Medical Care for Young Mothers and Children in India

Improving take-up of immunization and quality of health care
By Rishabh Chatterjee

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Image Credit: Huffington Post

Sanchita Sharma’s “Baby steps: Our infants are surviving, but they need better medical care,” published in the Hindustan Times, addresses three major policy issues in India: the infant mortality rate, vaccinations, and the quality of health care.

Key Takeaways of Article

The infant mortality rate in India has reduced due to more mothers giving birth at public health facilities (as opposed to home births) as well as the number of children receiving vaccinations increasing. The infant mortality rate is down to 41 in 2017 (per 1,000 live births), from 57 in 2005 (National Family Health Survey-4). While this is a marked improvement, 20% of under-five deaths in the world still occur in India. Close to half of these deaths are attributed to vaccine-preventable and treatable infections like diarrhea and pneumonia.

The article advocates for the use of vaccines to reduce deaths from these preventable causes, reasoning that “vaccines are the quickest and the most cost-effective way to bring down disease and death.” Despite its sporadic delivery over the past two decades, routine immunization has played a large part in reducing the annual under-five deaths from 3.3 million deaths a generation ago to 1.3 million deaths today (NHSF-4). The Indian government is rolling out four new vaccines this year to combat under-five deaths from polio, diarrhea, measles-rubella, and pneumonia. Sharma notes that under-five deaths are expected to fall sharply with the rollout of these vaccines.

Two crucial issues come into play regarding why take-up of routine vaccinations has not reached 100% among Indian households. Take-up simply refers to the percentage of households who choose to provide immunization that is available for free to their children. Nachiket Mor, director of the Bill and Melinda Gates Foundation (BMGF) in India, noted that availability of vaccines is not the issue, but rather the issue is of accessibility. Many individuals are unable to gain access to treatment, preventing India from providing routine vaccinations to 100% of its citizens. A second issue preventing take-up is that India has had its share of conspiracies regarding vaccines, such as misled parents denying their children polio drops for fear of impotence and MMR for fear of autism. These conspiracies delay children receiving the vaccinations they need to reduce preventable and treatable diseases.

The article also touches on the quality of care at public health facilities. More than half of India’s children are born in a public health facility, making the quality of care available critical to the health of the mother and child. In fact, the BMGF notes that quality of care has surpassed immunization as the top strategic priority of the organization in India, with emphasis on understanding the level of treatment options available from delivery to when the baby leaves the facility. One way the BMGF is addressing quality of care is by sending out nurse mentors to public health facilities in Bihar and across 25 districts in Uttar Pradesh, where about 40% of India’s 27 million births take place.

Relation to Empirical Evidence

The article mentions the unfortunate reality that India has had “its share of conspiracies around vaccines,” with many families electing not to vaccinate their children due to misconceptions regarding side effects of certain vaccines. This is consistent with a key point made in a Dupas (2011) paper titled Health Behavior in Developing Countries, which reviews studies of health-seeking behavior in low-income nations and discusses its implication for policy. “Information campaigns carried out by governments with a bad track record might be doomed to fail…In India, few children with diarrhea were treated with ORT in the early 1990s, despite 10 years of vigorous ORT campaigning by the Indian government (Rao et al. 1998). One could hypothesize that the lack of success of the Indian government’s ORT campaign was related to the forced sterilization effort carried out by the government…between 1975 and 1977, and the subsequent distrust, among the population, of any government initiative related to family issues.” This point made in the Dupas (2011) paper about a general mistrust of government-led health initiatives can be seen in the article as well, with Sharma writing that misled parents are, “denying their children…vaccines for fear of big pharma dumping unwanted products in India.” As long as skepticism remains in some households over take-up of vaccines, the delay in immunization means India will continue to lose mothers and young children to diseases that are preventable.

Let’s now look at another major takeaway of the article: the importance of quality health care. This topic relates to Das et al. (2008): The Quality of Medical Advice in Low-Income Countries. The empirical paper provides an overview of recent work on quality measurement of medical care and its correlates in four low and middle-income countries—India, Indonesia, Tanzania, and Paraguay. A pertinent conclusion reached is that competence of doctors in developing countries is low and that further, the quality of care provided to patients is even lower than would be suggested by a doctor’s competence. The newspaper article provides new evidence that is consistent with the results from the Das et al. paper. The article states, “The Gates foundation is working…to improve women and newborn care at public health facilities,…[where] stillbirth rates, maternal deaths, asphyxiation at birth and sepsis are very high. We have 200 nurse mentors in Uttar Pradesh who go from facility to facility to provide additional training and guide the nurse through the process,” said Mor. The BMGF is very aware of the issue mentioned in the Das (2008) paper regarding the quality of care provided by doctors and nurses in India. They are addressing the issue of competence by sending mentors across these two states to improve education among nurses who assist in childbirth. The Dupas (2008) paper suggests that intervening in such a manner is useful as a conclusion reached in the paper is that training matters for doctors, while experience does not.

