The Case for Looking at Convergence in Healthcare to Prevent a Health Crisis
Rachita Mishra in a conversation with Neeraj Jain, Dr Rajani Ved, Dr Rachna Jain, and Nachiket Mor on the need for convergence and consultation across sectors in the management of public health.
The past two years were critical for the health sector, as the COVID-19 crisis laid bare many of the glaring gaps in the public health systems across the world. In this panel that discusses the complexities and simplicities of public health Rachita Mishra, Associate Director, SELCO Foundation, anchored the conversation between Neeraj Jain, PATH, Rajani Ved, Bill and Melinda Gates Foundation, Rachna Jain, Jan Swasthya Sahyog, and Nachiket Mor, The Banyan Academy of Leadership in Mental Health.
The panel was opened by Neeraj Jain who said, “The challenge always is that we don’t actually say what we know about or what we feel about our failures. That’s also because as a not-for-profit, funding is extremely important for us, and partnerships with the government are extremely important, so we are constantly doing a peacock dance to make sure that everybody likes us and they believe that we can deliver. This is a very competitive sector and we normally talk about the truth only in closed rooms, unfortunately.”
PATH was an integral player in the government’s response to the COVID-19 crisis and was instrumental in the setting up of massive infrastructure to mitigate the oxygen crisis that India was facing during the delta wave. “We currently have about 4,000 oxygen plants across India, every district hospital has probably two and we’ve got plants lying all over the country, most of them are were functioning at some point or the other. There were also three lakh oxygen concentrators that came into the country. They’ve been spread all over the place and I can tell you from experience that 80 percent of them have never come out of the box. Today we are thinking about how to deal with this immediate crisis, on how to make sure that these things are going to be actually operational beyond COVID. Somewhere along the way, we missed the boat on sustainability, we missed the boat on how these assets could be really useful going forward for the health system.”
Dr. Rachna Jain took over and discussed the failures they encountered in their attempt to develop an institutional birthing programme like the Janani Suraksha Yojana, under the aegis of the National Health Mission in 2005. The objective was to bring in institutional delivery for all pregnant women and to ensure that by having skilled manpower, good infrastructure, adequate supplies, and a conditional cash transfer of INR 1400, along with free transportation to the institution. The programme was ambitious and eventually showed results, the number of institutional deliveries increased and there was a reduction in maternal mortality over the next 12 years. However, studies show that the decrease was slow and cannot be attributed to JSY. She says,
“There is still inequity in the JSY programme. It is a failure if you consider that if a pregnant woman is poor, lives in a rural area, belongs to a marginalised social group, or if she lives in the central or eastern parts of the country there is a high chance that she will die in childbirth as compared to a woman who is urban, educated, not so poor, and does not belong to an Adivasi or rural family.”
Continuing from where Dr Rachna Jain left off, Dr Rajani Ved, BMGF India, shed light on India’s ASHA programme and the mission to scale up a successful pilot intervention from Gadchiroli, Maharashtra, to a national programme, and then sustaining the scale-up and there were the failure lessons. Highlighting the major points of negotiation during the scale-up, she says, “There was a lot of pushback on training the ASHAs, supervisory mechanisms were stretched, and there were concerns over creating new mechanisms for training. We also insisted on residential training to build a sense of solidarity among community workers who would be trained together. There was also pushback from doctors who wanted to protect their professional privileges. The common refrain against training the ASHAs and equipping them with skills and the kit was, ‘Har ASHA ko doctor banaoge kya? Are you going to convert every community health worker into a doctor?’ Civil society also pushed back as they viewed the role of the ASHA as an activist mobiliser and by converting her into a caregiver they were running the risk of giving poor care to poor communities.”
Scaling up need more than just evidence, according to Dr Rajani Ved. “It needs contestations, negotiation and extensive consultation. Large-scale implementation implies quality loss and governments must be prepared for the quality loss and then figure out how to address the quality loss. The programme began with four tasks for the ASHA to perform, today the ASHA has about 40 tasks to perform, she has to go to the same home to follow up on leprosy, or on active tuberculosis case finding and newborn and maternal care. The idea of organising her day into a structured visit is an idea for us to work on.” Thinking it’s a simple solution, the scale, the institution, the partners, and the stakeholders involved, is not a simple issue at all.
How do we cater to the needs today while making sure it doesn’t emerge as a need again in the future? The biggest indicator of our solving the problem is that we are not needed anymore. We don’t exist anymore.
Nachiket Mor illustrates this with an example, “You know about half the population has latent tuberculosis and the key concern in the Here and Now is how do I treat somebody who’s got tuberculosis so that it does not escalate. But a more significant question to ask is how can I make sure latent TB doesn’t turn into active TB and that has got a lot to do with building codes that cities are implementing that compromise ventilation. There is a very nice study that came out of Bombay that showed that new buildings that were built since 2007 under the Slum Rehabilitation Act where slums were being cleared to make way for high-rises for middle-income populations didn’t follow a hundred-year rule which gave people enough light and air. The study showed that the first-floor TB burden in those buildings was 10 times higher than the TB burden on the tenth floor of the same building because of the changes in light and air availability by level. As we think about the long-term, curative systems start to become far less important and social determinants of health were becoming more important.”
When asked about silos and how to break them up, Nachiket Mor took the example of coronavirus. “Coronavirus was a problem and it was the travel industry that really transmitted it but neither the railways nor the airlines or commerce had any idea what to do. They do have health departments but everybody was waiting for the health ministry to say what to do. Maybe they are not well equipped to do that. So one way to deal with coordination is to explicitly recognise that coordination is going to fail upfront and then design for that so that coordination is not necessarily a problem but a design problem.”
In conclusion, it was observed that the economics of projects, social determinants, the capacity of the system, people’s behaviour, the convergence of problems, opinions of stakeholders and conflicting ideologies, and sometimes the lack of a larger vision are all barriers when it comes to taking a programme to scale. These are all factors to bear in mind when designing and planning for a large-scale programme.
