The World Health Organization defines healthcare as “a health system that consists of all organizations, people, and actions whose primary intent is to promote, restore, or maintain health. This includes efforts to influence determinants of health as well as more direct health-improving activities. A health system is, therefore, more than the pyramid of publicly owned facilities that deliver personal health services. It includes, for example, a mother caring for a sick child at home; private providers; behavior change programs; vector-control campaigns; health insurance organizations; occupational health and safety legislation.”
Healthcare is delivered in India through frameworks where each healthcare organization operates according to certain standards and with no interconnectivity to other healthcare services. Healthcare is often misconstrued to include primary medical care in the Indian rural context. Primary hospitals and other healthcare providers are only one part of an interrelated system that must work together to improve societal health.
An effective healthcare system includes the use of a “systems thinking” approach where interconnectivity with standardization completes the system. In a vast and populous country such as India, efforts of the state are found wanting due to inadequate human resources, shortage of funds, and an inability to reach the masses. The systems approach adopts a route that includes and promotes “efforts to influence determinants of health as well as more direct health-improving activities” through direct intervention and partners in progress.
Some key initiatives healthcare initiatives: A systems approach to healthcare
National Rural Health Mission (NRHM). Realizing the need to adopt an integrated systems approach, the government launched the NHRM to address the needs of the large Indian rural population. The long-term goal of the NHRM is to assure a fully functional and decentralized health delivery system. It also aims to provide intersectional coordination among the determinants of health, such as education, nutrition, sanitation, water, social equality, and others.
These goals are set with a broad perspective that goes beyond mere healthcare to a system that includes a host of interventions, such as convergence of health and related programs at the village level and community interventions and others. The key features and benefits of the NHRM could be summarized as follows:
1) Providing Quality Healthcare in Rural Areas. Creation and improving access to healthcare infrastructure for the vulnerable population in rural areas with special emphasis in states that lag in health outcomes as well as development indicators (known as EAG states).
2) Free Medicines and Diagnostics Services. Under NHM, all states are to provide free essential drugs in public health facilities. As part of this initiative, government support is provided for the provision of essential drugs free of cost in public health facilities.
3) Building a Network of Accredited Social Health Activists (ASHAs). As a part of community-level care, the role of ASHAs is key to the success of primary healthcare. ASHAs serve the rural communities as facilitators, mobilizers, and providers, playing a stellar role in immunization, disease prevention, and maternal support besides promoting nutrition, sanitation, and healthy living. ASHA workers include about a million accredited female health workers who play a crucial role in connecting the community with the health system to ensure primary healthcare services.
4) Village Health Sanitation and Nutrition Committee (VHSNC). Community empowerment has a major role to play in realizing the vision of the NHRM, concerning sanitation and nutrition outcomes. Representatives of panchayats, ASHA, and other frontline workers comprise members of VHSNC and draw on the local community to disseminate information on the long-term health benefits of maintaining sanitation and nutrition.
Integrated Child Development Services (ICDS)
The population of children up through age six years as per the 2011 census was 158 million and growing. This human capital of the country needs to be nurtured, especially in rural areas, to make them productive for the times to come. As part of the government’s commitment to capacity building for this vulnerable section of the population, the ICDS Scheme was launched in 1975 with a focus on children (0–6 years), pregnant women, and lactating mothers. The scheme looks to address the challenges of malnutrition, morbidity, and mortality besides providing preschool nonformal education.
As part of the implementation process of ICDS, the government started anganwadis: rural child care centers. A rural anganwadi center extends beyond the beneficiaries of ICDS and provides basic healthcare in a village and is an integral part of the public health care system. Anganwadis are managed by trained workers who are paid a monthly honorarium by the government. These workers are drawn from the local communities and further the government’s goal of increased social participation for enhanced self-care and self-reliance in health.
Several positive benefits of the ICDS program have been noticed. There has been a significant improvement in the mental and social development of all children irrespective of their gender. Studies have also documented improvements in birth weight and infant mortality of Indian children along with improved immunization and nutrition.