The Dupas paper refers to a Banerjee et al. (2010) study in Udaipur, India that addresses two main points of the newspaper article: quality of public health facilities and lack of accessibility. The study observes that public health facilities that are supposed to provide free immunization are subject to high rates of absenteeism, with 45% of medical staff absent from work on any given day. Many households in low-income nations face high transportation and opportunity costs, and because a full immunization complement requires at least five trips to a public health facility, unreliable service often prevents households from fully immunizing their children. The Udaipur study shows that increasing the reliability of the supply- by holding well-advertised immunization camps with consistent hours of operation – can have a significant impact on immunization rates, from 49% of children having at least one immunization when the supply is unreliable, as opposed to 78% when the supply is reliable.

Conclusion

There are some valuable conclusions that can be reached after considering empirical evidence and points mentioned in Sanchita Sharma’s newspaper article. The vaccine complement is fully available, but getting take-up to 100% remains an issue for two main reasons. 1) Mistrust exists regarding government-led health initiatives for some Indian citizens, delaying and in some cases preventing children from receiving immunization and 2) High rates of absenteeism among medical staff at public health facilities often prevents households from fully immunizing their children. Another major takeaway is that the quality of care available to mothers and children at public health facilities is underwhelming. Current efforts by the BMGF in India to provide training to nurses is a step in the right direction according to empirical evidence.

 

Works Cited

Banerjee, Abhijit Vinayak, et al. “Improving immunisation coverage in rural India: clustered randomized controlled evaluation of immunisation campaigns with and without incentives.” Bmj 340 (2010): c2220.

Das, Jishnu, Jeffrey Hammer, and Kenneth Leonard. 2008. “The Quality of Medical Advice in Low-Income Countries. “Journal of Economic Perspectives, 22(2): 93-114.

Dupas, Pascaline. “Health behavior in developing countries.” Annual Review of Economics 3.1 (2011): 425-449.

“Key Findings From NHSF-4.” National Family Health Survey, India. National Family Health Survey, 2009. Web. 08 May 2017. <http://rchiips.org/nfhs/factsheet_NFHS-4.shtml#&gt;.

Sharma, Sanchita. “Baby Steps: Our Infants Are Surviving, but They Need Better Medical                Care.” Hindustan Times. HT Media Limited, 04 Mar. 2017. Web. 02 May 2017.

Health Care Facilities in Tribal Areas of Rajasthan

An analysis of the inaccessibility of health care in rural regions of Rajasthan, India.

By Trisha Biswas

Providing accessible health care to developing countries has become an important goal towards eradicating poverty. Countries such as India, have implemented government mandated programs that intend to provide rural communities with health care. The National Rural Health Mission (NRHM) was established in 2005 and aimed to provide quality health care that was both accessible and affordable to the most vulnerable populations in India.

A recent article published by the Hindustan Times, “Provide Accessible healthcare in Rural Areas, CAG tells Rajasthan govt.”, discusses issues on compliance by the state governments in providing proper health facilities. Following the rules and regulations brought on by the NRHM, the Comptroller and Auditor General India (CAG) requested the Rajasthan state government to comply with the Indian Public Health (IPH) standards to provide rural areas with accessible health care facilities. Based on the data collected by the CAG, fewer number of health centers were implemented in tribal areas as compared to non-tribal areas. The report provided by the CAG states that the Rajasthan state government was unable to provide basic facilities in 75.77% of rural health centers. The CAG also reported that health centers that were constructed for the tribal areas were built in “inaccessible and uninhabited locations”. Overall, this report mentioned that the requirements of Community Health Centers (CHCs), Primary Health Centers (PHCs) and sub-centers as per IPH standards in non-tribal areas were provided in excess as compared to tribal regions where the number of these health centers fell short of IPH standards. Additionally, many of the health centers that were implemented in tribal areas faced severe deficiencies in facilities and quality of care.

