joshua thaisen

Infant mortality declines in tribal India highlight the benefits of de-centralizing rural healthcare services.

 

At the end of 2015 UNICEF released a report stating that India was unlikely to meet their Millennium Development Goal of reducing infant mortality to 26 deaths per 1000 live births. However, in the southern state of Karnataka, a rural healthcare provider called the Karuna Trust claim to have reached this target, reducing infant mortality over the last decade from 77 to 14.3 deaths per 1000 live births in one of the most impoverished tribal regions in India.

 

Looking beyond the statistics; the rapid declines in infant mortality achieved by the Karuna Trust are the result of an intervention program that employs over 3000 community health workers to deliver culturally specific healthcare in conjunction with national policy that aims to address the social determinants of disease.

 

Surrounded by steaming jungle inside the Biligiri Rangana (BR) Hills Tiger Reserve, the Vivekananda Tribal Hospital (VTH) —established in 1980 by the Karuna Trust—functions as the primary health outpost for the Soliga tribe. According to hospital records published in July this year—the burden of communicable disease is low, and there have been no maternal or infant deaths among the Soliga tribe in 2016. In the last year doctors treated over 16,500 patients—yet intriguingly—the hospital beds at the VTH are frequently empty and only 191 people were admitted for overnight care.

 

An empty hospital ward may seem inconsistent with an urban understanding of effective healthcare delivery, however Dr. Hanumappa Sudarshan—leading physician, tribal activist and founder of the Karuna Trust— claimed that “hospitals may not be the best place to treat all forms chronic illness and disease.” Instead he suggested “one of the most effective ways to improve the health of rural communities is by training Ashas (community health workers) to deliver individual care and treatment inside the home.”

 

Illnesses that require ongoing treatment pose a collective challenge for rural healthcare providers around the world. To take the strain off government hospitals, the Karuna Trust has decentralized the location of their services by training Ashas dispense medication, clean wounds, and assist patients complete their prescribed treatments at home.

 

Dr. Chandra Shekar—an emergency physician at the VTH—said “Home care is the most important tool we have to ensure people complete treatment. Ashas are very important because majority of the care we deliver is in the home.”

 

Ashas play an important role in the treatment of complicated illness by arranging emergency transportation, accompanying patients to hospital, and supporting families that become more economically and socially vulnerable during recovery.

 

“Ashas are the pillars of our healthcare program. There is no need separate people from their families. The Soliga can get lost in the bigger hospitals and prefer to receive treatment at home.” Dr. Sudarshan added.

 

The most vulnerable members of the Soliga tribe live deep inside the interior jungle along poorly maintained trails and roads that can only be accessed by off-road ambulances. To ensure the entire community receives care the Karuna Trust has spread five village health sub-centers and 25 Ashas within a 25km radius of the VTH. Village health sub-centers—managed 24 hours a day by an auxiliary nurse and midwife—act as the nodal point for maternity care, transportation, immunizations, health education and the distribution of supplemental nutrition.

 

The Asha program has provided skills and employment for Soliga women living in deep poverty.  Women are voted into the job by their village based on their family’s financial vulnerability.

 

Sunita has been a Soliga Asha for eight years working as a malaria specialist and birthing assistant. “I have two children and I was unemployed before I had this job, now I look after 165 families also coming from very poor conditions. I really enjoy my job. We hold mother’s meetings every week to educate women about the health of their family. I think health education is very important, but I couldn’t do this job unless the community trusted me. It makes me very happy that the community agrees with our work.”

 

De-centralizing rural healthcare can create a more flexible medical system that can adapt to a person’s cultural needs. The Karuna trust has successfully integrated the Soliga’s traditional medicine and healthcare practices across all of their tribal hospitals.

 

 “Their herbal medicine is very good and we have found that it can address about 10-15% of their primary healthcare needs. For coughs they have a simple remedy that involves making a tea out of two different leaves, the other option is a colorful, expensive cough syrup full of sugar, alcohol and anti-histamines. We like to preserve the practices that are working well in the community and also let them know when they should refer to us.” Dr. Sudarshan said.

 

“Culturally, the Soliga give birth in a squatting position, so we have two labor rooms. One where we can assist the traditional delivery methods and another room with an obstetrics table where we can deliver lying down if there are any complications.” He added.

 

The Indian Government’s development policy for tribal India has come under regular scrutiny by the national media for being underfunded and neglectful of the social determinants of disease. However, the alliance between the Karuna Trust and a Karnataka State Government—who fund 75% of the primary healthcare budget in the BR Hills—highlights how the National Rural Health Mission’s (NRHM) strategy to de-centralize healthcare can be effective when delivered in a culturally specific way.

 

Health education and employment opportunity has empowered the Soliga to take ownership of the health and wellbeing of their community. The Karuna Trust invite each village to monitor and evaluate their services, and local health and sanitation committees have been established to maintain clean drinking water and hygiene standards. 

 

However, it has been a long and arduous journey to arrive at this current picture of health. After Indian partition in 1947 the Soliga were stripped of their land rights and traditional sources of income by the newly formed Indian Forest Service. Consequently, hyper-endemic leprosy, tuberculosis, HIV and malnutrition and crippled the Soliga population for nearly 40 years.

 

“The Soliga were reasonably healthy until they were stripped of their rights. We were struggling against the Forest Department for 30 years, however two years ago we won back the land rights for the Soliga. This had a tremendous impact on the social conditions of the Soliga. Now they have rights over their land and are given access to make an income.” Dr. Sudarshan said.

 

About 75% of India’s health infrastructure is concentrated in urban areas, while 73% of India’s population still live in rural villages. This disparity of resources illustrates the need to innovate and expand healthcare services in rural India.

 

Dr. Sudarshan believes the Asha program can easily be introduced to other regions in India, because “an individualized approach allows our program to adapt to local cultures.”

 

“We have taken up the challenge to work in difficult environments including militant areas of Aurenchal Pradesh and areas under Maoist control. We recommend that the government provide social workers for all tribal patients.” He added.

 

Public healthcare was non-existent in the BR Hills before 1980—now most illnesses can be treated within a 25km radius of every village and empty hospital beds have become a salient symbol for effective healthcare.

 

Within the broader context of development—majority of rural India is still waiting for basic healthcare, however the rapid improvement of the Soliga’s health provides compelling evidence that a de-centralized healthcare system is a very effective way to support the overall wellbeing of vulnerable rural communities.