Cradles of hope

Cradles of hope

At least 103 babies die for every 1,000 live births in Shravasti, a district in Uttar Pradesh that borders Nepal, reports the Annual Health Survey 2010-11. Though this first-of-its-kind district-wise survey is limited to nine most backward states, the number is the worst in the country. Infant mortality rate (IMR) is less than six in the European Union. By India’s own estimates, Kerala has the lowest IMR of 14. Yet Shravasti’s plight does not raise eyebrows as it comes at a time when Uttar Pradesh is entangled in allegations of siphoning Rs 5,000 crore off the National Rural Health Mission (NRHM). The mission has programmes to reduce child and maternal mortality by improving healthcare delivery in rural areas. What comes as a surprise is despite such crumbling health and administrative systems, Hamirpur, another district in the state, has managed to keep its IMR much lower than the national rural average of 51 (see table).



Annual Health Survey is done by the Office of Registrar General of India, which carries out state-wise Sample Registration Survey every year.

In fact, all the states covered in the survey have certain areas that buck the trend. Most states have at least one district with IMR much lower than the national average; some have already attained the UN’s Millenium Development Goals of 28 by 2015. Some states also have districts whose IMR is comparable to that of war-torn countries.At an IMR of 103, Odisha’s Balangir district is worse than that of the world’s poorest countries like Mali and Burundi. This is puzzling.

As Down To Earth travels to districts with worst rural IMRs, it realises these areas could not have fared any better. Doctors and nurses are unwilling to serve these areas. Shravasti, for instance, has only one paediatrician to cater to the population of over a million. Even districts with best rural IMR reel from short supply of iron and folic acid, which are a must for pregnant women.

What seems to be working in these areas are ASHAs (Accredited Social Health Activists), appointed under NRHM, and rural health workers like ANMs (auxiliary nurse midwives) appointed by the district administration. In Bilaspur, a course for rural medical assistants is paying off. And in Rudraprayag, where the tough terrain creates a barrier between the healthcare system and people, dais or traditional midwives are the saviours.

Search for the way out

Since doctors are not willing to work in rural areas, the solution may lie in strengthening rural health workers

Tackling infant mortality is not easy. The survival of a newborn hinges on several factors, right from mother’s age, health, nutrition and birth intervals to access to healthcare and protection of the child from diseases like diarrhoea and sepsis.

Perhaps this is the reason, two ministries of the government—Ministry of Health and Family Welfare and the Ministry of Women and Child Development—have several schemes and interventions to improve maternal and child health (see box on facing page). The National Rural Health Mission (NRHM) under the Union health ministry is the biggest umbrella programme introduced so far in this regard. Since its inception in 2005, the government has spent some Rs 45,000 crore on improving healthcare in the country’s rural parts. Despite the whopping investment, India failed to meet the IMR target of 30 it had set for itself in the 11th Five Year Plan. Now, for the 12th Plan period, starting in April, it has set an ambitious IMR target of 28, and has an obligation to meet the IMR target of 27 by 2015 under UN’s Millenium Development Goals (MDG). How to achieve these targets?

Low IMR   Could it be fudged?   The health personnel in the country are hard pressed to reduce infant mortality rates. A slight fudging of data can help them show reduced IMR on paper. For instance, a baby is considered live if it shows any sign of life such as movement or heartbeat after it comes out of the body. The child is considered live even if these signs are momentary. One easy way of reducing IMR is to say the baby did not show any sign of life and was born dead. If there are 40 deaths over 500 live births, IMR would be 80 per 1,000 live births. If 10 of these are labelled as still-birth, IMR is 30 in 490 live births or just 61. “Even if the baby is still-born, it is the responsibility of the district. The mother must not have been taken care of, resulting in the death of the baby,” says Vandana Prasad, National Convenor of Public Health Resource Network in Delhi and also part of the National ASHA mentoring group.

The answer lies in the success stories of Rudraprayag, Kota, Bilaspur and Hamirpur, and the stories of failure in Shravasti and Balangir. Though it is difficult to assess how these districts managed to achieve a low infant mortality rate (IMR), what seems to be working in these areas is the presence of healthcare workers, even in the remote pockets.

Recognise the skill

In Bilaspur and Hamirpur, by the state health officials’ own admission, community health activists like mitanins and ASHAs are responsible for the decline of IMR. But they hardly receive recognition for their work.

