There exists a huge chasm in healthcare facilities for women in urban and rural India and organisations like Bill and Melinda Gates Foundation are actively trying to reach out to women in the interiors through frontline health workers to bring about a change. Girindre Beehary, India Country Director, Bill and Melinda Gates Foundation reveals more in an interview with Shalini Gupta
What are the areas of focus for Bill and Melinda Gates foundation in India particularly in women’s health?
We partner with the Government of India and the governments in Bihar and Uttar Pradesh to reduce maternal and child mortality. We help to improve the delivery of primary health services through the public health system, private providers and working with communities. Much of this work focuses on the frontline health workers – ASHAs, Anganwadi workers, ANMs – to improve the quantity and quality of their interactions with pregnant mothers. This includes equipping them with the tools, skills and information they need to provide high quality, consistent information. We also work with the government to improve the quality of care in facilities, including nurse mentorship. In recent months we have given added impetus to supporting the government on improved use of data and monitoring, which we believe are critical in achieving our goals.
What have been the major projects undertaken over the last few years in these areas? What progress has been achieved?
Our model aims to achieve impact at scale. We don’t just work in one or two villages, or even blocks, but – for example, in Bihar – right across all 38 districts. As a result of the enormity of the challenge and the complexity of the solution, it is difficult to show major progress, fast. That being said, we have just conducted a thorough evaluation of our work in partnership with the Government of Bihar, and the findings are very encouraging. We see that, indeed, by investing in frontline health workers, it is possible to increase the quantity of interactions between them and the women in the community – and, at the same time, increase the quality of those conversations. That’s very exciting, because it means that if we keep investing in these workers, we should slowly see health outcomes improve for both mothers and children. The frontline workers are heroes!
The sort of investments that we are making that we are now seeing bear fruit are various. There is a suite of mobile tools created by BBC Media Action, which – in the hands of the frontline worker – offer skills training and job aids. We are seeing a new approach to incentives, focused on teams rather than individuals, working well: our partners at CARE are driving that project.
What areas of women’s health has India progressed in, where does it lag behind?
While India has made good progress in achieving a number of its Millennium Development Goal targets, it will only come close to achieving MDG 4 and miss MDG 5, which focuses on maternal mortality. In fact, India still accounts for 16 per cent of all maternal deaths. And yet the aggregate numbers, do not tell the full story. Uttar Pradesh, whose population exceeds that of Brazil, has a maternal mortality rate 50 per cent higher than the national average and eight times that of Sri Lanka, whose GDP is only twice as high as India’s. On the other hand, some Indian states, such as Kerala and Tamil Nadu, have been much more successful in reducing maternal mortality.
The fact is that both the causes of maternal deaths – as well as the solutions – are well known. Many deaths can be prevented through the scale up and quality delivery of known interventions. These include simple things like preventing post-partum hemorrhage, treating maternal sepsis with antibiotics, and providing emergency transport and obstetric care. There is also a strong case for the introduction of new lifesaving interventions, including offering women a choice of high quality family planning services, so that they might choose whether and when to have a child. The provision of improved sanitation and hygiene solutions, and better nutrition, is also fundamental to saving lives.
What remains the Achilles heel in tackling maternal mortality?
Well, first of all, India spends too little on health overall. That’s a huge challenge. Right now, India spends only one per cent of GDP, which is far behind other countries: around three per cent in China and four per cent in Brazil, for example. That number needs to go up. Additionally, we need to do better in identifying high risk pregnancies and referring these expectant mothers to the right facilities that can provide the appropriate level of care. This needs to be accompanied by an overall health systems management imperative to improve the quality of primary healthcare provision in the public system: for example, a focus on the quantity and quality of human resources committed to the system.
That is not to say that private providers cannot play a role. In fact, quite the opposite is true and the government needs to look at innovative and efficient ways to work with private providers on quality service provision. Finally, renewed attention on these management challenges must be accompanied by a genuine commitment to performance. That means truly knowing whether or not a particular facility, or health worker, is delivering quality services to their community – with implications for situations where standards are not being upheld.
Sadly, there is no silver bullet, but I remain optimistic. India has demonstrated that with the political will and the requisite resources, it can overcome challenges that seem intractable: the fight against polio is an amazing example.
What are the barriers to access to family planning and contraception? Have you done any studies/ research around this?
Giving women in India access to the tools and information they need to time and space their pregnancies will improve their health, and the health of their newborns and children. In doing so, all efforts must be underpinned by the core principles of choice and quality. In India, around one in five women of reproductive age do not want to get pregnant but are not using a modern method of contraception. Furthermore, we know that around 77 per cent of women who opt for sterilisation have never before used any other method. The reasons for this are various and complex.
However, we do know that voluntary contraceptive methods other than sterilisation are not widely available in the country. Newer contraceptive options that are widely used elsewhere in the world, such as injectables and implants, are especially limited. Even condoms and OC pills can be hard to come by for women in many of India’s poorest communities, for whom primary health care services are often inaccessible and of low quality.
Providing all women access to high quality, voluntary family planning services is essential to ensuring the rights of women and girls to choose freely, and for themselves, whether, when and how many children they want. We are working with the Government of India and the governments in Bihar and Uttar Pradesh to ensure that all women – no matter where they live – can choose to access high quality family planning information, tools and services.
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