convinced you that this sensible-sounding but often-ignored maxim is true. And we hope you see, from the examples earlier in this article, that practical insights and tried-and-true tools will let you tackle performance and health simultaneously. We fervently believe that business, and even society as a whole, will improve when organizations begin to report—and be judged—on their health just as frequently and rigorously as they are on their performance.

Sunday, September 22, 2013

The Apathy Of Hospitals: One Doctor For 2,100 Indians

By M H Ahssan / INN Live

Last month, tragedy struck Bhargavi and Laisan Kanhar in Sambalpur district of Odisha. The tribal couple’s only child Banita who was in Class III fell into a hot egg curry cauldron at her school in Girischandrapur village while she waited for the midday meal.

The eight-year-old suffered severe burns and was rushed to the nearby primary health centre (PHC), where the only doctor was absent. The hospital staff applied first aid and referred her to the VSS Medical College and Hospital at Burla. 

However, there was no ambulance to take her to the hospital 72 km away. She finally reached there in a private vehicle nearly four hours after the accident. The same evening, she was again referred to the SCB Medical College and Hospital in Cuttack, nearly 300 km away. By next morning, Banita was declared dead at the hospital in Cuttack.

Wednesday, February 13, 2013

How UPA Is Pushing India Into A Public Health Disaster?

Recently when the government of India allowed compulsory licensing of two hugely overpriced cancer drugs, the jubilation was not confined to India alone. Along with their Indian counterparts, public health activists across the world hailed the decision.

That is the relevance of India and its scale for the healthcare of the poor in the world. In fact, the government hadn’t done anything extraordinary. In quiet and gingerly steps, it decided to break the patents of two life-saving drugs with abusive prices.

One of them, that costs about Rs. 2.8 lakhs is available at less than Rs 7,000 now. The other one is yet to be made in India, but when it is available, it shouldn’t cost more than 10% of its current price.

The points CIPLA’s Yusuf Hamied made in a farewell interview with Business Standard is hugely relevant here: India’s policies should be suitable for Indians and the country should have an automatic right to break patents in the case of a national emergency.

As an example, he refers to multi-drug resistant TB (MDR-TB) as a national emergency and the need to make generic versions of available MNC drugs against it. He says that an MNC was working on a drug to sell in India and CIPLA wanted to join hands, but the former was disinclined. According to him, this is an ideal situation for the government of India to issue compulsory license (break the patent) and let Indian companies make generic copies that would not cost more than a fraction of the the original drug.

That is, if the Indian government is interested in the health and welfare of its people.

MDR-TB is certainly an emergency. India has close to a third of the world’s TB population and about 100, 000 of them are untreatable because the disease they have is resistant to the available drugs now. The solution is new generation of drugs, which are branded and prohibitively expensive. Without these drugs, not only these patients will suffer and die, but they will also infect others who will also become untreatable. The cycle will fast-breed more people who are terminally ill.

MDR-TB is just one of the health emergencies in India. The truth is that the country’s entire public health system is in a state of emergency.

India, with more than a billion people, has the largest number of sick people in the world for any disease – both communicable and non-communicable -, but the central and state governments don’t even attempt to acknowledge more than 20 per cent of them. The majority is dumped and doomed!

End of last year, an outspoken Jairam Ramesh said exactly this, when he deplored that the country’s public health system had collapsed. He said even Bangladesh and Kenya were better than us and that medical cost was the biggest reason for indebtedness in rural areas.

He also said what public health activists have been saying for long – “India is a unique country” where 70 percent of the health expenses are bourn by the people themselves. Some say, it is not 70 percent, but 80.
But does his UPA government care?

Forget the ideal universal public health systems in countries such as the UK, France and Canada where the State takes care of its sick, even a terribly greed-driven America is changing its ways with Obamacare. Any sensible government knows that bad health of its people is a national security issue.

The AIDS epidemic in many sub Saharan African countries, where every socio-economic indicator including the GDP, drastically fell over a short period of time is a grim reminder that if your citizens are sick, the country is sick. Even MDR-TB had similar impact in countries such as Haiti. India has several health emergencies – ranging from killer communicable diseases to lifestyle illnesses – rolled into a single behemoth, but the government doesn’t care.

The reason is not resources, but politics. Health is the most neglected and politically low- profile ministry that no ambitious politician wants to touch. Some time back, a prominent Congress woman politician, reportedly sulked for long when she was made the health minister. Both the UPA and the NDA had assigned the ministry to low-weights and junior allies, whose prime occupation was to clear medical colleges and framing policies to help pharma industries and hospitals profiteer. It’s this neglect that resulted in a booming and rather unregulated private health sector, and the collapse of the public sector.

As an article in the latest issue of Outlook magazine, notes, the government seems to have abandoned healthcare to the private sector. The article quotes Amartya Sen: “India is the only country in the world that’s trying to have a health transition on the basis of a private healthcare that does not exist…It doesn’t happen anywhere else in the world. We have an out-of-the-pocket system, occasionally supplemented by government hospitals, but the whole trend in the world is towards public health systems. Even the US has come partly under the so-called Obamacare.”

With examples from different parts of the country, the article establishes how our public health system has collapsed and how endangered are the lives of millions of poor people. It shows that even the vertical programmes funded by the Government of India and the state run programmes are poor and hugely inadequate. It’s absolutely justified to note that during the nine years of the UPA regime, public health sector has shrunk further and the private sector boomed.

