Two messages come through from the Indian experience: First, strong primary health care is essential to achieve the maximum impact. Second, public financing is vital for infrastructure development, health workforce skilling, and stimulating demand for services.
The Union health ministry recently reported a significant fall in maternal mortality ratio (MMR), from 167 in 2011-13 to 130 in 2014-16. MMR is the number of deaths in pregnant women per 100,000 live births. India has now achieved the target set under the Millennium Development Goals (MDGs) for 2015 and seems poised to reach the target of 70 by 2030, set under the Sustainable Development Goals (SDGs). When we look at the past MMRs of 677 (1980) and 556 (1990), the progress achieved has been commendable.
There is no doubt that, despite the recent acceleration in decline, we still have a long way to go, in terms of catching up with a South Asian neighbour like Sri Lanka (MMR of 30). China has a low MMR of 19.6, though the sudden rise in births after the recent change from a single child norm to a two child norm is challenging the health system. The lowest global MMR of 3, reported by Sweden, Finland and Iceland is still very far off for low- and middle-income countries.
One of the sharpest recorded rates of decline in MMR has been in Rwanda which started with a huge handicap of poverty and a dysfunctional health system after the terrible genocide of 1994. Yet, by 2013, MMR dropped to 320 from 1,300 in 1990. Rwanda was one of the nine countries that achieved the 75% reduction target set by the MDGs. This was accomplished by the government prioritising reproductive, maternal, new-born and child health. Rwanda invested its limited resources and donor assistance in rebuilding basic systems and services through health workforce and infrastructure development, strong community involvement, a comprehensive community- based health insurance scheme and systems-strengthening through innovative data collection tools. Much of this success was achieved through community health workers and nurse-managed primary health centres.
In India, too, the launch of the National Rural Health Mission (NRHM) in 2005 provided the impetus to investment in, and more effective delivery of, maternal and child health services. The emergence of Accredited Social Health Activists (ASHAs) as community health activists sharply increased the number of institutional deliveries to 79%. In public facilities alone, the increase has been dramatic—from 18% in 2005 to 52% in 2016. Strengthening of primary care infrastructure and monetary support, through schemes such as Janani Suraksha Yojana (JSY) and Janani Shishu Suraksha Karyakram (JSSK), helped overcome access barriers and spur demand for health services. The Pradhan Mantri Surakshit Matritva Abhiyan has improved access to specialist care and tracking of high-risk pregnancies.
Two messages come through clearly from both the Indian and global experience. First, strong primary health care is essential for providing maternal health services that achieve the maximum impact on MMR as well neonatal, infant and child mortality rates. Second, public financing is vital for infrastructure development, health work force skilling and need-based deployment, assurance of essential drugs and supplies and stimulating demand for services. Public financing must prioritise primary health services, ranging from community- and facility-based antenatal services to institutional capacity for normal deliveries and emergency obstetric care. These health system investments must be layered on social determinants like women’s nutrition, education and empowerment (including their ability to exercise free choices on marriage, contraception and pregnancy).
Even as the fall in the aggregate national MMR is a cause for satisfaction, the huge gaps in MMR within India warrant attention. The NRHM accorded special priority to 18 states, collectively labelled as the Empowered Action Group, providing enhanced support for improving their performance in maternal and child health. It is striking that 8 states account for 70% of all maternal deaths in India. While Kerala (46), Maharashtra (61) and Tamil Nadu have already gone beyond the SDG target, Assam (231), UP (201) and Rajasthan (199) have a huge gap to bridge. This can only be done by boosting the availability and quality of primary health services under the National Health Mission. Even within states, greater support has to be provided to districts with dismal health indicators and attention must be given to the needs of vulnerable rural, tribal and low-income urban communities.
The lessons from NRHM and the messages from MMR must also serve to shape our response to the expanded agenda of the health system which now has to effectively address the major new public health challenges of non-communicable diseases and mental health disorders. The most effective and equitable way of controlling the health and financial burdens of these chronic diseases is to strengthen primary health services that encompass health promotion, preventive risk reduction measures, early detection and cost-effective care to prevent complications, along with structured protocols for referral to advanced care facilities and follow up care on return.
There is good evidence from many countries, including field research in India, that hypertension and diabetes can be well managed by technology-enabled nurses and community health workers. Landmark trials in India have shown the effectiveness of community-based management of mental health disorders. Doctors in primary care too must play their part in improving preventive, diagnostic, curative, palliative and rehabilitative services. Most importantly, continuity of care for chronic diseases is best provided by primary health services which are located close to home.
This calls for increased public financing of primary health care. India’s commitment to universal health coverage, ensconced as a key SDG target, can only be achieved if public funding of health is used to both provide quality assured primary care for the largest number of people and reduce out of pocket spending which is highest in outpatient care. Further, in this 40th anniversary of the Alma Ata declaration on comprehensive primary health care, it would be wise to apply the lessons of our experience with MMR for expanding the agenda of the National Health Mission as promised in the National Health Policy of 2017. Amidst all the media attention on the National Health Protection Scheme that provides financial protection for hospitalisation, we should not lose sight of comprehensive primary health care which is the other component of Ayushman Bharat, Indeed, it is that component that will deliver us Swasth Bharat.
The author is President, Public Health Foundation of India. (Views are personal)