A recent visit to the offices of the local government health offices and the tertiary level hospitals confirmed what I had suspected for ages, after working in the field of public health for over two decades. There are two key reasons why our public health system is in shambles on the ground, despite India being one of the first countries to sign the Alma Ata Declaration. Briefly, the first is the completely top down approach of the government hierarchy and mindset of medical education. The second is the colossal divide between the preventive and curative wings of our health system. This article explores the first fact, the second I leave for another day.
Permit me to outline how the first operates in translating great planning on paper to a non-functioning apparatus in the field. The experience of these visits will be used to illustrate why, even if we straighten out the “systems”; integrated, holistic, affordable care will never be available to our one billion people, while our “experts” in the field hold conferences on achieving Universal coverage in New Delhi and Geneva.
In every document that outlines how the public health systems in the rural and urban areas should function, the interface with the population of responsibility is seen as being important. Obviously, people should know who they should rely on for health care, but experience has shown that it is equally important that the health care services should be responsible to the population they serve. The balance of this translates as a spectrum of community participation- from the lowest level where people are passive recipients of care to the highest level where communities plan, monitor and evaluate the services.
We strive to the latter goal. Let me clarify who ‘we’ are. As a team of researchers, trying to bring both private and public providers onto a platform with local community leaders, we have been working for two years with the local doctors and community members in a single geographic ward of the city. Time and again we have been struck by the warm hearted welcome in the homes, particularly the poorest. The home of a patient in the community may consist of a single room, 6 feet by 10 feet, in which a family of 2 to 8 members might live. Even so, in this room, where walking is restricted by the tiny space, there is no awkwardness in rolling out a mat or putting out the single foldable chair to make one feel at home. And with this single human act of trying to make the visitor feel at home, a relationship is established which dictates the future partnership.
Contrast this with the reception our team met with in the various offices we visited last month. In an effort to meet the officers in charge of the health services in the city, we hired a taxi and went from office to office, hopeful that someone in the system might be interested in what we were attempting. And everywhere the response was the same. More often than not, a waiting of 15 -45 minutes outside the room, a cursory invitation to enter, not necessarily to sit…a brief look up from the files to hear what we had to say. And before we had launched two minutes into our story , an interruption with “ So tell me Madam, what is it you want me to do?” as we shuffled on our tired feet.
The interesting fact is, in both cases (the patient with us and then us with the officer) the only need was to be listened to. But in the first, the community member has taken the proactive step of setting the stage for listening to happen. (I remember a senior physician who taught us in Medical College saying that sometimes the most important input for an inpatient on rounds is the doctor sitting by the bedside in order to listen to him or her.) And in the latter, a power equation that invisibly translates from officialdom – top-down. The assumption on the part of these authorities is that they already know what needs to be done, so your presence in their office could only be for audience, permission or financial aid. And undoubtedly, the stroke of a pen on a file changes the response down the line. A three minute brief at the Commissioner’s office got us the desired result.
So we were honoured by the visit of the officer-in-charge to the ward, at the behest of the senior authority a day later. The visit and her interface with the community workers can be best described in their own words. “Madam, when they learn to be big doctors and officers like this, are they not taught manners?”
So I conclude that while community participation and corridors of power are identical, mutually exclusive acronyms, like all health system reforms, work must happen at both ends.