Neighbourhoods of care: Place-based healthcare design for community action

Neeraja Kudrimoti, Associate Director, Transform Rural India (TRI) stresses that healthcare is very supply-heavy and disease-oriented. There is a mission or scheme for almost every disease in India. But by the time it reaches the communities, it’s diluted into a fragment of the mission, heavily reliant on the hope that the frontline will absorb and deliver it

Health history, baggage, and complexities in understanding

India grappled with a lot of public health issues, especially a huge burden of communicable diseases in the early ’80s. Consequently, a very ambitious Universal Immunization Program was launched, which helped transform the public health scenario in India with a more preventive and curative approach. A significant investment was made in infrastructure development, after which the understanding of healthcare became ‘hospitalised’. Many outreach services were then provided, such as Village Health Sanitation and Nutrition Day (VHSND), outreach clinics, the availability of medicines, emphasis on accreditation, community health workers, and increased safety nets. There is an abundance of data but a lack of insights. There are proven pathways but a dearth of their adoption. The understanding of healthcare was, and still is, mainly around the ‘supply of services’ of ‘facility-based’ care.

Public health an ‘unsung warrior’—overworked, overburdened, and under-equipped

Health and nutrition care in rural India is quite complex and a serious matter. The government’s prioritisation of and commitment to healthcare is impressive given the trend of growing healthcare expenditure. The hospital market in India, valued at USD almost a 100 billion in 2023, is expected to double¹. We also have the world’s largest government-funded health insurance plan, Pradhan Mantri Jan Arogya Yojana (PM-JAY), which covers nearly 55 crore individuals from vulnerable families². There is a declining trend in out-of-pocket expenditure. In terms of infrastructure, Sub-Health Centers (SHCs) and Primary Health Centers (PHCs) have been established with a principle of “time to care” of not more than 30 minutes.

Struggles in healthcare

According to FAO, 75 per cent of Indians are unable to afford a healthy diet, with rising food costs not matched by rising income.³ 31.7 per cent of children under five years of age suffer from stunted growth.⁴ India recorded the highest rate in the region, with 18.7 per cent of children under five years of age being wasted (low weight for height).⁵ Women, especially, are grappling with malnutrition, including anaemia, obesity, metabolic syndrome, reproductive health issues, breast and cervical cancer, osteoporosis, hormonal disorders, mental health issues, and domestic violence. 58 per cent of women in rural India live within 5 to 9 km of a health facility⁶, which is significant when it comes to maternal health, especially given the lack of timely access to emergency care and childbirth complications contributing to maternal mortality. Although there is a decline in OOPE, the fall in consumption of public healthcare points toward reduced healthcare demand (forgone care), which may reflect underlying localised distress that needs to be identified. Another interesting fact is that the doctor-population ratio in the country stands at 1:834, which is better than the WHO standard of 1:1000. However, the sad part is that 80 per cent of Indian doctors live in urban areas, so more than 2/3 of the country has only 20 per cent of doctors.

Significant progress has been made through several initiatives; however, the community is the critical force that should be at the center of Indian healthcare and its future.

Role of neighbourhood

The paradox of public health is that it is driven by communities but led by everyone except them. What can be done to solve this complex interlock? Is there a way that the demand side knows what to demand, how to demand, and where, and can that potentially complement the supply side? There is a way to build the collective capacity of communities living in a neighbourhood, operating locally, to carry out collaborative vigilance and coordinated action to improve social determinants of health and nutrition. The locality development compacts of the community collectives, panchayats and the frontline workers, can help build a network of support, develop neighbourhood infrastructure and resources, foster leadership development for planning, implementation, and monitoring, and work on attitudes and behaviours. We need to discuss the critical role of the entire design of healthcare in rural India for the future, ensuring that not only the healthcare supply side but also the demand side is empowered with the services and tools needed for quality, outreach, safety, efficiency, and overall well-being.

The design and strategies of healthcare in rural India need to be organised around the communities and have to be localised addressing the place-based needs, within their locality. Currently, healthcare is very facility-based or medication- or treatment-based. Health is not just physical well-being and mental or emotional well-being; it is also about social well-being and tapping into the potential of social capital or social networks. We need to address that and carve a way forward around it.

Healthcare is also very supply-heavy and disease-oriented. There is a mission or scheme for almost every disease in India. But by the time it reaches the communities, it’s diluted into a fragment of the mission, heavily reliant on the hope that the frontline will absorb and deliver it.

