Vyom writes about a recent field visit to a maternity centre in Delhi. The obvious and straightforward solutions such as increasing the capacity and effectiveness of primary and secondary level of health services instead of centralising tertiary care facilities are not given their due. This impacts the health of the already vulnerable the most.
We all are afraid of getting ill. But, illness impacts us as per our socio-economic background. If for me my health is of utmost importance, for those without the kind of privileges I am endowed with, health concerns may come only after concerns for food or income. Sometimes they may have to even put their health at risk for ensuring basic survival. Although an expanded understanding of health and wellbeing would include interlinkages between health, food, income, rights, democracy and much more, but often in reality, when none of this is easily available, people have no choice but to prioritize, and those priorities are reflections of our privileges. Unfortunately, good health and timely healthcare have become such privileges: while some are endowed with these, others remain deprived.
Even though basic healthcare is one’s basic right, it is routinely violated in India. Inefficient and increasingly commercialized public health settings, rampant privatization of healthcare and general apathy towards the wellbeing of the marginalized sections have increased the health inequities which now mirror the social inequities and inequalities. Excluded from the public health system, the poor have no choice but to be indebted to avail private health services or fall at the mercy of quacks, who do more harm than good to their already vulnerable health. Statistics corroborate this: India’s Out of Pocket expenditure on health is anywhere between 60 to 80 percent, whereas State’s expenditure on health is as low as 1.3 percent of the GDP. Is it still very hard to understand why we as nation fail so terribly in ensuring good health of the population?
One of the biggest challenges that public health services system in India faces is the shortage of health personnel at almost all levels, but more acutely in primary and secondary levels. My short field visit to a Maternity centre in Srinivaspuri, Delhi, substantiated this.
Maternity centres in Delhi come under the Municipal Corporation of Delhi, which are run as per the guidelines of Reproductive and Child Health programme (RCH). RCH was launched by Government of India in 1997 with the aim of reducing infant, child and maternal mortality. Although there are many critiques of the programme, one of which is its aggressive focus on population control rather than ensuring empowering and overall healthcare to women, some believe that it is still one of the only programmes through which women have some contact with the health system, and thus is important.
But the programme too suffers immensely from the shortage of staff. The maternity home in Srinivaspuri covered a population of around two lakh, but had only one gynecologist, one pediatrician, two medical officers, twelve staff nurses and seven ANMs. The number of health personnel was way below the prescribed guidelines. This Maternity Centre is a secondary level unit, and according to the guidelines issued by Indian Public Health Standards, a secondary level unit should have “essential and emergency obstetrics care including surgical and other medical care” for maternity care ( p 4, IPHS). However, there was no obstetrician. There were also no anesthetist, blood bank, oxygen cylinder and monitoring OT. Only ‘normal’ delivery, that is delivery without any complications, was being done at this centre, that too of second pregnancy. Rest of the cases were either prima-gravida (prima= first, gravida= number of times a women has been pregnant, that is first pregnancy), or declared complicated and thus referred to tertiary level unit, such as Safdarjung and AIIMS. In 2014-15 only 664 cases were delivered at this centre out of 2447 ANC cases registered.
I came to know about the impact of high rate of referrals when I met mothers who came for routine immunization. One of them was Munga Mahto who came with her 9 month old grandson Siddhant for last round of immunization. When her daughter-in-law came for the first time at this maternity centre, she was referred because it was her first pregnancy and there were high chances of complications. For them going to Safdarjung Hospital for delivery was a herculean task, especially when the sole earning member of her family who worked in a warehouse couldn’t not afford few days of leave. To avail services without any hassle they went to a nearby private nursing home which charged them around fifty thousand rupees. Though the amount was large and pushed them in debt, they were happy that the child was safely delivered. However, for the friend of Munga Mahto, who accompanied her to the centre, her first grandson was born at Safdarjung Hospital at free of cost because one of her relatives was a government employee who knew someone at the hospital.
Near the maternity centre was a slum. There I met Ujni Devi. Ujni is 45 years and works as domestic help. She lives with her daughter and son-in-law and three grandchildren. Her first grandson was delivered by a midwife in her village in Bihar. Second granddaughter was delivered at this maternity centre. But, complications arose when her daughter was pregnant third time. As usual the maternity centre referred her. She couldn’t imagine the idea of going to Safdarjung. Private nursing home was out of question, she could have been in debt for the lifetime. Left with no other option, they called a midwife from the neighboring slum and the baby was delivered.
By the evening I was confused. At one hand there were efforts made by the government to improve ‘average’ figures of mortality. On the other hand, to avoid the stigma of maternal deaths, and also challenged by shortage of staff and infrastructure, secondary level maternity centres routinely referred large proportion of cases to even more understaffed and hugely overburdened tertiary level facilities, increasing the sufferings of poor families.
It is obvious that more efforts must be towards increasing the capacity and effectiveness of the primary and secondary levels of health services system which are closer to the reach of the population, instead of centralizing care in tertiary levels. But when has the obvious and seemingly straightforward solutions ever attracted attention of policy planners in India?!