Two Sides to the Problem: Supply vs. Demand

 Many studies have been conducted to form concrete reasons behind the disproportionate number of health care facilities in rural/tribal areas. There are two sides to this growing issue, the supply side and the demand side. The problem from the supply side stems from recruitment and retention problems, of highly educated health care professionals. Many health care providers may not want to work in rural areas due to inadequate staffing of hospitals and health facilities. The doctors do not want to take on the burden of treating hundreds of patients alone. Therefore, they do not accept job offers in rural/tribal health facilities. In a 2008 paper, The Quality of Medical Advice in Low-Income Countries, written by Jishnu Das, Jeffrey Hammer, and Kenneth Leonard, discuss a particular story in Delhi. At this particular facility, there were only two working doctors who provided care to more than 200 patients per day. This greatly decreased the average amount of time the doctors could spend on each patient. On average, the doctors asked “3.2 questions, and [performed] an average 2.5 examinations (Das et al., 2008).” The numbers presented in this study show that a sufficient amount of time was not being spent on each patient to properly diagnose them.

Consequently, the supply side problem leads to the demand side problem. The quality of care provided to low-income countries are considered to be inferior to other developed nations. Das et al., discussed that doctors employed in health facilities in developing countries and regions have lower education levels than their counterparts. This effects the quality of care provided to the patients. However, it was found that these doctors administer an even lower quality of care than they are trained to provide. The poor quality of care can affect the decision making process of the individuals living in these rural areas. First and foremost, most of the health care facilities located in tribal areas are stationed in remote regions away from the villages. In addition, if the residents of the rural villages are aware that traveling the great distance does not guarantee proper health care, they do not have any incentive in making the extensive trip.

The incentive to travel to far located health facilities are also affected by the availability of doctors. In many instances, after patients have traveled long ways to see a doctor, they come to find out that the doctor is not present or the entire facility had closed for the day. A 2011 paper written by Pascaline Dupas, “Health Behavior in Developing Countries”, referred to a supplemental study completed by Banarjee et al. (2010) in Udaipur India, which showed that public facilities that provided free immunization for children had a very high rate of staff absences. It was found that “45% of the health staff in charge of immunizations [were] absent from work on any given day, being neither at the health center nor on their rounds in surrounding villages (Banarjee et al., 2010).” Due to these uncertainties many families do not complete the full round of immunization for their children. It was found that if health facilities properly advertised the hours of operation for immunization camps, the immunization rates drastically increased. The immunization rates increased form 49% of children completing one round of immunization shots when supply was unreliable to 78% when the supply became reliable. The consensus of the studies showed that if proper health care was supplied to the patients, there would be a high demand in health care.

Conclusions and Possible Outcomes

As previously mentioned, the low number of health care facilities provided in rural/tribal areas are due to both supply and demand side issues. However, based on the data it can be seen that if rural families are provided with reliable and quality health care, take up increases drastically. It is important for the health care facilities to be fully staffed with well qualified doctors so that residents of rural areas have access to quality health care. Spending more time with each patient will increase the likelihood of correctly diagnosing the patients and therefore increase their chances of a healthy life. In addition, correctly advertising the operating hours of the health care facility will allow the residents of the rural areas to know exactly when the correct times are to go to the facility. If individuals from tribal areas know that the health centers will be open when they arrive, their incentive to make multiple trips throughout the year will increase. Improving these different components, will increase the value of expected returns in receiving medical care for the tribal area residents. It is possible that if one individual had a decent experience at the health center they will spread the word throughout their community, therefore making other people more likely to visit the health facilities. Overall, increasing the supply of proper health care will create more incentive for people to make frequent visits. This will ensure the increase in the demand in health care in tribal regions as well.

 

Works Cited

Banerjee, Abhijit, Esther Duáo, Rachel Glennerster, and Dhruva Kothari (2010). Improving Immunization Coverage in Rural India: A Clustered Randomized Con-trolled Evaluation of Immunization Campaigns with and without Incentives. British Medical Journal 340:c2220.

Das, J., Hammer, J., & Leonard, K. (2008). The Quality of Medical Advice in Low Income Countries. The World Bank, 1-38. Retrieved April 16, 2017.

Dupas, P. (2011). Health Behavior in Developing Countries. Annual Review of Economics, 3, 1-39. Retrieved April 16, 2017.

Provide accessible healthcare in rural areas, CAG tells Rajasthan govt. (2017, April 01). Retrieved April 16, 2017 from http://www.hindustantimes.com/jaipur/provide-accessible-healthcare-in-rural-areas-cag-tells-rajasthan-govt/story-4zDflT3SA2WMDBmROjo8hI.html

Universal Health Coverage. (n.d.), Retrieved April 16, 2017, from http://in.one.un.org/task-teams/universal-health-coverage/

Top image by Ejaz Kaiser, Ruchir Kumar and Subhendu Maiti from the Hindustan Times