In the new age of digitisation, we have to leverage healthcare technology for rural areas, tapping into rural behavioural economics. COVID has expedited the acceptance of digital health. The number of households using e-pharmacies has tripled in India. We need to discuss and leverage this.

Healthcare needs to shift to what communities can do themselves, and what will matter is the cohesion between the permanent residents of rural localities, such as:

1. Communities, especially the women-led Self-Help Group (SHG) network,

2. The Panchayats that have the power to drive the developmental agenda in their locality, and

3. Local administration, which is the front end of health and nutrition services.

Neighbourhoods of care

Neighbourhood of Care is a concept developed by Transform Rural India (TRI) with the belief that the community itself will be able to take on certain roles and responsibilities for providing care in their neighbourhood with the integration of social and ecological determinants of health. It is less prescriptive and yet more aspirational, based on community priorities and aspirations. It is embedded in their everyday activities, which will bring about a change in the public health situation in their neighbourhood. One way is through activating and strengthening the Locality Development Compact for Neighbourhoods of Care.

The SHG ecosystem, through the process of visioning and Village Prosperity and Resilience (VPRP), has raised many health-related demands, especially entitlements, which are a powerful tool in the neighbourhood. Although the supply side may not be able to fully cater to these dreams, there could be some local solutions arrived at based on these aspirations.

Similarly, Panchayats, with the devolution of power, funds at their disposal, and rights to enforce, can play a crucial role in strengthening healthcare in the neighbourhood with powerful processes such as the Gram Panchayat Development Plan (GPDP). They are also part of a powerful social contract such as the head of Village Health Sanitation and Nutrition Committee (VHSNC) and an important part of Jan Arogya Samiti (JAS). Lastly, frontline workers in health and nutrition are key to providing the service on time. It is imperative that the demand side is strengthened, and vigilant, and that they own the healthcare of their neighbourhood.

TRI’s new design of Neighbourhoods of Care goes beyond a preventive and curative approach to an aspirational approach for communities. It’s a place-based, human-centred, gender-transformative, climate-action-oriented approach to shared ownership of care. It is grounded in everyday activities at home, social spaces, and healthcare interfaces. It is supported by a sound knowledge system that integrates clinical, social, and ecological intelligence. The vision is that through a strong social network of private players such as pharma companies, women collectives such as SHGs, techies, healthcare providers, seekers, and others, we can become active voyagers in this journey. It’s a platform for health equity ranging from temporary to continuous care and standardised to localised care.

Kanker: First to pilot NoC

Kanker district in the Bastar region of Chhattisgarh is one of the districts with a high burden of multidimensional poverty, especially due to malnutrition. Maternal and child health issues are still alarmingly high. According to NFHS-5 (2019-21), 65.2 per cent of women aged 15-49 years are anemic, and 36.1 per cent of children under 5 years are underweight (weight-for-age).⁷ Kanker district falls under the sickle cell belt in the state, which means there is a higher prevalence of sickle cell disease among the population, making it further complicated and vulnerable. There is also growing concern over increasing trends of noncommunicable diseases (NCDs) in the district, but population-level screening for common NCDs, including cancers, is very low. Although there is a high prevalence of anaemia and detection of high-risk pregnancies (HRP) in VHSNDs, there is also a lack of availability of basic amenities such as functional toilets, hand wash, and curtains for privacy during clinical examinations. This often results in low footfall and uptake of counselling services, including P&C of NCDs, sickle cell disease, and screening for cervical cancer. An interesting outlier is the village of Kokpur, situated on a highway, which showed a high propensity to access faith healing and traditional remedies, challenging the assumption that greater accessibility to healthcare facilities reduces reliance on traditional practices.

Returning to Kanker, the communities here have aspired for free-of-cost treatment, healthy villages, and access to health facilities and doctors in their neighbourhoods. These aspirations were consolidated and presented to the district authorities in a recent health dialogue held in Kanker. Following this, a technological solution for activating telemedicine was launched in two of the most difficult and aspirational blocks as part of Sampoornata Abhiyaan. This initiative is integrated into the NoC approach, which is close to an in-person consult, allowing real-time interaction and making the perception of visual cues easier, including patient identification and virtual inspection. This compact has been the foundation stone of the Neighbourhoods of Care in Kanker, paving the way for creating a continuum of care at the neighbourhood level and helping rural communities navigate their journeys within.

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