The UPA government has to certainly own up this mess. It has been irresponsible to its people and doesn’t seem to be in no mood to change its policy. A High Level Expert Group (HLEG) of the Planning Commission had clearly suggested that India needed to move towards universalisation of healthcare and that it had to raise its health expenditure to 2.5 per cent during the 12th Plan period. The HLEG also said insurance was not the model that the country should adopt.

The HLEG report was a remarkable piece of policy advice, but the Planning Commission and the UPA were not interested. It committed less money, half-hearted attempts and also proposed more privatisation through the backdoor in the form of PPP. The CPI leader A Raja, quoted in the Outlook article is bang on when he says that “the government is working as a facilitator for the private sector.”

Such a pity that less than a year ago, Manmohan Singh committed to his countrymen that the 12th Plan would be a health and education plan. The PMO had said that if all went well, the health-spend of the government would triple during the plan period.

Look where he, his Planning Commission and government are now. Even countries such as Thailand, or even Philippines to some extent, know that the State can’t look away when its people are sick.
Indians are in deep trouble. They will have to spend more and more non-existent money for healthcare because the only option available to most of them (70-80%) is the private sector, which is a greedy and self-contained domain by itself.

What the mandarins of the Planning Commission and the UPA bigwigs do not understand is that ultimately bad health of our people will catch up with them as well. We have lost important people to diseases of the poor that scaled their high walls. Unless they build impossible green-houses at sea, they will not be safe.

What prevents the country, which doesn’t mind struggling over an impossible UID scheme, from implementing a cashless, universal healthcare system?

Wednesday, June 03, 2009

Lives sacrificed: Women and health in South Asia

By Deepti Priya Mehrotra

A new World Bank report looks at the state of reproductive health of poor women in five countries -- Bangladesh, India, Nepal, Pakistan and Sri Lanka -- and makes a case for decentralised planning, delivery and expansion of health services, with a clear focus on enhancing inclusion

‘Sparing Lives: Better Reproductive Health for Poor Women in South Asia’, by Meera Chatterjee, Ruth Levine, Nirmala Murthy and Shreelata Rao-Seshadri, the World Bank, MacMillan, 2008

This World Bank report, released on March 5, 2009, investigates the state of reproductive health of poor women in Bangladesh, India, Nepal, Pakistan and Sri Lanka. It also makes a case for increasingly decentralised planning, delivery and expansion of health services, with a clear focus on enhancing inclusion.

The report highlights a number of significant concerns. Sri Lanka, despite ongoing conflict, fares remarkably better than the other four countries in terms of maternal mortality, pregnancy and delivery care, infant weight and death rates, contraceptive acceptance and fertility rates. This is attributable to a high commitment to health on the part of successive governments. With decentralised planning the cornerstone of health delivery, services are provided at all levels, as an integrated package. The report notes that Sri Lanka’s relative success is “not because it spends more per capita, but because it uses resources more efficiently and equitably… Low unit costs in Sri Lanka contribute to high reproductive health access…”

Gopalakrishnan, a representative from the prime minister’s office, India, noted that the findings of the report are “disconcerting”; he reiterated the “urgency of concerns” to be addressed. Enormous disparities exist in India throughout the realm of maternal health and services delivery. For instance, while some antenatal care and tetanus toxoid reached 77-78% of women in 2005-06, only half of the poorest women received care as compared to the richest. Scheduled caste and scheduled tribe women have far lower maternal health service coverage levels than other women. While overall fertility reduction and contraceptive use have improved, the improvement is not as much as is desired. Between 1998-99 and 2005-06, fertility declined from 2.8 to 2.7 births per woman, the greatest change occurring among 15-19-year-olds. Kerala, Goa, Tamil Nadu, Himachal Pradesh and Punjab have achieved replacement-level fertility, while Bihar, Uttar Pradesh, Madhya Pradesh, Rajasthan and Orissa will contribute over 50% of the country’s increase in population over the coming decade. As for contraceptive use, only 48.5% of couples used modern methods of contraception (in 2005-06), one-fifth of these being temporary methods. Terminal methods, ie sterilisation, continue to be dominant. The average age for female sterilisation is amongst the lowest in the world (below 25 years). The poorest women in India are four times more likely than the richest women to have an ‘unmet need’ for contraception, underlining the urgency of ensuring wider access to temporary contraceptive methods. The gap between the poor and the rich in contraceptive use is much less in Bangladesh and Sri Lanka, as compared to India, Nepal and Pakistan.

The average risk of maternal death in these five South Asian countries (1 in 43) is almost a hundred times greater than that of a woman in the industrialised countries (1 in 4,000). Maternal mortality rates in India, Bangladesh, Nepal and Pakistan are still two to four times higher than the Millennium Development Goals (MDGs) set for 2015. While the lifetime risk of dying during pregnancy for a woman in Sri Lanka is 1 in 430, in Bangladesh it is 1 in 59, in India 1 in 48, in Pakistan 1 in 31, and in Nepal 1 in 24. India needs to reduce its maternal mortality rate by two-thirds to meet the MDG -- from the current estimate of 301 to 100 (by the year 2015).

Malnutrition contributes to maternal mortality, and infant and child deaths. Over two-fifths of all children under five in the region are malnourished, the figure even in Sri Lanka being as high as 22%. While 34.3% of women are acutely undernourished in Bangladesh, in India nearly half (47%) of mothers aged 15-19 years are undernourished. Compared to the richest quintile of urban women in India, the poorest urban quintile is 4.8 times more likely to be undernourished, and the poorest rural quintile, 5.6 times more likely. Over 45% of rural children under five years of age are undernourished, and almost one-third of urban children: a total of about 50 million undernourished young children in India.

