What ails Bengaluru’s healthcare? There’s plenty. According to data collected by Anahat Foundation and Aam Aadmi party volunteers at medical screening camps in poor slums, the city presents a dismal scenario of malnutrition and chronic and lifestyle illnesses, inadequate spread and staffing of Primary Health Centres (PHC) and ineffective implementation of the Central government’s National Urban Health Mission.
AAP camps were held with qualified doctors and technicians in the slums of Central Bengaluru and their findings shed light on common ailments, the availability of public health services, and access to facilities. Anahat Foundation also works with other partners in camps around the city.
Since 2014, NUHM has aimed to improve accessibility to primary health care for “vulnerable” and slum populations (listed and unlisted slums, low income families and the homeless) identified through a benchmark survey. Unfortunately, NUHM plans focus on 597 Slum Board notified slums, ignoring slum-like conditions in places like labour colonies of migrant construction workers on vacant sites or land provided by contractors. Independent studies show that there may be more than 2,000 slums in Bengaluru, making the NUHM coverage a gross underestimation.
Lifestyle and ailments
The camp data found that most slum residents live in cramped temporary/semi-permanent houses, with public taps and community toilets. The large slum rehabilitation colony of L R Nagar, has household water and toilet connections. However, all the residents who came for our camps told us that water was not supplied through the taps, but through community taps, and women have to climb 4 flights of stairs with water pots.
Incidence of other ailments is also well above norms, and should be cause for serious concern. We estimate from our data that around 4% of the population in the CBD requires further testing for TB.
Chronic “lifestyle” disease prevalence figures are also very worrying. We found that among adults in the CBD, 22% showed high random blood sugar, and blood pressure readings of 21% of adults were high. More alarming is that most of these patients are unaware of the illnesses. In addition, cancer, heart disease and neglected eye ailments among older persons require immediate and sustained attention.
Screening camp data has been shared with doctors in government and BBMP primary health centres and reported to policy makers - the Director, NUHM; the Health Commissioner; and Principal Secretary, Health. Solutions are also self-evident.
The disease profile emerging from camp data is alarming. Body mass indices indicate undernourishment among 60% of the children screened, although there are anganwadis for pre-school children under the Integrated Child Development Scheme of the Women and Child Development Department, and a daily midday meal in government schools.
Undernourishment seems more prevalent among children going to private schools, who slip through the cracks of existing programs. When poor parents scrape together money to send children to private “English medium” schools (which rarely offer good quality education), they condemn them to poor nutrition levels too. Even more alarming 11% of the children in slums in the central business district (CBD) do not go to school!
To tackle the problem of widespread undernourishment among children, we need radical reform in primary education to upgrade the infrastructure and teaching quality of government schools, and increase enrolment to draw more children into the mid-day meal program.
To take health care to the community level, NUHM uses community health workers-ASHAs (Accredited Social Health Activists), who are married women of reproductive age. These part time workers are paid Rs 3500 per month, with additional incentives, when they assist antenatal care patients or patients suffering from chronic diseases.
This is a perfect recipe for failure.
Rs 3500 is a pittance for any city job today. Using women to do such part-time work is gender biased and exploitative. No wonder half the posts of ASHAs in Bengaluru are still vacant and wages are in arrears (supplementary payments from different budget heads are delayed). Narrow focus on eligible families and bad payment mechanisms for ASHAs reduce the coverage of NUHM to probably less than a quarter of its mandate!
A comprehensive survey of vulnerable areas is essential to compute the actual requirement of ASHAs in Bengaluru. The camp experience confirms that ASHAs are essential for basic screening of key parameters, to monitor progress in medical treatment and assist and accompany the weakest patients to PHCs and hospitals.
ASHAs must thus be full-time government employees, with better kits and appropriate training. Salaries must be drawn from one source, not appropriated from various budgetary silos. The Central Health Ministry must incorporate such changes into the core program.
This community health setup must be complemented by an effective network of PHCs, unlike the disappointing setup we presently have. For decades, we have not gone beyond the mantra that one urban PHC will serve 50,000 persons. No one knows if the norm is fulfilled, since urban population figures are only “guesstimates” prepared from recent census data.
We do know, however, that BBMP has opened no PHC in the 110 villages added to the city a decade back. The 83 UPHCs in the city centre are not dispersed evenly; many wards have not even one. The Shantinagar PHC, for example, caters to both Neelasandra and Shantinagar wards, but Neelasandra residents do not use it due to distance, and because the Koramangala UPHC is 300 metres from their colony.
Most PHCs are located in cramped conditions, with poor facilities for staff and patients. Systems also need thorough overhaul. Yet, the sector is badly neglected and this is reflected in meagre budgetary allocations and even poorer expenditure.
The current BBMP budget does not provide for new PHCs anywhere. Less than Rs 2 crore was apparently provided last year for construction or improvement of PHCs and no expenditure has been booked. Rs 5 crore in the BBMP budget for NUHM was not utilized. Since both BBMP and State PHCs handle NUHM in core and peripheral areas of Bengaluru, program expenditure is likely to be consolidated by the Society which administers NUHM, but its annual report is not readily available online. However, it is clear that there are substantial savings, which could be used for making it more effective if coverage is extended and the Central government makes the badly needed changes.
The PHC model is totally inadequate to cater to the needs of an expanding city. The Delhi system of a mohalla clinic for 6,000 persons gives far better access to public health facilities for all sections of the population and will dramatically improve health parameters.
There is little justification for continuing to run two distinct sets of PHCs a decade after large peripheral rural areas were added to the metropolis. PHCs in the new wards which are still with the government must be integrated into the BBMP health setup.
Many voluntary organisations and private players are already organising screening camps in poorer areas with the knowledge of civic authorities. If data obtained in these activities is shared (with appropriate confidentiality) with PHC staff, integrated services could be provided for follow-up and treatment by government agencies themselves. Screening techniques could also be developed for specific diseases for use by ASHAs or in camps run by specialists.
No remedial measure however will make a dent in the prevalent disturbing urban health scenario unless substantial funds are allocated to the health and education budgets and community caregivers given full support through better pay, tools and training.
Renuka Viswanathan is former Secretary to the Govt of India in Cabinet Secretariat, now with Aam Aadmi Party
Rani Desai is co-founder of Anahat Foundation & recipient of Healthcare Excellence Award at 3rd Elets Healthcare innovation summit 2019, also with Aam Aadmi Party
Abhiraj Gupta is a National Innovation Award (GYTI) recipient (given by the President of India); Founder|Developer WoundHeal Analytics (a non-profit research inititaive), also with Aam Aadmi Party.