This is Part 1 of a four part blog series where Shelly Batra, founder of Operation ASHA, reflects on some of the challenges associated with providing health care to the bottom-of-the-pyramid (BOP) and how we can overcome them moving forward.
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 Rs 16,000 (US$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 (US$0.60) 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 in spite of the economic boom and billions of $$ spent on health programs, the govt has not been able to fulfill 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 and 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 treatment 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 in spite 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 coordinating with each other for smooth and efficient functioning.
But if we look beneath the surface we can see the cracks in the system….
Read Part 2 and the continuation of this blog series.