Poverty and Healthcare: Cause and Effect
India’s rural health system is characterized by the absence of an efficient public health system. Public health facilities, provided by the central and state governments, deliver low-cost care, and are generally overcrowded. Poor households incur high health spending and bear a higher burden of diseases in the absence of resources and proper guidance. This results in rising spending on health and leads to high out-of-pocket expenditure, and catastrophic health spending, thereby increasing poverty. Being unable to access and afford healthcare as it exists, the effects lead to a vicious circle of poverty. The vision of the government is to adopt a systems approach where healthcare initiatives derive synergy from prevention and cure. This would include comprehensive integrated health services that integrate primary care as well as public health; policies and actions to address the link between health, external conditions, education, etc. This can be achieved by engaging and empowering communities through social participation that leads to enhanced self-care and self-reliance in health.
For universal health coverage to be achieved, a shift is needed from health systems designed around diseases and institutions to health systems designed for the people, with people, and by the people. Thus, primary healthcare interventions designed with a systemic approach can result in a better outcomes for rural communities and relieve them from the vicious cycle of poverty.
S M Sehgal Foundation: Promoting Local Participation and Sustainability
S M Sehgal Foundation (Sehgal Foundation), a rural development NGO in India, has been working to improve the health outcomes of rural communities of the country. One of its five main program areas focuses on Local Participation and Sustainability through which it creates awareness among the communities about important issues.
Sensitization and Awareness-Building for WASH Behavior Change
S M Sehgal Foundation, in partnership with CAWST (Centre for Affordable Water and Sanitation Technology) Canada, is working with the most-vulnerable rural population on WASH (Water, Sanitation and Hygiene) through a pilot project named “WASH for Healthy Homes” in the Vaishali district of Bihar. The project focuses on five hamlets of the poorest of the poor (daily wage laborers).
A situation analysis study among the most vulnerable 317 poorest families in Vaishali, Bihar, revealed that many do wash their hands with water or with water and soil, but not regularly. It was also observed that they often suffer from waterborne diseases such as diarrhea and typhoid. Sensitization and awareness-building sessions are thus aimed at improving WASH behavior. In every session, people are informed that most diseases occur due to not washing hands before cooking meals, before eating meals, and after the use of a toilet.
Lack of resources and knowledge are the major barriers to the poor state of handwashing practices. With the awareness-building sessions, the community understood the need for hand hygiene, and they started adopting those practices in their daily lives, however, they did not have enough money to build a proper handwashing station. Understanding this situation, the project team started promoting tippy-taps, the zero-cost solution for a handwashing station. These simple, low-cost and locally made systems for washing hands with running water with no hand touch motivate people to practice handwashing appropriately.
Positive changes are observed in the community through sensitization, awareness building, and recall. As people correct, be consistent and adopt continuous WASH behavior in their lives, better health outcomes will be achieved.
e-Poshan Kendra: Promoting A Healthy Lifestyle
S M Sehgal Foundation implemented a CSR-supported project initiative in Nuh, Haryana, in June 2021. The project included the setup of a Village Development Committee (VDC) in the project village to oversee the initiatives and sustain them for the future.
The panchayat choupal (community building) was in a dilapidated state and used as a garbage disposal site. The area was prone to the spreading of diseases like dengue, malaria, and others due to growing filth, and acted as a breeding ground for mosquitoes. In October 2021, the project team initiated the endeavor to transform this choupal into E-Poshan Kendra (E-nutrition center).
The project team mobilized the people by conducting a series of training, and door-to-door awareness sessions; the VDC and women’s group members also influenced the people. In January 2022, the choupal was transformed into E-Poshan Kendra. Solar panels were installed in the E-Poshan Kendra for a sustainable source of energy. Community women became keenly interested in the E-Poshan Kendra and started regularly attending the training sessions held there on nutrition and a balanced diet.
The project transformed the otherwise abandoned panchayat choupal into a wonderful meeting place in the village. Gradually the E-Poshan Kendra became a hub of information provision on good nutrition practices, sanitation, as well as on key government services. E-Poshan Kendra provides structured training to village women, and showcases thematic films and inspirational stories on sanitation and nutrition, and vaccination drives for village children were organized.