Saturday, June 18, 2016

Indian Health Crisis : Part One

In this series of blogposts, we shall learn more about Indian Health care system, its achievements, bottlenecks, challenges and the remedies. Stay tuned. The source is the same as before : An Uncertain Glory, Amartya Sen and Jean Dreze. 

Sometimes, the most important things in life are least talked about. The overall coverage of health issues in editorial discussion of leading Indian *lightweight* newspapers remains miniscule- about 1 percent of the total editorial space (even if we adopt a very broad definition of health-related matters). The low visibility of health issues in India's mainstream media and democratic politics applies also to child health, adding to the neglect of children in political discussions in general. There is a very little public awareness of the fact that India's immunization rates are among the lowest in the world.  Since the practice of democracy depends greatly on which issues are publicly discussed, the comparative silence of the media on health care makes it that much more difficult to remedy the problems from which Indian health care suffers. There are, thus, two interrelated problems faced by health care in India: first, its massive inadequacy, and second, the near-absence of public discussion of this inadequacy. 

Public expenditure on health in India has hovered around 1 per cent of the country's GDP for most of the last twenty years- very few companies spend less than that on health care, as ratio of GDP. India's 1.2% compares with 2.7% in China, 3.8% in Latin America, and a world average of 6.5% (including countries in European Union). In absolute terms, this translates to $39 per person per year in India, compared with $66 in Sri Lanka, $203 in China and $483 in Brazil. Public expenditure accounts for 29% of total health expenditure in India, and this is some indication, among others, that India has one of the most commercialized health care systems in the world. 

The unusual reliance on private health care in India results largely from the fact that the country's public health facilities are very limited, and quite often very badly run. Health facility surveys conducted by the International Institute for Population Sciences (Mumbai) in 2003 gave a chilling picture of the state of public health centres around the country. To illustrate the point, only 69% of the PHCs had at least one bed, only 20% had a telephone, and just 12% enjoyed 'regular maintenance'. These are national averages, and the corresponding figures for the poorer states are much worse. In Bihar, for instance, a large majority of PHCs had to make do without electricity, weighing machine or even a toilet. 

Even when health facilities are available, their utilization leaves much to be desired. Absenteeism among health workers is a major issue. The problem is, naturally, most intense for the poorer Indians, but the bias towards private facilities, affects even the relatively well-off. The technology and expertise are usually available, but public facilities are highly inefficient and disorganized, and private facilities are virtually unregulated, leaving patients at the mercy of unscrupulous practitioners. Fraud, over-medication, exploitative pricing and unnecessary surgery seem to be quite common in private health sector.

In the next section we shall read more about the "Nutritional Failure" of the Indian sub-continent. 

My Visit to SEARCH, Gadchiroli

13th till 15th June 2016, I spent in the serene campus of SEARCH situated at Gadchiroli. For those of you who do not know what SEARCH is, allow me to tell you that SEARCH stands for Society for Education, Awareness and Research in Community Health. It is an organization created by Dr. Abhay Bang and Dr. Rani Bang to cater to the health needs of the tribal people. For more detailed information, please visit .
In this document I will enlist my experience of those three days and the vital takeaways in this very short time. The time I spent was small, but by no means insignificant. I believe I planned this visit at an apt time, when equipped with theory I had formidable knowledge and SEARCH opened a beautiful class analogous to that of a practical chemistry lab.
Tribal people seated for bed net distribution. Village name: Udaygaon. 

First day, was understanding what SEARCH is - beyond accounts, books, newspapers, magazines and all sources that we can get while sitting in front of our laptops. The moment I entered the campus, I felt baffled at this place in the midst of a place where on both the sides of serpentine roads one can only see bushes, trees and jungle. It gave a glimmer of peace when I entered, I could make out easily that this was indeed friendly to the people who are served in the premises. Right at the entrance is the small temple of danteshwari devi, the chief god of the tribal people. One official accompanied me and explained to the me the working of the hospital which is inside the campus. This hospital equipped with all modern facilities helps tribals and villages alike in their times of ill-health. There are special modern cemented huts where the family of the admitted person can also stay, something which the tribal themselves told the doctor couple. The doctor couple often allude to the Chinese poem:

Go to the people
Live among them
Learn from them
Love them
Start with what they know
Build on what they have:
But of the best leadersWhen their task is done
The people will remark“We have done it ourselves.”