The five countries together have a huge population of poor people: approximately 500 million. About four-fifths of the population of Bangladesh, India and Nepal live on less than 2 dollars a day, and two-fifths in Sri Lanka. Governments are certainly not directing sufficient resources into reproductive health services for the poor. Integrated health services and nutrition are critically needed and ought to be very high on the priority agendas of all the nations. Noting that poverty and poor reproductive health form a vicious cycle, the report emphasises the need for a renewed focus on adolescent health and nutrition, and accessible contraception, pregnancy and childbirth services. It also acknowledges that gender discrimination exists in society as well as in the health services sector, and that needs to be tackled.

While the report provides useful information on poor women’s reproductive health, it does not attempt correlations with macro factors like food security, unemployment, access to potable water, political participation and so on. Such correlations are needed, to arrive at a more comprehensive analysis of causes and policy implications. Several elements required to help South Asian poor women to climb out of the abyss may still be missing from the jigsaw.

During the video conference at the simultaneous release of the report in the five countries, Dr Mohammad Abdul Qayyum, director general of family planning, Bangladesh, gave voice to a woman-friendly policy understanding: “We want to provide and strengthen safe birth practices wherever the woman wants to be.” He noted that maximum births could take place at home, and spelt out Bangladesh’s commitment to community clinics, where referrals for high-risk and emergency services could be made available. Indu Capoor, a women’s health professional and director, CHETNA (Centre for Holistic Education, Training and Nutrition Awareness, Ahmedabad) pointed out that rejection of home births and traditional birth attendants, to be replaced wholesale by institutional births and ‘trained’ attendants, is a deeply flawed and highly questionable policy for South Asian countries.

Pakistan, India and Nepal would do well to heed the practical wisdom inherent in Bangladesh’s policy choice. This debate highlights the need for policymakers to listen far more to grassroots health activists who may have different points of view on how to handle issues. As Gouri Choudhury, director, Action India, remarked: “We have been saying much of this for the past 20 years. What is new?… The health volunteers appointed by the government are called ASHA now, but they are still underpaid and overburdened… This is not decentralised service delivery!”

Wednesday, July 08, 2009

World Population Day 2009 - Fight Poverty, Educate Girls

By M H Ahssan

On 11 July 2009, people around the world will be observing the 20th World Population Day in different ways. This year's theme is chance to build awareness of the importance of educating girls to a wide range of development issues, including poverty, human rights and gender equality.

There are many ways to promote this theme:

- Consider inviting local celebrities to help spread the message.
- Organize events to generate widespread attention about the importance of girls' education.
- Spark discussion with seminars, conferences and debates. Host essay and poster contests.
- Work with community groups to create plays and soap operas.

Encourage women and girls to speak or write about the impact of education in their own life. The messages can come to life when different people from different circumstances share their own experiences and knowledge.

Investing in Women is a Smart Choice
No one knows yet what the full scale of this global economic crisis will look like. We do know that women and children in developing countries will bear the brunt of the impact. What started as a financial crisis in rich countries is now deepening into a global economic crisis that is hitting developing countries hard. It is already affecting progress toward reducing poverty.

Policy responses that build on women's roles as economic agents can do a lot to mitigate the effects of the crisis on development, especially because women, more than men, invest their earnings in the health and education of their children. Investments in public health, education, child care and other social services help mitigate the impact of the crisis on the entire family and raise productivity for a healthier economy.

Protect the gains achieved
Investments in education and health for women and girls have been linked to increases in productivity, agricultural yields, and national income — all of which contribute to the achievement of the MDGs. Investments by governments worldwide have raised school enrolment rates, narrowed the gender gap in education, brought life-saving drugs to people living with AIDS, expanded HIV prevention, delivered bed nets to prevent malaria, and improved child health through immunization.

Today, as we commemorate World Population Day, the global financial and economic crisis threatens to reverse hard-won gains in education and health in developing countries. Among those hardest hit are women and girls. This is why the theme of this year’s World Population Day focuses on investing in women. Even before the crisis, women and girls represented the majority of the world’s poor. Now they are falling deeper into poverty and face increased health risks, especially if they are pregnant.

Today, complications of pregnancy and childbirth are leading killers of women in the developing world. And maternal mortality represents the largest health inequity in the world. This health gap will only deepen unless we increase social investments, maintain health gains and expand efforts to save more women’s lives.

In countries and communities where women have access to reproductive health services—such as family planning, skilled attendance at birth and emergency obstetric and neonatal care—survival rates are high and maternal and newborn deaths are rare.

Access to reproductive health, in particular family planning and maternal health services, helps women and girls avoid unwanted or early pregnancy, unsafe abortions, as well as pregnancy‐related disabilities. This means that women stay healthier, are more productive, and have more opportunities for education, training and employment, which, in turn, benefits entire families, communities and nations.

And investments in reproductive health are cost-effective. An investment in contraceptive services can be recouped four times over—and sometimes dramatically more over the long-term—by reducing the need for public spending on health, education and other social services.
It is estimated that family planning alone could reduce the number of maternal deaths by as much as 40 per cent.

Our world today is too complex and interconnected to see problems in isolation of each other. When a mother dies, when an orphan child does not get the food or education he needs, when a young girl grows into a life without opportunities, the consequences extend beyond the existence of these individuals. They diminish the society as a whole and lessen chances for peace, prosperity and stability.

