Hello from India,
I was away without internet access for 3 days, so I could not write as planned. I’ve been in India over a week now, and there’s so much to say. I’ll try and spare you ALL the many details, but let’s just leave it at every day is really a new day here.
I arrived in Delhi, the night of September 6th. I expected the airport to be flooded with people and hectic, but it was quiet and easy to get around. I did have an emotional breakdown when I thought my bag was missing, but it was just rotating around the carousal….typical.
When I finally reached the exit, I had a driver waiting for me with my name written in pencil on blank computer paper. On the way to my new apartment, I noticed how busy the roads were with cars and people out and about (even though it was past 9pm). I live in a sector of Delhi called Vasant Kunj, it is also where I work at the Public Health Foundation of India (PHFI). My flat is just the right size and my room is cozy. I have two roommates, both very down-to-earth and friendly.
The very next morning I woke up to meet with my research overseer at PHFI. I took an auto-rickshaw to work, and had my roommate accompany me the first day. I knew I had to learn quickly, because if you act too slow, you will get ripped off or lost. So, my first two days here really felt like 2 weeks. After the initial panicky couple days, I felt like I could really get used to it here.
At PHFI, I discussed my interests in the field of public health; mainly to understand the health care system that exists here and described my skill set background. My supervisor gave met a set up papers to read and broke down some important research he’s involved with. He also explained to me how the health care system works in broad terms. The health care system in India is quite complex! I’m still trying to understand it all.
The country of India is the largest democracy in the world. The potential for public health debate to be put on the political agenda is huge. However, health is rarely a decisive political issue in national or state elections. Looking at the health care system, it is one of the most privatized in the world. Since almost all private services require money out-of-pocket at point of service, the poor bear a large portion of the financial burden. More than 40% of Indians borrow money or sell assets to cover their medical expenses, leaving more than half of Indian households to fall into poverty.
Public health expenditure accounts for about 1.10% of the GDP, and there’s much variation of resource allocations between states and territories. Per capita government health expenditure in India is one of the lowest in the world – US$7,000 compared to US$2,548 in the United States.
You might be wondering if there is a place for health insurance? India’s tryst with health insurance program goes back to the late 1940s and 50s when the civil servants (Central Government Scheme – CGS) and formal sector workers (Employees’ State Insurance Scheme – ESIS) were enrolled in a contributory but largely subsidized health insurance program. However, these programs, especially ESIS were confined to a small part of the society, and enrollment remained low due to the fact that it was only for formal sector workers. The informal labor sector represents 95% of the population. CGS, ESIS and the private health insurance (which started in the 90s, for high income groups) took up about 5% of the population.
Notwithstanding, since 2007, a whole slew of initiatives have been created, both from the central government and state governments. The goal is to upscale government health expenditure to 2-3% of the GDP through innovative schemes. Consequently, this would enhance access and availability of health care services and protect households from financial risks. Two big schemes are the National Rural Health Mission (NHRM), and Rashtriya Swasthya Bima Yojana (RSBY) – there are also state specific initiatives, which really vary across the board. Research now is being done to have a more integrated model and have the 3 central government schemes under one umbrella which would ensure efficient allocation of funds, and expand access to better care and private facilities. There is also a lot of research and direction towards universal health care in India, and essentially a single payer system.
This past week, PHFI gave me the opportunity to travel with some maternal/child health researchers to the state of Uttarakhand. The purpose of the 3 day trip was to meet with various stakeholders and mothers/families in the community to monitor and get a feel for a health voucher scheme in place in 5 districts. In 2005, the government of Uttarakhand launched the National Rural Health Mission (NRHM) in the state to provide health care to the rural population, especially disadvantaged groups like women and children, by focusing on public-private partnerships (PPP). A voucher scheme system was created to give provision for reproductive health services to BPL families (families making less than a dollar a day).