Getting signature while distributing bed nets.
Village name: Paraswadi
This poem best illustrates the concept of community and the strength that community cooperation can bring to the people who are part of it. The person, named Ganesh, helped me understand and get acquainted with various sections of the campus, and also told me about the programs that are run under the ambit of SEARCH. He told me about their popular program for youth- NIRMAAN, tobacco de-addiction program for the tribals , HBNC (Home-based neonatal care), sex education program for adolescent. He also showed me the evidence of their programs through statistical results which are well displayed in the room dedicated to the exhibition of SEARCH and its activities. The same day I met with NIRMAAN program co-ordinator, who enlightened me on the way the program operates and the objective of the program. I was convinced that NIRMAAN, is one of those programs which very clearly seeks for the commitment in the youth and at the same time allows them the liberty to pursue what they wish to, in ways they wish to with a belief of making the world a better place. Later in the day I met Dr. Yogesh who has been working with SEARCH for the past five years and is intrigued by the cases of stroke and hypertension in the tribal areas. Dr. Yogesh has worked in USA for the past six years but when he ruminated about his long term life, he ended up at SEARCH.

Home based neonatal care (HBNC) Kit
Village : Bodli
He lives in SEARCH campus with his family. In fact, most of the instrumental pillars of SEARCH stay in the campus with their families: a fact that almost led me to a state of amazement. I understood very clearly, “Acknowledging that things need to be repaired, mended and tended to is a different thing, taking efforts on the other hand after acknowledgment is altogether a different thing. Many are willing to acknowledge, but extremely few who come forward and make efforts”. One has the power to make effort where he is, with what he has, lack of will can be the only blocker. Later in night, after prayer: a custom observed at SEARCH at 6:30 pm, I met Nikhil. A post graduate from IIT Kanpur, the way he expressed his motivation to have come to search was very beautiful. His statement, “I was living on an island with all facilities, uninformed about the reality of the world and then I decided it was time to work for the reality”, still echo in my mind. This is definitely one of the many profound statements I have heard and choose to keep in mind. Nikhil works on how technology can play a great role in assisting the health care drivers for the tribal and village people, majorly.

First day was a good introductory day, not to forget the delicious food served at the mess of SEARCH. Second day was to be a field day.
Primary health care centre. Village: Bodli

Second day
The day started with three of us, a girl doing her practical training in summers, an ANM (auxiliary nurse midwife) and me ensconced in the gypsy. Second day was about distribution of bed nets in two of the forty eight villages that SEARCH has taken responsibility of : Udaygaon and Paraswadi. First was Udaygaon. In this village live 62 families. We distributed close to 180 bed nets, one bed net to be shared among two. Not that I have not been in a village before, but being a part of the process made me realize the responsibility we carry, as being the educated and hence the empowered lot. We also had lunch in a tribal house. These people do farming for some three months and then use the harvest to eat throughout the rest of the year. These villages were really deep in the wilderness. Then we did the same at the Paraswadi.

The interesting thing I discovered was that these tribal people often resort to using the bed nets for fishing, thus, there was an agreement that was signed by everyone that these chemical-induced bed nets will not be used for fishing purposes. After the end of the first day, I had a couple of deep thoughts in my mind. I saw someone having the most common symptom of filariasis, elephantiasis. This was the first time I saw someone like that, and I was shocked to see it. I did not even know the name of this condition. I looked at my legs and I looked at heaven above. Its a miracle that I have a well-shaped body without any inherent deformities, something that we take so much for granted. Education, is the biggest asset of any human. When I was in village, I felt nostalgic of my own roots and the humble roots from which father has created an empire for us. I just can never thank him enough for having given me the kind of life I live and cherish today. Education, I am convinced is the greatest asset and blessing a human can ever acquire, and by bestowing that on me, my father has done me a favor beyond limits. An interesting observation was that sanitation was non-existent, if at all. On inquiry, it was learnt that there was not much funding to avail that facility. And I understand why funding is a problem. Funding is a problem, primarily because the health budget is not used fully and hence the government feels compelled to reduce the offerings the next time. Certainly, plans are not being implemented as deftly as they are posited in the papers.
At the home of traditional birth attendant (TBA)
Village: Bodli

It was quite a hot day with scorching heat and high humidity, but lessons which were like a breeze of cool air. This is just one incidence, when I have been at such a distribution, but I could easily make out the paper overhead that is a big problem. Data managing can be quite a task using papers, that’s when my next lesson came up: “Technology need not be complex, but it ought to be useful”. It almost seems vacuous to me that technology is growing in leaps and bounds, making lives of rich people further easier but doing so little to enhance the basic processes in the areas to assist them in living in better way. And I decided to make an effort in this direction.