UNFPA, the United Nations Population Fund, remains committed to supporting countries to advance women’s empowerment, gender equality and sexual and reproductive health.

Today, on World Population Day, I call on all leaders to make the health and rights of women a political and development priority. Investing in women and girls will set the stage not only for economic recovery, but also for long-term economic growth that reduces inequity and poverty. There is no smarter investment in troubled times.

Friday, August 12, 2016

Health Crisis: India's Wealthier States Are Showing An Alarming Decline In Immunisation Process


The warning signs from the latest National Family Health Survey data have gone unnoticed so far.

A fair amount of media attention has been given to the resurgence of diphtheria in Kerala, which has been attributed to some Muslims rejecting immunisation efforts due to misinformation. However, a much more dangerous and widespread trend of declining immunisation rates as evidenced by the recent National Family Health Survey 4 data, seems to have gone entirely unnoticed.

Thursday, June 25, 2009

Finding Market Opportunities in 'the Best Place to Get Sick'

India's health care industry ails from severe under-penetration among its population, especially in rural areas. Still, the low penetration levels are a glass half full for global pharmaceutical companies, many of whom have steadily increased their investments in the country, drawn by India's talent base and R&D capabilities for drug development, and its strengths in alternative medicine, like Ayurveda (India's traditional system of holistic medicine). Insurance providers, meanwhile, like the country's low cost of health care, which has made it a destination for so-called "medical tourists" from developed countries.

Those are the key drivers for pharmaceutical firms, hospital chains and investment funds as they look for opportunity in India's health care industry, according to a panel discussion on "The Health Care Duopoly: India, the Medical Center of the World" at the recent Wharton India Economic Forum in Philadelphia. The panel included top executives from pharmaceutical companies GlaxoSmithKline and Cadila Pharmaceuticals, Asia's largest health care chain Apollo Hospital Group, and investment funds, who identified areas of advantage in an otherwise dismal scenario.

The Upside of Low Penetration

"I am happy and delighted there is under-penetration [in India's health care industry]," said Anula Jayasuriya, co-founder of the Evolvence India Life Science Fund, a US$90 million venture capital fund formed three years ago to invest in pharmaceutical, biotechnology, medical device and related contract service companies based in India. "From an investor's perspective, we see a great opportunity" to extend the health care industry in under-served areas.

Jayasuriya added that she expected Indian pharmaceutical companies to become a bigger force globally in the near future. "My crystal ball says ... I see an Indian company and a European and U.S. pharmaceutical company becoming one," she said, noting that Sanofi-aventis and GlaxoSmithKline are reportedly talking about a possible acquisition with India's Nicholas Pharmaceuticals. That's only speculation, she said, "but that [kind of deal] would be one measure of success."

Jayasuriya was responding to a relatively pessimistic scenario offered at the beginning of the session by the panel's moderator, Michael Fernandes, executive director of the investments division and country head for India at Khazanah Nasional, the investment arm of the Malaysian government. Fernandes said that while global pharmaceutical companies had steadily increased their investments in India over the last 50 years, including contract research in the last five years, the overall results of these investments have been disappointing. He also noted that the largest Indian pharmaceutical company -- Ranbaxy Laboratories -- was sold last year to Japanese firm Daiichi Sankyo.

"It doesn't seem like an Indian company would be among the top three in generics globally," Fernandes said. "Some experts say it may not happen at all." Pharmaceutical innovation in India, too, has had "a number of false starts," he added. "Lots of phase two and three products have failed; not a single Indian-innovated product has been launched globally, although there are a number in the pipeline."

Jayasuriya read the scenario differently. "Innovation is an attrition game," she said. "The number of molecules that failed in India is not surprising, even if you use a fraction of the U.S. failure rate." She added that she is encouraged by the pipeline of Indian generics, and that while pharmaceutical drug development in the U.S. has many of its roots in universities, "Indian companies are hotbeds of innovation." Offering an example, she talked of Indian biotechnology company Biocon launching the country's first new drug -- a monoclonal antibody for head and neck cancer. The drug was originally created in Cuba, "but that is also a developing country, an emerging market," she said.

Hasit Joshipura, GlaxoSmithKline's vice president for South Asia and managing director of GlaxoSmithKline India, was also optimistic about the ability of India's health care industry to deliver on new drug development. "I can see an Indian role in every major new drug, such as developing medicines for AIDS or other problems of poor countries," he said. For many years, pharmaceutical companies in India were, for the most part, subsidiaries of multinational players, so "there was no need to look at innovation.... But now you see frenetic activity, and in five to six years, you will see the next innovative products coming out of India."

Indian pharmaceutical companies could seize the opportunity to be "at the forefront for the next generation of vaccines and biologics," according to Michael Ross, president of the U.S. subsidiary of Indian drug firm Cadila Pharmaceuticals. His company is currently working on a vaccines program. "For every dollar you spend on vaccines," he noted, "you save US$8 down the line. It's a very efficient way to lower costs of healthcare."

Here Come the Medical Tourists

Ross said India's relatively lower health care costs have also spurred a surge in "medical tourism -- although I hate that term." Hospitals in India could secure accreditation from the non-profit Joint Commission International to take advantage of the increasing interest from patients and insurers in developed countries, he added. "The cost of a procedure is a third less in India, but the care is excellent. You will see more and more people going overseas for health care."