Basically, mothers in rural areas were given vouchers that would give them an option to deliver and get reproductive services through either a public or private provider free of charge. As you may already know India has a really high infant mortality rate; 47.57 out of 1,000 live births. Many rural mothers cannot afford to give birth in private hospitals or simply do not give birth in a health facility, leaving them more vulnerable to such things as hemorrhage, toxemia, anemia, obstructed labor, and puerperal sepsis. Their newborns are at risk of pneumonia, tetanus, prematurity, and birth asphyxia. When mothers do deliver at the government hospitals are faced with overcrowding, poor quality services, lack of gynecologists, untrained nurses, and lack of resources. Therefore, this voucher scheme gives mothers who are BPL the opportunity to have their delivery, prenatal, postnatal and antenatal care, sterilization, and family planning services taken care of in a facility of their choice. The voucher itself gives them a sense of confidence to get their needs met.
The team and I visited two districts in Uttarakand – Haridwar and Dehradun. Haridwar is an important pilgrimage city and is seen as one of the seven holiest places for Hindus. Dehradun is located in the foothills of the Himalayas, and is situated between the Ganges and Yamuna rivers. The two districts really varied from one another in terms of the delivery and views of the scheme, but in a general sense the voucher scheme did contribute to about 16,000 deliveries in private hospitals. Some village mothers were clueless about the scheme, having been missed from receiving their BPL cards (you need it to receive the vouchers), but the second scaling up phase of the scheme will reap better results. The pilot scheme was an utter success, however the scaling up phase 1 faced some challenges with financial adjustments/financial cuts, but appropriate measure have been set for the scaling up phase 2. Overall, the mothers were open to talking to us, and it was incredible to see the state of living of the BPL families. I was shocked to see first hand the places in which these large families (extended families) lived in, but could see that even with the little materials they had, they were functional and some places were impeccably clean and efficient with their scarce resources. I felt so lucky to visit both places, and was able to experience the beauty of it. PHFI’s main objective is to monitor the scheme and to also create a documentary on the findings and successes. I’ll definitely share the final product when it is made. My role now is to create a case management paper for this particular scheme.
I’ve explained a lot so far! I really wanted to write earlier, but could not get around to it because I was traveling and busy getting myself together. I will really try to post more often!
Aside from my interning, I have been able to explore. I went to the Garden of Five Senses, and took in all the exotic flowers and plants. I also found out gardens are a really great place for young couples to hide out and spend time alone together. There was also a random dance off with awesome music in a section of the garden; a bunch of adolescents were hanging out and having a good time.
I was able to go to Agra last weekend to visit the Taj Mahal. It felt unreal being at the Taj Mahal and making my way inside; the architecture, stones, calligraphy, and carvings were beautiful – it felt very persian and familiar. I went with a co-workers friend, along with an organized toured called the “panickers.” It was quite funny, because as soon as we thought we lost the group, the guide would say, panickers, panickers, come here. haha. So appropriate. We went to the Agra fort, Taj, and then a Hindu temple around 10pm. Right when we got off the bus to get to the Taj Mahal, it began to rain so hard, so we opted for umbrellas given by some young boys at the side of the road. Funny enough, later that evening, as soon as we arrived at the temple it started to pour again. I experienced walking through the wet ground completely barefoot, quite a trip.
Going back to Haridwar and Dehradun, all I could say is wow. Haridwar really is the hub for spirituality; there were Sufis, mystics, and pilgram types all around. I was lucky enough to get to see and put my hands in the Ganges river (don’t worry, i’m still alive!), it was really something. In Dehradun, the Himalayas was on the backdrop, and it was so green and clean. The mountains were so quiet and peaceful and the families were generally happy and extremely friendly and hospitable.
Overall, I’m really getting used to it here. The cows, the dogs all around, the traffic, the quick power outages, the random rains, my new friends, and the every day uncertainty is keeping me on my toes.
Okay, here are some pictures —
The Garden of Five Senses – Prayer for Peace
Little puppies built a home under the wood
In front of the Taj Mahal
Random cow relaxing
The families baby lamb (yes, that’s a bug bite not a bindi)
Poster material bringing awareness of the voucher scheme
Lovely family in the hills of Dehradun
Beautiful grandmother – she wanted her picture taken
The Accredited Social Health Activist community health worker (ASHA), mother and I
Put my hands in the Ganges River!
Well, I’ll post again very soon! Miss you all!