Third day:
Third day I visited a relatively near place, an urban village named Bodli. There I, along with two others got the opportunity to meet the health messengers (aarogya doot) which are the principal drivers of home-based neonatal care (HBNC). She gave us a very comprehensive demonstration of the way she carries out the responsibility of taking care of the health of the new borns and their mothers. It was a clear cut message, “equip the villagers with suitable knowledge and skills, they can take care of themselves”. This message is clearly aligned with the gist of the Chinese poem that is shared above. We also happened to visit the PHC (Primary Health Care) centre in the village and the facilities there were quite impressive. It was a very brilliantly built infrastructure. Alas! That time no doctor was present, else it would have been informative to know more about the functioning of this PHC. After that visit, we came back to our campus. And it was time to travel back to Bangalore.

This was certainly a rich experience and something that will remain in my mind. The important takeaways can be formulated as follows:

  1. Technology need not be complex, but if it is not useful for those who need it, it is not serving its full purpose.
  2. If village people are equipped to take care of themselves and their community, they need not depend on full-time external assistance.
  3. There are people who still think of rendering meaning to their lives by service to others rather than being lost in the race of status and money.
  4. Acknowledging that things need to be repaired, mended and tended to is a different thing, taking efforts on the other hand after acknowledgment is altogether a different thing. Many are willing to acknowledge, but extremely few who come forward and make efforts. But, all of us are capable of creating meaning wherever we are, with whatever we have.
  5. None of us is as strong, as all of us.

I would like to thank Tushar Khobragade for having given me this opportunity to stay at SEARCH and enlighten myself beyond books.

Saturday, June 4, 2016

Indian Education: Development, Achievements and Challenges

In this post, we discuss and try to understand the Indian education scenario. 

The bulk of India had astonishingly little schooling- for India as a whole, when the British left, the adult literacy rate was only around 18 per cent. This neglect of school education continued solidly through the post-independence years, until quite recently. It is encouraging that in recent years the neglect of school education in India has been partially addressed. But there is a long way to go to remedy this long-standing neglect. India's official statistics show a steady increase in school enrolment both girls and boys-and in the facilities available in the school. Governmental decisions as well as orders of the Supreme Court have contributed to these developments, and the enactment of the Right to Education Act in 2010, uncertain as its impact may be, is certainly an attempt to move things forward. The all-India Sarva Siksha Abhiyan ('campaign for universal education'), implemented by state governments with central government support, has also been of great help in expanding and improving school facilities across the country.

The progress that has come about is apparent not only in the government's own report but also in the independent studies. Progress has been envisaged in the school enrolment rates in the remote areas of India. Though far from complete, the rapid movement towards universalization of primary-school enrolment across social groups is nevertheless impressive. But apart from all this statistics, the standard of education in schools in India is far from satisfactory. This can largely be attributed to the truant teachers who are absent most of the time and if present do not attend to the students. Students are also, as an effect become handicapped to discern the beauty of education and that leads to their absenteeism. There is a dearth of teachers in India, largely because they feel that the salary that is given to them is not sufficient.

In the PROBE states (Bihar, Chattisgarh, Jharkhand, MP, Rajasthan, UP, Uttarakhand), the official number of school days per year is around two hundred. But with a teacher absenteeism rate of 20 percent, and a pupil absenteeism rate of 33 percent, the combined probability of a child and his or her teacher being present on an average day is only just above 50 per cent. This brings down the number of teaching days effectively to one hundred days or so. But this is not the end of the story, because the survey also suggests that even during those hundred days, about half of the time is bereft of any teaching activity. So, the actual teaching time is more like fifty days- about one fourth of what would happen in a well-functioning schooling system.

School education in India suffers from two principal deficiencies: firstly, limitation of coverage, and secondly, poor standards of the education that is offered and received. Teaching methods are quite often dominated by mindless rote learning, including repetition- typically without comprehension- of what has been read, and endless chanting of multiplication and other tables. In short, the quality of education suffers due to the lack of dedication and commitment in the Indian teachers, which gets affected due to their low salaries. This makes me refer to one of my observations I had, "Indian are their own nemesis".

In the next post on this series, we will talk about "privileged excellence and social exclusions" in the education sector in India.
Most of the inputs in this blogpost, are taken from the book "An Uncertain Glory".