Insurers like Blue Cross waive a patient's co-pay if they go overseas for surgery because of the lower costs. For companies having trouble keeping up with today's medical expenses, this could be a tremendous opportunity, Ross said, joking that ailing companies like General Motors could benefit. In fact, he suggested to fellow panelist Shobana Kamineni, executive director of Apollo Hospital Enterprises, that her chain consider alliances with large insurers to lower the cost of its services for patients, and thereby expand its market opportunity.

According to Kamineni, about 15% of Apollo's patients are foreigners, and they come not "for vanilla care" like cosmetic surgery, but for complex surgeries like hip replacements. "India can become a real hub for medical tourism," she said, noting that Apollo attracts patients from Canada, the U.K. and even countries like Afghanistan because of lower costs and also shorter wait times. Over the years, costs for medical services have remained low in the country because they would be otherwise unaffordable for most of India's citizens, who are unable to obtain health insurance beyond age 60. "India is probably the best place to get sick -- it is the cheapest," Kamineni said.

In recent years, health insurance in India has been growing at a rate of 38% to 40%, according to Joshipura of GlaxoSmithKline. He said that although India has shown increases in life expectancy, its health care industry will have to factor in the need to treat a wider range of diseases as health awareness and affordability grows, especially in the larger rural markets.

Increasing Reach

Joshipura stressed the need to develop health care infrastructure to ensure access to the rural markets. He pointed out that India's expenditure on health care is just about 4.5% to 5% of its GDP, compared with 10% to 11% in France, Germany and Switzerland, and more than 15% in the U.S. The government could play a greater role in expanding access to health care in India, he added: Government-funded health care reaches only 0.9% of the market; the private sector fills in the gap.

But intelligent use of technology could help reach "the 500 million people who don't have access to health care" in India, according to Jayasuriya. She cited applications for India's rural markets, such as diagnostic labs in kiosk-like facilities where, for instance, a sick child's parents could determine whether or not an infection calls for rapid intervention. Sanofi-aventis had a model built around such kiosk-type labs that don't necessarily have to be staffed by doctors, she noted. Similar applications could also find uses in developed markets like the U.S. in, for example, neonatal screenings. Another technological innovation Jayasuriya referenced was a reverse-engineered home dialysis machine that Indian computer maker HCL had developed for US$400 compared to a price of US$4,000 in the U.S. market.

Expanding the reach of health care services is easier said than done in India, Kamineni said. Apollo Hospitals, which now has 42 hospitals and 8,000 beds nationwide, plans to open four hospitals next year in Mumbai. Creating new capacity in hospital beds is a formidable challenge, she noted, adding that the high cost of land in urban areas is not offset by any government concessions even though the end use is health care. "My dad [Prathap Reddy, the group's founder and chairman] says it is easier to build a liquor factory, because the risks are so much [higher] with hospitals. It's like flying a plane every single day."

Finding good talent is also a problem, Kamineni said. Her group runs two medical colleges and 14 nursing schools to serve its talent needs. The solution lies in privatizing education with a for-profit model to attract investors, she argued. "There is no [talent] planning in the health care business. Between last year and this year, we added 20,000 people to our work force."

Alternative Medicine

Kamineni was, however, optimistic about the possibilities with India's traditional systems of alternative medicine, notably Ayurveda. Johnson & Johnson is looking for Ayurvedic drugs, for both prescription and nonprescription uses, including non-alcoholic mouthwashes and pain-relieving medications, according to Ross. "They are hunting in India for products to sell all over the world."

According to Joshipura, India hasn't done enough to develop its alternative systems of medicine. "China has done a good job with Chinese medicine," he said, suggesting India follow that example. "It's going to take time for a Western company to develop familiarity [with alternative medicine systems like Ayurveda]." Ross agreed: "If you talk to the multinationals [about alternative medicine], you have to develop scientific data; it's not just about word of mouth."

Saturday, April 25, 2009

Waning Motherhood - The Cursed Bliss in India

By Sheena Shafia

"Mothers Reflect God's loving presence on earth."

Motherhood is such a blessing in woman's life, that as a loving mother, she forgets her own self for the tender love of her dear ones and trains her children to virtue. The bond between a mother and her child is a powerful component in a child's life.

But mothers who die during childbirth or before the birth of a baby leave behind their never ending stories, their children and families and numerous reasons as to why their lives ended so early.

Every time a woman in the third world becomes pregnant, her risk of dying is 200 times higher than the risk run by a woman in the developed world. Approximately 30 million women in India experience pregnancy annually, and 27 million have live births. In India every one woman dies every 5 minutes from a pregnancy-related cause.

Maternal mortality is generally defined as the death of a woman during pregnancy or delivery, or within 42 days of the end of pregnancy from a pregnancy-related cause.

The maternal mortality ratio is nothing but the maternal death per 100,000 live births in one year. The maternal mortality ratio in India is somehow near about 267 (Urban estimation), rising to 619 in rural areas where as the developed countries in contrast have a maternal mortality ratio of around 20 per 100,000 live births.

Given the high maternal mortality rate in India, the women who lose their lives as a result of pregnancy and childbirth remain invisible in general. Therefore, reliable estimates of maternal mortality in India are not available. However, WHO estimates show that out of the 529,000 maternal deaths globally each year, 136,000(25.7%) are contributed by India, most of which can be prevented. This is the highest burden for any single country.

The indirect estimate done by Bhat (Maternal mortality in India: An update. Studies in Family planning, 2002) shows that MMR is higher in eastern and central regions and is lower in north-western and southern region. Similar picture is also shown by data collected under Sample registration system by Registrar General of India in 1997.

States with high maternal mortality include Rajasthan, Madhya Pradesh, Jharkhand, Orissa, Uttar Pradesh and Bihar.