Consider this: an ASHA is supposed to cater to a population of 1,000, where she tracks the health of young mothers and children, ensures institutional delivery and vaccination, coordinates with anganwadi for nutrition and spreads awareness. For all the work she gets performance-based incentives: Rs 200 for ensuring institutional delivery and Rs 50 a month for vaccination of a child, for instance. An assessment by the Department of Health of Chhattisgarh last year shows that on an average a mitanin gets about Rs 200 as incentive a month. In Kota, ASHA sahyoginis are fortunate. Before being roped into ASHA, they were working as anganwadi helpers and still continue to be paid Rs 1,000 by the Union ministry of child development.

In places like Hamirpur district of Uttar Pradesh, where the government is yet to introduce free transport service for pregnant women, ASHAs are given transport allowance of Rs 250. The health activists say the amount is meagre, given that travelling to the nearest primary health centre (PHC) costs upwards of Rs 500. Residents allege most of the times ASHAs siphon off the money and ask the woman’s family to bear the expenses.

Vandana Prasad, national convenor of Public Health Resource Network in Delhi and also part of the National ASHA mentoring group, demands that ASHAs be given a basic salary along with incentives. Reducing work load on the health activists can also help improve the IMR. In Chhattisgarh and Uttarakhand, where the governments appoint one health activist per 277 and 569 people respectively, all the posts remain filled. This could have led to a low IMR in the states.

“It is important that the government recognises the work done by ASHAs and pays them regular wages,” asks Jayati Ghosh, professor at School of Social Science of the Jawaharlal Nehru University in Delhi.

Time for rural healthcare course

The responsibility to lower IMR largely rests on the shoulder of health professionals. But doctors do not want to serve in rural areas. Shravasti is a classic example (see ‘103-worst places to be born in’).

Model of excellence   In Bilaspur’s Ganiyari village, a people’s health support group, Jan Swasthya Sahyog (JSS), has managed to bring down IMR level much lower than the level of its district by training village women to take care of the health of pregnant women in the community. They were trained to monitor blood pressure and haemoglobin. Pregnant women were offered insecticide-treated bed nets and chloroquin to prevent malaria. Though government recently advised against chloroquin, fearing it might lead to abortion, JSS says it is a cost-effective method and should be continued until a better alternative is found. JSS has devised technologies to reduce infant death. For protecting newborns from hypothermia, it has a sleeping bag, in which packets of heated palm oil are kept. The bag can be used at home and parents do not need to hospitalise child in new born baby corner. To provide nutrition to infants, JSS runs 72 creches or phulwaris where around 1,000 children in age group of six months to three years are fed under the supervision of a worker. This is not expensive, says Yogesh Jain, executive member of JSS. Each child requires less than Rs 12.50 per day for care and food and one worker can take care of 10 children. JSS claims since 2003, when it introduced the programme, IMR in Ganiyari has declined from 86 to 32. Jain says the government should include phulwari model in its nutrition programmes to reduce infant and child mortality. Under the government programme, take-home rations are given to mothers which may or may not help the child. The nutrition of child remains unmonitored for three years until he or she gets enrolled in anganwadi. By that time, it is too late to tackle malnutrition.

Chhattisgarh circumvented the problem by employing rural medical assistants (RMAs) to fill up the posts of medical officers. This way the government also saves half the salary that it would have given to an MBBS doctor. But the state government discontinued the rural healthcare course following objections from medical practitioners.

“We will not allow any kind of short-term courses to be introduced for medicine,” says G K Ramachandrappa, president of the Indian Medical Association (IMA). The association says such courses would produce substandard doctors. When asked whether the doctors would agree to go to rural areas, he is blunt. “Doctors in government jobs are paid less and transferred often. There is no opportunity for their children to study in rural areas. How can they serve in such areas?”

A study by the Public Health Foundation of India, a Delhi-based advocacy organisation, however, negates IMA’s viewpoint. RMAs in Chhattisgarh are equipped to tackle problems they face as well as an MBBS doctor. Government is hiring AYUSH medical officers, who are trained in traditional systems of medicines. But they are less competent than MBBS doctors and RMAs, notes the study.

Appalled by years of neglect of healthcare in a village, Meenakshi Gautham, a post-doctoral fellow with the Institute of Health Policy and Management at Erasmus University in the Netherlands, had filed a public interest petition in the Delhi High Court in 2009. The petition cited an NRHM Task Force Committee report on medical education in 2007 that recommended introducing a three-year medical course to train people at the district level and meeting the requirement of qualified health workers in rural areas. Responding to the petition, the court asked the Union health ministry to consider introducing the course. In November 2010, the Medical Council of India (MCI), the apex institute for medical education, in its submission to court, said it would take a decision regarding the Bachelor of Rural Health Care course within two months after which the ministry would bring it into effect.

