India’s Public Health Spending Is Less Than 1.2 Percent Of GDP: Ashok Alexander, Founder Director, Antara Foundation

Health-care is one of the most critical elements of sustainable development, and India still has miles to go in terms of providing adequate healthcare for maternal and child health. In an exclusive interview with BW Businessworld, Ashok Alexander, Founder Director of the Antara Foundation discusses the healthcare delivery system in Rajasthan and what the foundation aims to achieve through its efforts towards improving maternal & child health outcomes.

Can you talk about some key learnings from the communities that you’ve worked with?

I’ve had the good fortune to work closely with some wonderful communities including sex workers, drug users, truckers, transgenders, and frontline government health workers. The big mistake I made in the beginning was to come in with my outside solution, presuming I already know the problem. The biggest learning for me is that communities often best understand their problems, and therefore often know the right solutions. The key is to be able to say to the community – “I don’t know the answer to the problem –how do you think we should go forward?” In a way, this was unlearning my McKinsey training of ‘always know the answer’.

What are the significant changes, in terms of healthcare delivery system and maternal health outcomes, you foresee in the near future?

There are three changes I expect to see in the health delivery system: better data use by frontline workers, especially with the use of technology; bringing health facilities from the sub-centre up to have at least the bare minimum facilities; and much more community involvement. There are good trendlines in each of these. If they happen, better maternal health outcomes – fewer maternal, neonatal and infant deaths, and improved nutrition will follow.

What gaps in the Rajasthan healthcare delivery system is Antara looking to address?

The same as the ones we see in most states – data use by frontline workers, facility strengthening and community mobilization. In terms of frontline data use we are doing this in three ways that are linked – greatly simplifying the voluminous register; Village Mapping, enabling focus by health workers on the most critical cases, and the AAA App that digitizes this process. We contribute to facility strengthening through our Nurse Mentoring program. We work with communities through a program we are experimenting with that involving Adolescent Girls as change agents. In all these, the work is through the government public health system, because that is the only way to achieve scale and sustainability.

How do you define delivery in scale?

Scale is defined by coverage of a defined population group, that may be concentrated or scattered. The two key factors to consider in achieving coverage are quality level, and speed of delivery. It is also important to ‘understand the denominator’ – how large is the population group, and how much of it do you need to cover for impact? Each factor has its exact analogues in business.

How has the Foundation moved the needle in improving maternal & child health outcomes via the Akshada program?

Two of our innovations – the AAA Platform and the AAA App bring the ‘Triple A’ of ASHA, Auxiliary Nurse Midwife (ANM) and Anganwadi Worker together on a single data sharing platform. The AAA platform is based on digitized, hand-drawn village maps; the app infuses technology. These are already moving the needle in terms of health outcomes. We are thrilled that the state government is scaling these up under the name ‘RajSangam’. Each of these was based on our learnings from making the ANM’s service delivery register simpler to use. This register that we proposed is now used across the state as well.

How do you see the Foundation advancing the public health priorities of the government of Rajasthan?

Maternal and Child health, including malnutrition, is a key government priority. We are working squarely in this area, and aspire to create innovations in health delivery that will serve government well.

How does Antara foundation measure impact of its measures?

There are two ways. The first is by evaluating the extent to which we have contributed to a substantial and lasting strengthening of the public health system. The second is to evaluate the extent to which health outcomes ( eg, exclusive breastfeeding; anemia levels in pregnant women) have improved. In both these, we will not be able to exactly attribute the impact our program Akshada has had if only because the government is already doing things on its own. The goal is to assess the contribution we have made. 

What opportunities does the Foundation see in advancing maternal & child health and nutrition outcomes – in Rajasthan and in India?

The biggest area of opportunity is to focus on managing the crucial 48 hours after birth. This is when the biggest amount of neonatal mortality (first four weeks after birth) happens. More broadly, it is in the scaling up of measures to stimulate frontline data use, and involve communities in the solution.

What is your take on the heavy investment in the health sector yet complete negligence towards the front line workers, as per budget 2018?

I don’t agree at all about the ‘heavy investment’ in the health sector. India’s public health spending is essentially flat at less than 1.2% of GDP. India’s total health spending is 3.9% which means that around 70% of health spending is private spending. Poor people are spending where the government should be spending. By way of comparison, Sri Lanka’s public health expenditure is around 1.9% of GDP while China’s public health spending is over 3% of GDP.