The most common responsible causes of maternal deaths are hemorrhage (ante partum or post partum), eclampsia, pre-eclampsia, infection, obstructed and prolonged labour, complications of abortion, disorders related to high blood pressure and anaemia.
Causes of maternal death (%)

Haemorrhage 30
Anaemia 19
Sepsis 16
Obstructed labor 10
Abortion 8
Toxemia 8
Others 9

MAJOR CAUSE: Anaemia is one of the major causes of maternal mortality in India. It is noted painfully that after 61 years of independence India leads iron deficiency anaemia cases in the world and more than 90% of Indian women, adolescent girls and children are anaemic. Everyone is aware that anaemia results in physical weakness, mental shortcomings, low intelligence and increased vulnerability to a number of diseases and causes adverse pregnancy outcomes and even death of expectant mother. The anaemic mothers also bear anaemic children. The Ninth Plan envisaged universal screening for anaemia in pregnant women and appropriate use of IFA tablets is also indicated .But just like other plans and policies the programme had not been operationalised fully. In none of the states were services for anaemia included as a component of antenatal care. Data from Rapid Household Survey indicated that even iron folic acid consumption is still very Low. The target during the Tenth Plan was to make every effort to fully operationalise the Ninth Plan strategy for prevention and management of anaemia. But still now it has not faced much success. Only 22.3% of pregnant women consume Iron and Folic Acid supplementation for 90 days and the percentage is less than 10% among the non-educated women compared to 50% among the well-educated. Also the disparity between rural and urban areas is significant (18% and 34.5% respectively).

OTHER CAUSE: There are various other causes of maternal mortality. Eclampsia is one of them, which is a fallout of pregnancy-induced hypertension. This usually happens due to improper antenatal care. Hypertension during the course of pregnancy can ultimately culminate in convulsions. Eclampsia if not treated with care in time may lead to the death of the mother.

Another reason of maternal death is Haemorrhage. This may once again be caused by poor antenatal care, anaemia during pregnancies or during operative deliveries.

Obstructed or prolonged labour occurs when the foetus does not deliver in the anticipated time. This may be due to the wrong position of the foetus, if it is a too large a baby or if the pelvis of the mother is narrow. In urban India, obstructed labour is generally not among the primary causes of maternal deaths anymore but in rural India, due to lack of interest in institutional delivery it is still a cause of maternal deaths. Till now, in India only 43% of deliveries involve a skilled birth attendant compared to between 86% and 99% in Mexico, China, Sri Lanka, Brazil and Thailand.

Sepsis, another major cause of maternal deaths, may arise from infections, unsafe abortions, anaemia and improper care during pregnancy. Women who do not eat nutritious food during pregnancies are susceptible to infection. In rural, India this is one of the commonest causes of maternal deaths.

INTERMEDIATE CAUSE: They include the low social status of women, lack of awareness and knowledge at the household level, inadequate resources to seek care, and poor access to quality health care. Other causes are untimely diagnosis and treatment, poor skills and training of care providers, and prolonged waiting time at the facility due to lack of trained personnel, equipment and blood. The other prominent dark chapters of our society are the early age of marriage and child bearing, child spacing, family size and fertility patterns, literacy, socio-economic status and the and the customs and beliefs.

Under the Reproductive and child health (RCH)care programme efforts were made to improve the coverage, content and quality of antenatal care in order to achieve substantial reduction in maternal and perinatal morbidity and mortality.

In the ninth plan the antenatal and intra partum care contained features like,

* Early registration of pregnancy (12 - 16 weeks);
* Minimum three Ante-Natal Check-ups;
* Screening all pregnant women for major health, nutritional and obstetric problems;
* Identification of women with health problems/complications, providing prompt and effective treatment including referral wherever required;
* Universal coverage of all pregnant women with TT immunization;
* Screening for anaemia and providing IFA tablets to prevent anaemia;
* Advice on food, nutrition and rest;
* Promotion of institutional delivery / Safe deliveries by trained personnel etc.

But according to the Household Survey 1998-99 the actual scenario was something different. A ntenatal coverage in states with poor health indices such as UP, Bihar, MP was very low. Whereas in the southern states antenatal coverage was quite good.

The main problem areas of antenatal checkups lie herewith:

* Inadequate coverage; lack of trained health personnel in antenatal screening, risk identification and referral services;
* Over crowding in PHCs/hospitals
* Lack of Emergency Obstetric services etc
One of the major goals of Government of India's Department of Health and Family Welfare is to reduce maternal mortality and morbidity. The focus has shifted from individualized interventions to attention to the reproductive health care, which includes skilled attendance at birth, operationalising Referral Units and 24 hours delivery services at Primary Health Centres and initiation of Janani Suraksha Yojna (National Maternity Benefit Scheme).

Not only that, improving women's health require a strong and sustained government commitment, a favourable policy environment, and well-targeted resources. The government's strategy should include extended care to women whom government programs do not reach. The government of India has been making policy and programmatic statements time to time and setting goals of reducing maternal mortality.

Major policy and program goals in MM ( Maternal Mortality)

Health policy statement by Govt of India
MMR reduction by 200-300 by 1990 and below 200 by the year 2000

National population policy
MMR reduction to less than 100 by 2010

National health policy
MMR reduction to less than 100 by 2010

Tenth Five year plan
MMR reduction to less than 200 by 2007

The challenge for the government is to help direct and improve privately provided services through appropriate regulatory arrangements and by encouraging an expansion of their scope to include promotion and prevention, in addition to curative care.
The link between pregnancy-related care and maternal mortality is well established. National programmes and plans have already stressed on the need for universal screening of pregnant women and operationalising essential and emergency obstetric care. Focused antenatal care, birth preparedness and complication readiness, skilled attendance at birth, and access to emergency obstetric care are factors that can help reduce maternal mortality.

