By Rittika Bramhachari, Researcher, IIHMR
When I first visited the Sundarbans in the year 2012, I was amazed by the beauty of the islands and mangrove forest hiding the endangered royal Bengal tigers. As we know ‘Every coin has two sides’ - this was the more advertised side of Sundarbans which most people are aware of. My subsequent visit to the region, however, gave me an in-depth understanding of the crisis the islanders are facing in terms of their healthcare, and this was the other side of the coin, hidden to all.
The children of Sundarbans are the most vulnerable to health shocks due to unacceptable levels of undernutrition and high prevalence of common communicable diseases. Underlying this is a complex landscape of interlinked factors that determine child health and the health system in the Sundarbans. Geographical inaccessibility remains a major problem for a large section of the population, and people often do not have many ‘desirable’ choices regarding health care. Publicly funded health care facilities are either non-existent or non-functional. Consequently, the gaps are filled by a huge army of unqualified health providers known as Rural Medical Practitioners (RMPs) – informal, unqualified or less than qualified medical practitioners, or simply quacks. About 85 percent of ailing children were treated by the RMPs, which potentially has huge implications for children’s health, due to the varying quality of services from RMPs and the virtually unregulated market. Future Health Systems (FHS), IIHMR research on child health in the Sundarbans found a ‘shortage of frontline health workers like Auxiliary Nurse Midwife (ANM), Accredited Social Health Activist (ASHA), and Anganwadi Worker (AWW), about one quarter to one third of the required manpower was not available’ and RMPs are filling this void within the health system – this cannot be ignored.
The core tenet of Universal Health Coverage (UHC) shows developing health systems is an important pillar in achieving the vision. This includes not only health financing but also the medicines, health workers and the health facilities. When we talk about health workers it doesn’t only mean formal health providers. We need to integrate the informal providers to ensure the sustainability of health care services in the hard to reach populations. The major bottlenecks found in implementing health interventions are paucity of passably trained and motivated health workers, which increases to unacceptable levels in geographically inaccessible regions like Indian Sundarbans, which constitutes approximately 4.5 million people scattered in remote islands interspersed by rivers. I feel achieving UHC needs urgent attention on integration of these informal providers into the health system because we cannot even think of the situation without the RMPs in such remote islands. In urban areas people can get health services from private qualified providers, but for these poor islanders there is no option in an emergency. A RMPs says ‘I delivered 28 babies in last 3 years on boat while crossing the river or when the boat gets non-functional, out of fuel otherwise they would have died on the way due to heavy bleeding’. Over the years they built blind faith from the community by giving unconditional support and health care services during the emergency cases where public services are absent.
In a recent study, I explored the linkages between RMP’s and other health system actors in Sundarbans (because they are not working in isolation) by using Social Network Analysis approach as a methodological underpinning. With this, I constructed a RMPs social network, capturing different actors within the health care market to explore the genesis, the present situation, and its impact on overall healthcare delivery system in the Sundarbans. The study highlights the complex relationship existing between various actors within the health system. I found RMPs are very resilient actors within the health system. Their network acts as a backbone, making them resilient enough to face the shocks such as, firstly and most importantly, acceptance by the formal health system, and secondly, frequent climatic shocks which increases emerging diseases and problems which require more expertise and infrastructural support to address.
Through this present study, I am trying to explore the linkage within RMPs and other stakeholders – both government and private – to understand the context of embedded market dynamics and inform the decision makers during pilot and upscaling of their RMP mainstreaming initiative to achieve UHC.
What are the factors that make RMPs resilient?
- Their ability to understand the social background of the disease or problem because they are very familiar and linked with the communities, local leaders, Panchayati Raj institutions (PRIs), and local Community based organization.
- They don’t need well-constructed infrastructure, as they can well accommodate themselves within the small portion of house or a single room within the shops.
- They are very flexible in delivering the services - they provide door-to-door services by only receiving a phone call from the patient’s family.
- They have a very strong referral process of taking patients to the specialized doctors in nearby towns/cities, sub-divisional hospitals, medical college, and big corporate hospitals in cities.
- They keep updating themselves on modern medicines. Here pharmaceutical companies play a big role in providing updates on latest drugs.
- They provide flexible options for payment of fees, because of strong linkages with the community.
- They maintain a proper decorum like formal health providers, which is an indistinguishable quality making them more acceptable by the communities.
- Socio-political pressure, as they have ability to raise voice. There is an association of RMPs called Progressive Medical Practitioners Association or Rural Doctors association which is approximately 25 years old, and they take stands on the issues faced by RMPs.
Recently, the West Bengal government has taken a landmark decision to incorporate RMPs and train them as Rural Health care workers for universalising its rural and hard-to-reach area health coverage. On one side, this decision is against the belief of Indian Medical Association (IMA), but on another side, their integration into the health system is well recognized by the government to achieve UHC. The pilot plan of government is to train them through the state Nursing Training schools and then to institutionalize them by integrating into the formal health system as ‘Health Workers’. Training of trainers (TOTs) would also be arranged. Also a State Monitoring cell would be set up along with district monitoring cell. They will be also getting salaries. FHS research evidence and its knowledge intervention may be finally yielding dividends. Still it is just the beginning. We want to collaborate and communicate with organisations and forums working on RMPs to monitor and add value to the process for a seamless scaling up through using a Complex Adaptive System (CAS) lens. The additional Chief Secretary has recently requested FHS to carry out research of the pilot study so that the government would be able to fine-tune their intervention while scaling-up. The evidence has the potential to affect the care-seeking of over 62 million people living in the rural areas of this Eastern state of India.