But so far there is no clarity on the status of the course. Sources say the Body of Governors of MCI plans to confirm the curriculum by April 2012, just a month before its term expires. A delay could put the course in cold storage.

Infrastructure hurdles

Health workers can bring down IMR only to a certain level. For further improvement, better infrastructure and better nutrition are needed, says Samir Garg, senior programme coordinator of State Health Research Centre, Raipur.

The latest report released by the UN on the development of MDG of Asia Pacific region also highlights that maternal and infant mortality in the region is likely to fall if mothers facing obstetric emergencies can rely on good roads to reach hospitals as well as reliable electricity supply to enable adequate treatment. Effective transport systems are vital for effective immunisation programmes, the report notes.

An effective transport system—an ambulance system, for example—also complements work done by ground-level health workers. The ambulance service made available on toll-free number 108, introduced by state governments under the public-private-partnership, has become the backbone of the healthcare system in Uttarakhand, Rajasthan and Chhattisgarh. To improve the system the health centres and district hospitals must also be equipped to handle complicated cases.

In Rudraprayag all complicated cases are referred to Srinagar Medical College, 30 km away, because none of the PHCs or even the district hospital is adequately equipped. Basic requirements of a newborn, as promised under NRHM, are not met at all major hospitals. Hamirpur Mahila District Hospital does not have a single incubator and manages only with newborn baby cornors, which are essentially a light bulb to keep the baby warm. The Planning Commission’s working group report on NRHM points out that investment in district hospitals during the 11th Plan period has been inadequate to meet the increased load of institutional delivery due to Janani Suraksha Yojana. It recommends that in the 12th Plan period, number of beds should be increased.

Nutrition puzzle

Nearly 50 per cent of the infant mortality is linked to nutrition-deficiency of both the mother and the child. Thus the nutritious food provided through anganwadis plays a vital role in maternal and child health. “But we never get to know if anganwadis are working properly. There is a disconnect between NRHM and ICDS,” says A N Siddiqui, chief medical officer of Hamirpur.

The disconnect was palpable during Down To Earth’s visit to different districts. Anganwadi in Rudraprayag’s Bhatwari village has no cooking gas or vessels. The worker has no option but to buy chips and distribute among children. In Hamirpur, some anganwadi workers sell the multigrain flour in the open market. When asked, one worker said requesting not to be named, they have to make up for the bribe of Rs 500 they pay the contractor who supplies the flour. In Hamirpur, some anganwadi workers do not register malnourished children. “It is a hassle as we have to give extra ration and monitor their growth,” says a worker.

“There is a need to improve IT enabled programming to reduce corruption and leakages,” says Rajiv Tandon, senior advisor with Save the Children, an international charity. Alongside, focus should be on spreading literacy and awareness programmes which go a long way in ensuring infant mortality.

IMR is the single most important indicator of development of a community. Putting more money on strengthening rural health workers should be on the mind of policymakers as they sit down to make the 12th Five Year Plan.

With inputs from Richard Mahapatra

Schemes for health   National Rural Health Mission, Ministry of Health & Family Welfare Janani Suraksha Yojna To promote institutional delivery, women from rural areas are given monetary incentive. ASHAs provide antenatal and postnatal care such as vaccination and nutrition supplement Janani-Shishu Suraksha Karyakram Free transport, delivery, medicines and food. Free treatment for sick newborns up to 30 days after birth Facility Based Newborn Care To provide special newborn care units, newborn stabilisation units and newborn care corners Infant And Young Child Feeding Promotes early breastfeeding and exclusive breastfeeding for the first six months, and continue supplement breastfeeding for two years Nutritional Rehabilitation Centres Health facilities for inpatient management of severely malnourished children, with counselling of mothers Reduction In Morbidity & Mortality Due To Acute Respiratory Infections And Diarrhoeal Diseases For diarrhoeal diseases and other acute respiratory ailments, the government follows WHO guidelines like providing ORS for control Micronutrient Supplement Provides Vitamin A, iron and folic acid Universal Immunization Programme To immunise infants against seven vaccine preventable diseases such as tuberculosis, diphtheria, pertussis, polio, tetanus, hepatitis B, measles Integrated Child Development Services Scheme (ICDS), Ministry Of Woman And Child Development Supplementary Nutrition Provides nutritious food, monitor vitamin A deficiency and anaemia Health check-up Antenatal and postnatal care to young mothers and treatment of diarrhoea, de-worming and other diseases