Also published by Center for Health Market Innovations.
The phrase “bottom of the pyramid” was first used by U.S. President Roosevelt, and later by Professors C.K. Prahlad and Stuart L. Hart. This term has now come in vogue. Media-persons, NGOs, corporate head-honchos and management gurus all talk of the BOP, either about serving this segment or about the fortune that can be made from this burgeoning market. In India, BOP families have been defined as those who earn less than Rs16,000 ($267) per month. Then there is another group, the BPL (Below Poverty Line), incredibly described by the Indian Government as those who earn less than Rs 32 (60 cents) per day. But these are just numbers. What do these numbers really mean? Who are these people? What is the quality of their lives? What are the challenges they face? And more significantly, what do they do in times of sickness?
Let me begin with what is the reality about BOP families, especially those who are BPL.
This is 1977, my first day in med school. The first thing I noticed was that an entire shanty town had sprung up outside the hospital. What struck me was the fact that there were thousands of people camping there, sleeping, eating, cooking on paraffin stoves, entire families sleeping in the open air or under tarpaulin sheets, waiting indefinitely for their loved ones to recover, who were either admitted or getting treatment as outdoor patients. And they all looked alike in the sense their eyes were dimmed with the same expressions of hopelessness & helplessness & despair.
My first day in the wards: meeting patients, and spent in history taking. Invariably, it was the same story. I sold my land when my child fell sick. I sold my cow. I took a loan 30 years ago for my wife’s delivery, and still haven’t paid it. I have no food to eat. My children have no food. We have no roof over our heads. My children cry in their sleep because they are cold & hungry. My daughter was raped by the money lender.
Welcome to India, the land of Gandhi and Mother Teresa. The country of 700 million mobile phones but not enough toilets. The country where starvation deaths do NOT make headlines, where slavery exists, where inspite of the economic boom and billions of $$ spent on health programs, the govt has not been able to fulfil its promise to its citizens, of affordable, equitable, and accessible health care.
What happened after Independence? Let’s do a post mortem examination of India’s moribund health system. In the 1950s, the government started developing a huge health infrastructure and initiated well meaning and ambitious programs. We have the National TB Control, Malaria Control, RCH, NRHM, NACO, Universal Immunisation etc. Now, there are some very interesting things about all these. Let me begin with what are the plus points of the existing public facilities. There is a huge health infrastructure, which includes equipment & manpower, that has been built painstakingly by the government ,and just waiting to be put to good use. Unfortunately, the machinery is rusted and doesn’t work. At the lowest level, which is the village, we have the government ASHA workers, one for each village of 1000 people. ASHA stands for Accredited Social Health Workers, ( not to be confused with Operation ASHA, which is a not-for profit working for Tb treamnet in india and Cambodia). These government ASHA workers are young women from the village with basic primary school education, employed by and trained by the government to deliver health care. They are supposed to do everything under the sun, from safe delivery to antenatal care to immunisation to TB treatment. The government has trained 600,000 such workers. But tall claims by the government do not translate into reality. The reality is that inspite of this widespread network of local community health workers, India’s maternal mortality and neonatal mortality figures, which reflect the health of a population , are alarming, to say the least
Then for 50 villages, there is a PHC or Primary Health Centre. For 100 villages, there is District Hospital. Most of these are equipped with facilities for surgery, obstetrics, immunisation, etc and there are doctors and nurses posted there. In big cities there are huge secondary and tertiary care hospitals, some with medical colleges attached to them, and what seems an army of resident doctors and other staff. Each is as large as a small city and functions like one, with various departments co-ordinating with each other for smooth and efficient functioning.
But if we look beneath the surface we can see the cracks in the system. There are multiple challenges that exist, which are as follows:
- skewed doctor patient ratio,
- not enough beds,
- long lines for tests and medicines,
- crowded OPDs so doctors barely get a minute to examine and prescribe,
- long waiting list for OTs, cancer treatment, or dialysis, heart surgery and transplants.
India’s doctor patient ratio is 1:800 in cities, but 1:3000 villages or even worse. The WHO recommends a doctor patient ratio of 1:1000. But absenteeism is common, a government job being a euphemism for a cushy life where one can get a salary and benefits and pension for doing a negligible amount of work. At the PHCs, you often find that there are no docs, no nurses, no paramedics or staff. The centres may be closed and shuttered for weeks, often there is no equipment and theft of medicines and disposable is a regular feature. And all this is because there is no accountability. The infrastructure exists, but is being misused. It’s a behemoth, guzzling funds.
