The news that India has slipped on the Global Hunger Index ranking from 97 to 102, despite the efforts put in by the government and the NGOs to tackle the problem of malnutrition has come as a shock. A host of welfare schemes run by the government including the provision of: subsidized food grains to the poor through the Public Distribution System (PDS); a minimum level of employment in rural areas under MGNREGA; integrated child care services under ICDS, etc. are meant to tackle the closely related issues of poverty and malnutrition confronting the country.

Besides strengthening the efficacy of these targeted schemes, a critical area that needs focused attention is basic health-care. Frequent infections inhibit growth and are an important factor behind ‘stunting’ (children with low height for age – reflecting chronic under nutrition) and ‘wasting’ (children with low weight for height) among children. To improve the efficacy of the basic health-care system, both the supply and demand sides of the problem would need to be looked at and the gaps filled-in on an urgent basis. Putting in place an effective basic health-care system continues to be a major concern for India despite this very critical objective being consistently addressed at the policy level by various governments.

Since independence, India has achieved some progress in improving public health standards as reflected in the success of initiatives such as Polio eradication and a marked reduction in Infant Mortality Rate (IMR) to 34 per 1000 live births in 2016 (as per NITI Aayog data) from 165 in 1960. With regard to the Child Mortality Rate (39 per 1000 live births), India has moved up the ladder now at par with the global average. However, there is no denying that the progress achieved in public health-care could have been significantly higher, which in turn, would have given a further push to productivity levels in the country, and thereby not only contribute to poverty alleviation but also positively impact national GDP.  For instance, the problem of extensive malnutrition resulting in ‘stunting’ (in 2016, around 38% of children in India were estimated to be stunted) and ‘wasting’ (estimated to be around 21%) needs to be addressed in a focused and sustained manner as part of public health-care.

Studies indicate that the financial return to investing in basic health-care can be very high as underscored by Abhijit Banerjee & Esther Duflo in their book POOR Economics – rethinking poverty & the ways to end it and subsequent case studies on the subject undertaken across the world by J-PAL. It is also known that a number of “low-hanging fruit” that could save many lives and substantially improve public health parameters at a minimal cost are available and have the potential to bring about a transformative change in people’s lives. These include comprehensive immunization including the indigenous Rota virus vaccine introduced under the UIP; exclusive breast-feeding until six months and its continuation for a year; use of chlorine to purify water for drinking purposes; prompt of Oral Rehydration Solution (ORS) in cases of Diarrohea; iron-fortified flour; and use of iodine-fortified common salt in iodine-deficient areas. However, a widespread adoption of these low-cost measures is still to be realized and the causes of failure appear to be multifarious.

As a result of low motivation levels, the absenteeism of government health workers, who are in charge of delivering basic health-care services, is known to be high. As per a World Bank Survey, in 2002-03, the average absentee rate of health workers in India was 43 percent. Other independent studies also point to similar high absenteeism rates. The unreliability associated with the government health-care services has pushed the poor towards private doctors/facilities even though many-a-times the treatment provided may be wanting. However, factors other than the performance of the public health system are also at work as underlined by a number of studies. In many instances, people do not seem to be particularly interested in receiving the services offered by the government through the public health centres or the NGOs working in the area of public health-care and exhibit indifference toward preventive measures. In some cases, they might also hold misleading beliefs about preventive health-care or simply procrastinate as is evident from low rates of full immunization resulting from non-completion of the immunization process. So, here, we need to intervene on the demand side of the problem.

To spread the use of low-cost preventive measures among the poor, not only do we need to address the high rate of absenteeism in the Primary and District Health Centres through administrative measures (closer monitoring, disciplinary action where required) and by raising their motivation levels (highlighting the importance of their work for the public good), but the people also need to be repeatedly sensitized and motivated to avail the various preventive measures for their own good.

For this purpose, enlisting of local health-volunteers, who could act as a bridge between the people and basic health-care facilities provided by the government and programmes/campaigns launched by NGOs or the government, could be an idea worth exploring. Since 2005, including in its 2018 report, the Annual Status of Education Report (ASER) Centre, a citizen-led initiative has demonstrated the positive role volunteers can play in assessing the learning level of school going children and also make the stakeholders realize the importance of education in improving the lives of children.

These young health-volunteers, who have completed Class 12, could be recruited by NGOs working in the field, on a periodic basis, from the local villages on payment of a stipend and provided a two/three-day training at the district level. Their work would involve educating the villagers in a sustained manner about the significant benefits of using preventive health-care measures.

Besides using health-volunteers to check the natural tendency of people to postpone things and to encourage them to make full use of available preventive health measures, small incentives could also be useful in promoting participation in immunization programmes and in use of other life-saving preventive measures. These incentives would need to be given at each step, instead of in the near future at the completion of a vaccination process. For example, after each immunization shot, and would need to be tailored to local conditions and needs/aspirations to make them attractive. The incentives could include provision of 2 kg of a sought-after staple food or free talk time for a month on mobile phones, in a tie-up with service providers that now have a very wide and ever growing spread across the country.  

The volunteers could detail the small costs (whether for the purchase of a bottle of Chlorine or in terms of time and energy required to go to an immunization camp or the low fever/discomfort that vaccinations sometimes cause) that discourage the use of a life-saving step and the long-term, life-saving benefits of vaccines and chlorinating their drinking water. They could also periodically monitor the health-status of the people in this regard using simple-to-fill forms devised for the purpose. This assessment would lead to identifying shortcomings and search for ways to further improve the system’s efficacy. They could also repeatedly tell the parents and children about the importance of maintaining a vaccination/health card for each child.

A bipartisan consensus exists in the country at the leadership level for providing basic health-care to all in a more effective manner. In this backdrop, measures like the provision of low-cost incentives and deployment of health-volunteers in a sustained manner could significantly enhance the harnessing of the true potential of preventive measures and other low-cost, wide-impact health tools.