The mind boggling high maternal mortality rate in India can be reduced by following the strategies enumerated below:

* Effective initiative from the government is required in terms of proper allocation of resources to all the health institutions specially Primary Health Centers. Even more important is to ensure that the funds actually reach the users whenever it is needed.

* Early registration of antenatal cases and effective health education of couples to make them understand the importance of antenatal check ups, hospital deliveries and small family norms.

* Local dais / birth attendants and female health workers should be imparted periodic training to update themselves with improved techniques and be incorporated as an integral part of health care system. The importance of observing proper aseptic measures while conducting deliveries should be emphasized to them.

* Prevention and early treatment of infection, ante partum and postpartum hemorrhage.

* Wide spread availability / supply of Iron – Folic acid tablets and nutritious food to the poor and remotest corners of the country.

* Treatment of illnesses like diabetes, tuberculosis and malaria during pregnancy should be ensured.

* Construction of better roads and transport facilities is required especially in the rural areas and urban slums to make the health care facilities more available and accessible to people in need.

* Providing facilities for hospital deliveries for high risk cases like severe anaemia, hypertension, diabetes and heart disease.

In conclusion it can be said that, a maternal death is often not only a result of technical incompetence or negligence, but is also caused by ineffective health system and limited knowledge, social attitudes and poor health and midwife practices by the family and community itself. Since the health of mothers is directly related to a child's health and without due attention to the causes behind high maternal mortality ratios, we are simply ignoring an important determinant of the health of our nation. In doing so, maybe we are running the risk of damaging our chances for all-encompassing prosperity in future.

Saturday, February 23, 2013

Mobile Medical Vans: Overcoming India's Last-Mile Health Care Challenges

There are few skin diseases more debilitating than leprosy. It is characterized by painful sores and lesions all over the body and the infections can lead to the loss of fingers, hands, toes and feet. Eventually, leprosy causes blindness and acute disfigurement. Chandra Babu, 36, from Kasabkheda village in the tribal belt of Orissa in Eastern India, had been suffering from leprosy for four years without knowing what was wrong with him. When he was diagnosed by a Mobile 1000 doctor and told it was easily curable, he flung himself at the doctor's feet with joy and gratitude.
"The areas we work in are so poor, people can't afford food and clothes. Health care is an absolute luxury; they choose to ignore illnesses. So we give them a service that is high quality, free of cost and at their doorstep," says Akshay Hudar, CEO of the Wockhardt Foundation's Mobile 1000 initiative.

Mobile 1000 is the flagship program of the Wockhardt Foundation, the corporate social responsibility (CSR) arm
of Wockhardt, a leading pharmaceutical company in India. The program, conceptualized and spearheaded by the foundation's CEO and trustee, Huzaifa Khorakiwala, involves the operation of mobile medical vans that travel through remote rural regions in India and provide primary health care services to millions like Chandra Babu. "Since Wockhardt is a health care company, we decided to keep our social work focused around health care as well," notes Khorakiwala. While the foundation has several other social outreach programs -- including initiatives related to water purification and biodegradable toilets -- Mobile 1000 receives more than 80% of the total funds.

The idea for Mobile 1000, so named because Khorakiwala's vision is to have 1,000 vans on the road by 2017, first
occurred to him when analyzing research conducted by the National Rural Health Mission (NRHM), a government agency for implementing rural health care. The survey showed that 700 million people live in India's 636,000 villages, but that the locales have only 23,000 primary health care centers among them. Some 66% of rural Indians do not have access to critical medicines and 31% of the rural population travels more than 30 kilometers to seek health care. Additionally, rural health centers, where they exist, are short of trained medical personnel.

According to a PricewaterhouseCoopers (PwC) report, "Emerging mHealth, Paths for Growth," India has only 0.6 doctors per 1,000 people, and the majority of the practitioners are based in urban areas. In addition, Indians cover 75% of their medical expenses from their own pockets, rather than with insurance.

"Even if we put one doctor in a village, he will not have enough work for the entire day because a village has an average population of 1,000," says Khorakiwala. "There are 10 patients a day, who take just over an hour for the doctor to see. So the more efficient way of utilizing the scarce resource [a doctor's time] is to have a mobile van."

According to Mark V. Pauly, a Wharton professor of health care management, "If this initiative works as promised,
it obviously will be useful. It surely will not be adequate to bring health care and health outcomes in India up to world standards but it will represent a step in the right direction. The question is whether it actually works."

Making an Impact
It is too early for the Wockhardt Foundation to conduct impact studies, but the project has so far met
Khorakiwala's efficiency requirements. Since it began in 2011, the number of vans -- all rented -- has increased from one to 75, and more than a million patients have been treated. "Overall, the program has been impactful," notes Vishal Kapoor, portfolio manager of Dasra, a foundation that helps to fund nonprofits and social businesses.

Kapoor was part of the team that assessed, screened and audited the applications for the Inclusive India awards that recognize substantial contribution to social development. The Wockhardt Foundation won for best social work in the area of primary health. Mobile 1000 was an obvious choice. Says Kapoor: "Mobile 1000 promotes higher quality primary health care as compared to currently available options across villages in India, such as local, self-proclaimed practitioners and alternative home-based therapies. By providing regular and concentrated health-related activities in villages, the program promotes health-seeking behavior."