The Government makes tall claims. For example, in 2006, the government of India declared that there is 100% DOTS coverage, which means the entire country has facilities for TB treatment. Unfortunately, the truth is very different from reality. There are 2 million new cases of TB every year in India, and half a million deaths. This is because the facilities exist, but are so remote that the poor cannot access them. It takes 2 days to go to the next village by a bullock-cart. How can someone go 60 times over 6 months for TB medicine? A similar situation exists in cities. People earning less than a $ a day cannot spend 20 cents for the bus fare and spend the whole day standing in lines for treatment, because, this would mean there is no food today, and no job tomorrow.
Now the government has several schemes in place for the needy. It is providing control of communicable and non-communicable diseases, providing curative as well as preventive/promotive care through a chain of primary, secondary and tertiary care health institutions. The government has also launched the National Rural Health Mission (NRHM) in 8 states. Some of these schemes were well conceptualised, but implementation has become a challenge. These are:-
- Health Insurance for the BOP: This is known as RSBY, in which a smart card is issued to BOP families. This scheme has now been extended to unorganized workers like street vendors, domestic helps, beedi workers and those working in building and construction sites. But the reality is that even the smart cards have not been issued to all, and if issued, are worthless. The RSBY card entitles a person to up to Rs. 30,000 in health-benefits (for admission). But no nursing home is willing to accept these patients, because the government has not paid up for the past bills. So the patients keep running from pillar to post for admission, and when they do not get admission anywhere, they go back to the public hospitals.
- All BPL patients suffering from mental disorders like depression, anxiety, adjustment and personality disorders, alcohol and drug abuse will get a free one-time grant of up to Rs 1 lakh for treatment at any super-specialty government hospital/institutes. Hospitals have been given a corpus of funds Rs. 10- 50 lakhs, for distribution.
- Vandemataram scheme- This is another optimistic idea, but quite impractical. The idea is that private nursing homes will do free distribution of RCH ( Reproductive & Child Health) services, ie immunisation, giving condoms, pills, ORS, iron and folic acid etc. But who is responsible for doing this work? what is the payment? How much is the work done? Is the distribution actually for free? These are questions that need to be answered. Another thought that comes to mind is that why on earth would a for-profit revenue generating nursing home waste time on this? The few private nursing homes who might be willing to do this get so disgusted and disillusioned by the hurdles they face in obtaining the free supplies that they just give up. In a nutshell, these schemes amount to unrealistic expectations on the part of the government.
So what is the solution?
I think the solution lies in building effective partnerships with the private sector. Serving the BOP should be the work of NGOs who have built the pipeline into disadvantaged areas, not the government. The government must realise and accept its limitations. Partnerships ensure that we are utilising existing infrastructure and personnel put in place by the government. This saves duplication of effort and brings down costs substantially.
Policies that are being laid by the government must be done in collaboration and after discussion with civil society representatives, who are aware of the harsh realities.
Accountability has to be a key component of every health enterprise. And accountability & transparency have to be in every aspect, whether its use of funds, or delivery, or results. Also we must measure outcome and impact, not just processes. The government says- we have trained 600,000 village health workers. But how many women had safe delivery? How many tetanus injections given? how many children immunised? And the million dollar question- how much of it is true? Recently, there was a sensational news item in the Times of India, where our health minister Mr Ghulam Nabi Azad declared- health data is fudged, which is a shame indeed. What is being done to ensure accuracy of data?
The solution lies in technology. If we harness the power of technology, we can solve these issues. My organization, Operation ASHA, is using fingerprint identification to identify every TB patient, to ensure every dose is taken, and to verify the presence of health workers, so no one can fudge data.( Visit www.opasha.org for more information on this). This is all the more important when cash incentives are given for delivery of results. Imagine if the government health worker had to take a fingerprint at the time of giving tetanus injections to pregnant mothers, or giving immunisation to children, or giving ARVs. Fudging of data would become a thing of the past. This is because data entry can be fudged, but not a fingerprint.
Another point to discuss is what should be the incentives for NGOs working in the health space. Well, I feel good work is incentive in itself. The biggest incentive a private player would have is excellence in its results, both qualitative and quantitative. Also, if an NGO is allowed to work in peace that itself is a great gift from the government . But the government can do a lot to smoothen the way ahead and facilitate work.
