Collectives And Public Health

The ongoing pandemic has emphasized the importance of creating a robust public health system. In Maheshwar, Madhya Pradesh the shortcomings of the health infrastructure in these trying times were visible not only in the infrastructural inadequacy, but were also highlighted by the lack of trust in the health system at large. We witnessed a sense of hesitation to go to government facilities for diagnosis and treatment owing not to expense related reasons but grim misconceptions like an indefinite quarantine and even death.

For the few who did end up at Government facilities were faced with a shortage of supplies. The pandemic, of course, has only accentuated an ongoing problem that has been plaguing the health infrastructure particularly in rural hamlets of the country for years. By and large, following are the some of the issues that dominate the public health system which involves both the health providers and seekers:

• Low and underutilized funding
  According to the National Health Profile, India spent nearly 1-1.5% of its GDP on healthcare. The recent revision of increasing the allocation to 1.8% in the 2020-21 budget is a step in the right direction, but not nearly enough to compensate for the devastation caused by Covid-19. What is even more concerning is the fact that the allocated funding is underutilized. According to a study conducted by Harvard T.H Chan School of Public Health in 2017, data from the first 10 years of NHM showed that the utilization of the budget is lower in poorer states even though they need the NHM funds the most. 
• Less focus on preventive healthcare
  The current structure of the public health system focuses more on curative measures than preventive measures. While preventive health campaigns exist on paper and are supposed to be executed with the help of the ASHAs, the implementation of these programmes is severely lacking. 
• Low accountability
  Quality health services in India, by and large, are viewed less of a right and more of a favour done by the healthcare providers. This sentiment, coupled with lack of awareness regarding what to expect from the healthcare system, creates a sense of low accountability which perpetuates the substandard functioning of the health centers. 
• Overburdened health workers
  The ASHAs and ANMs which form the only link between the community and health systems are often overburdened without receiving the necessary acknowledgement and compensation. Poor incentives and an inadequate monitoring mechanism create structural flaws that impact the ASHAs output. For ANMs, poor infrastructure prevents them from reaching the patients/hospitals on time and contributes to reduced productivity due to excessive travelling.

Needless to say, this list is not exhaustive and finding solutions to these is no easy feat either. Shifting the entire responsibility of ‘fixing’ the health system on the authorities or the health providers would mean fixing just one aspect of a very complex problem. Working with Chaitanya and the collectives it has promoted over the years gave me a vantage point to view these fault lines in the public health system and look at the health seekers side of the equation. My experience of being on the field reminded me how important active participation of the community is in making the health system a success.

From refusing to access existing infrastructure to not having adequate information about or motivation to adopt preventive health practices, there is a lot of scope to leverage the strengths of the community to make quality healthcare a more achievable goal. The systems built for making credit accessible through the formation of women collectives can be leveraged to improve preventive healthcare. This article explores some of the typical characteristics of a collective that can be very well suited to address some of the issues in the health sector.

Can a collective help?

To make the public health system of the country robust, it is important to fully understand the community for which the health center is being opened. The environment, the cultural practices, infrastructure, etc. play a role in explaining the health makeup of the community. Adopting a human centered approach to building a health infrastructure can go a long way in identifying the root cause of illnesses as they may be caused by external factors like poor sanitation infrastructure, etc.

While the Primary Healthcare Centers (PHCs) and Community Healthcare Centers (CHC) involve participation of the community by having an ASHA as a point of contact, there is a lot that can be done to improve active participation from the community. A collective can contribute immensely on this front. A collective is based on active participation from the women who have complete ownership of the collective. Having a wide network also means that the needs of the communities are fully understood.

Additionally, having a three tiered structure of groups (village, cluster and block) can ensure presence in the remotest of hamlets and create a channel for transmission of information and resources between the block and villages. A health system that recalibrates itself  based on constant feedback from the community that takes into account their issues and needs can achieve more success in a shorter span of time. This decentralized approach can yield better results in terms of solving health related concerns as opposed to a one-size-fits-all approach.

Understanding the needs of the community and having a mechanism where the voices from the margins can make their way into concrete decisions can be achieved through a collective. The collective, therefore, can offer the right alternative to a top-down/centralized approach of implementing healthcare. By its very nature, the collective ensures active participation from the community which is crucial for the success of any system made to cater to the needs of the public.

The granular nature of a collective i.e. its presence at the village level and block level, means that the needs of the community are better understood at each level. This adaptability would catalyse problem identification and resolution. Most interventions fail because they are not the right fit for the problem they are trying to tackle, however, if the solution emerges from within the community, it has a higher success rate as the problem is best understood by those who are experiencing it. The collective can thus inform both- the immediate and larger ecosystem of the changes required basis the need.

My experience of the second wave of the pandemic in my field area highlighted the importance of trust- trust in the health workers, doctors, treatment and the health infrastructure at large. It can be argued that the mistrust in the health system has enabled the emergence of quacks, faith healers and other unqualified healthcare providers. While lack of awareness and money can also enable the emergence of cheaper, often substandard health facilities, absence of trust would prevent even those patients who can afford healthcare.

To improve the health seeking behaviour of the country, it is important to build trust among the community and ensure that the health infrastructure meets the expectation. Mistrust becomes an even more important issue when the health infrastructure exists, but people don’t avail the services due to lack of trust. One of the ways of resolving this issue is involving the participation of a local role model.

Only when the information is given by a source that the community trusts would the community move towards better healthcare seeking behaviour. In a collective, mutual trust is the binding factor that keeps the collective together. This trust in the community, when coupled with effective trainings, can be leveraged for fighting myths surrounding healthcare practices. Trust also gets formed more organically since the women themselves run the institution and make decisions pertaining to the local health infrastructure.

Another issue plaguing the health system, especially in urban areas is the low doctor to patient ratio. The Urban Primary Healthcare Centers are often severely short staffed and overworked due to which the quality of treatment can be compromised. The issue of lack of trained professionals can be offset by the network of the collective. With adequate training and mobilization efforts, the collective can bridge the gap between demand and supply. It can be leveraged for conducting capacity building trainings of not only the group but also of ASHAs, ANMs and Anganwadi workers. These trainings can be facilitated at the cluster level. It would be even more effective if the collective consisted of ASHAs/ANMs/Anganwadi workers. 

The collective can act as the channel for voicing concerns of the individual members and holding the health system accountable to deliver on its said goals. Part of the reason why PHCs and CHCs continue to provide substandard services is because of the absence of adequate checks and balances that ensure the proper functioning of the health center. Through the awareness campaigns implemented in the federation, the collective can possess the relevant knowledge needed to understand whether and by how much their local health center is under-delivering. 

The health system, like many others, is not an exception as far as gender inequality is concerned. Despite the fact that women have a higher utilization for healthcare services, they lack the awareness and agency required to make decisions that impact their physical and mental well-being. The collective, as is evident on the finance front, creates a safe space where women can identify and understand health related oppression and take steps to address it.

Moreover, given how complicated the problem of the public health system is owing to varied factors at play, the safe space created by the collective can be leveraged for understanding the issues faced by health centers and healthcare workers while providing health services. The frequent meetings of a collective can serve as the perfect platform for creating a discourse about preventive healthcare practices on a regular basis. This forum can be leveraged for discussing and implementing healthy lifestyle practices that, when followed, would eventually decrease the burden on curative healthcare centres.