Rana Mehta, executive director of the health care practice at PwC India, agrees. "Many thought health care
delivery would happen through the Internet, but in India we don't see that happening very much because penetration remains a problem and there are cost challenges. In today's context, when millions have no access to health care at all, such initiatives are useful supplements." A typical day in the life of a Mobile 1000 van is carefully planned. A semi-urban area is used as a base location.

The team -- a general physician, a pharmacist and a driver -- starts at 9 a.m. and covers about four villages a day, seeing on average 20-30 patients at each village. The van covers about 25 villages in weekly cycles and reaches 22,500 people a year at US$2.4 per person, a cost that is lower than the NRHM's US$3 per person because the Mobile 1000 program uses generic drugs. The van has on board primary diagnostic equipment and medical supplies that can treat basic illnesses like cough, cold, fever, infection, malaria, dengue, typhoid and hepatitis. For the more complicated illnesses, patients are referred to the nearest hospital.

Keeping Track
The command centre for the entire operation is the Wockhardt Foundation headquarters in Mumbai. Once the
van leaves a village, the team sends a report via text message from a mobile phone. "All the records are collected after each visit to each village and stored. That way we know how many villages the van visited, how many patients it checked, their gender and ages, the illnesses, the referrals made and so on," notes Hudar.

Providing quality service obviously comes at a price. The end-to-end operation of each van costs US$50,000 a
year. "We operate on a philanthropy model," says Hudar. "We use funds from the corporate social responsibility (CSR) budgets of various companies; we are an implementing agency for them." While the program has private sector donors like Infrastructure Leasing & Financial Services and Welspun, more than 80% of the money to run Mobile 1000 comes from public sector undertakings (PSUs) like Gas Authority and Indian Oil. Khorakiwala expects more with the passage of the Companies Bill that could require spending of 2% of net profit on CSR activities. "PSUs don't have enough reliable causes to spend on," he notes.

But Pauly is not entirely convinced. "The Wockhardt Foundation needs to commit to pay or find another stable
source of financing," Pauly says. "They should persuade the government of India or the state governments that this is a good way to spend additional money." The foundation is indeed working on collaborating with several state governments including Kerala, Tamil Nadu and Karnataka. Pauly, however, notes that while this is an initiative worth pursuing, "it is not clear that this is the best way to use those resources or that additional resources will be forthcoming even if this model does work."

Dasra's Kapoor is more optimistic about such partnerships. "The government of India runs its own mobile medical program across rural villages but suffers in part from planning and high quality implementation. [There is] opportunity for the government to partner with private organizations," he says. "In the long term, this will enable scale, sustainability and deeper access to good quality health care. However, if they remain dependent on their own ability to raise funds and implement this program, scale may be difficult to achieve."

Funding Needs
Like most nonprofit initiatives, Mobile 1000's ultimate goal is to become self-sustaining. But, according to
Khorakiwala, "Scalability depends on sustainability." He notes that sustainability can come from two sources -- either by making money from the operation or through large grant-based funding. "It cannot happen through private corporate funding because it is usually not more than US$1 million to US$2 million. You need government funding because that [amounts to] much more" than what private firms are willing to give. Eventually, Khorakiwala hopes to make Mobile 1000 sustainable by using the vans as points of retail, selling everyday consumer goods such as soap, shampoo, toothpaste, unfortified biscuits and mosquito nets. "But we will not begin selling until we reach 800 vans because we need mass production of the goods sold to bring down their cost and sell at prices that the poor can afford," he says. "It will require a capital of US$20 million in each state. But we hope to make a profit from that activity and that will sustain the free health care we wish to give."

Mobile 1000's profits will have to be substantial to make an impact on a national level, according to PwC's
Mehta. "I think this is a nascent industry in India and getting the correct business model is the biggest key to success. A developing country needs to have its own model. We can't ape anything that might have been done in the West."

But Khorakiwala and Hudar are not daunted by the enormity of their task. They are focusing instead on ironing
out the day-to-day operational wrinkles. Control and monitoring of the vans is a big one. One of the challenges is to have a genuine reporting system. "From Mumbai, it is difficult to monitor whether we are receiving accurate information: Has the van truly visited each village it claims to?" Hudar says. "So to counter that, we have fitted each van with a GPS tracking system. But certain villages are quite remote so even that becomes difficult."

Another big challenge is getting doctors to relocate to rural areas and keeping them there. Most want to go back
to urban areas after a few months in spite of being paid market salaries. "That's why our single most important criteria when recruiting these doctors is that they should be compassionate and truly believe in the cause," notes Hudar. Those are useful qualities, especially when dealing with the rural mindset.

Generating awareness among the people is Mobile 1000's single largest goal. "Because only when there is
awareness will people start taking care of their health and institute preventive measures," Hudar states. He has help there -- telemedicine and mobile health are making headway and are also spreading awareness.

These are promising innovations, but Khorakiwala says that his approach is best. "There are two major problems
[with the others]," he notes. "One, physical examination should form the basis of diagnosis. You have to feel the skin to sense its tenderness. And second, it's not easy to get connectivity in all rural areas."

But Mehta of PwC says that one innovation need not compete against the other. "They complement each other.
To really have a robust system you need a mix of all of them." On his part, Khorakiwala is thinking big. When the current target of 1,000 vans has been achieved, he says: "We will change the name to Mobile 25,000 and keep going."