Firstly, the government. must cut down on red tape, do away with bureaucratic hurdles, and simplify things for NGOs. All those multiple paper forms and MOUs that go on ad nauseum should be done away with.
Secondly, the government must keep its promises. NGOs must be fully funded by the government so they can concentrate on work, not fundraising! For most NGOs, fund raising is a constant ongoing process. Also, government funds must be adequate and given timely. At present funds are woefully inadequate. Too little is given, and too late. Government officers must be made to realise that they must not keep delaying and dillydallying on payments, it is most annoying, and will only serve the purpose of breaking a partnership. Another reason to pay more and on time is so that NGOs can afford good management who can be given market salaries. All payments must be performance linked.
Thirdly, the government and other international donor and technical agencies must study and promote best practices and incorporate them in the government programs. They must measure the outcome metrics, not processes or inputs, and fund low cost, high impact NGOs with the best results and eye on quality, and help them go to scale. This has happened already in Bangladesh where the government has given over the entire TB treatment budget and work to an NGO, BRAC, Bangladesh Rural Action Committee. BRAC is now directly getting funds from the Global Fund. This ensures a smooth path, ease of work, and minimal delays, all of which ultimately benefit the BOP segment..
Fourthly, the government must use the delivery channels laid down by established and successful NGOs to pump in other health programs. The last mile of the cable is the most difficult. For example, OpASHA has got the connectivity to serve the poorest of the poor for TB treatment. This pipeline can be used to deliver RCH programs, nutrition or anything else.
The government must also use NGOs for training health workers, which, all said and done, is a highly specialised discipline. In my opinion, it is as important to know what not to teach as what to teach, and overburdening CHWs with information will not help anyone. The government must take the help of NGOs in maintaining accountability. For example, the government has promised 50,000 worth of laptops, internet etc, and other things to its ASHA workers. But who will keep an eye on things? What will happen to the equipment? will the laptops be used or misused? Will they be sold off? If there is no accountability, this will be another waste of resources in a resource poor country, just more money going down the drain!
Another crucial point is that the government must honour its commitment to the poor. Often schemes fall flat because of government apathy.Of course, it has to upgrade and step up facilities in hospitals, build capacity regarding doctors and nurses and medical personnel, so both- the doctors and the patients get a fair deal.
Lastly, every employee must be made accountable. Use technology to prevent absenteeism and theft. Put systems in place where those chronic absenteeism leads to a Penalty.
Before I end this blog, let me write a little more about the BOP segment. When we talk of the BOP and backward areas, we must remember that they are of 3 kinds. These are villages, urban slums, and tribal areas. Each has a different character, different geography, and thus different challenges. Urban slums are densely packed with people, and patient density is also very high, they consist of migrants who have no family support, and there is a very high incidence of alcohol and drug abuse. In rural areas, patients are scattered, but there is a family and social structure which has a positive impact on health, and village leaders play a prominent role. The tribals are the most underserved of all of India’s poor. They have no food, no money, no health benefits, no housing or sanitation. So whatever we do, we must keep the socio-religious milieu and cultural norms in mind. Only then can we make a difference.
Another exciting thing that has happened in recent years is that health is no longer the domain of physicians alone. Economists, financiers, businessmen, technocrats, professors and management experts are all focussed on global health. This multi pronged and multi dimensional approach, perhaps, will provide the solution to global health issues.
At a personal level too there are many things to be considered. Life is not easy, and decision making can be tricky. Sometimes in life, we find ourselves at a crossroads. We see life stretching ahead of us like a long road, and there in front of us, two paths are diverging, as the post Robert Frost has immortalised in his lines:
“Two roads diverged in a wood, and I,
I took the one less travelled by,
And that has made all the difference.”
When you look along one road, you see dazzling lights, there’s money and music and fame and you can visualize a glamorous lifestyle. But the other road is dark and gloomy. There is squalor and sickness, you can hear the sigh of those who are suffering, and there’s an all pervading stench of death and disease. You want to choose the second one, but you stand trembling and irresolute and afraid for it’s a daunting task ahead of you, and you hesitate to use your expertise to provide succour to the needy. Now, this is where governments and NGOs can play a critical role. Simplifying procedures, improving working conditions and giving market salaries to those working at grassroots level will be one way to attract the best talent. And, that is the way ahead.
-Written by Dr. Shelly Batra, President, OpASHA