A few weeks ago I had the opportunity to visit the state of Uttar Pradesh (U.P.), and spend some time with a new organization looking to expand its rural healthcare delivery services. Having only previously been to this part of the country as a tourist, I would soon reevaluate just how hard it was to be a resident in the home of one of Hinduism, Jainism and Buddhism’s holiest cities. Temples and shrines were around every corner, but quality and affordable healthcare alternatives were harder to find.
On paper, the public health infrastructure in rural India is a well thought out three-tiered structure, with health facilities evenly distributed throughout the country based on population counts. The first point of access is a Sub Center (one for every 5,000 people), then a Primary Health Center (PHC)for every 30,000 people. At the apex of this system is the Community Health Center (CHC) which is built for every 100,000 people.
However, this structure on paper doesn’t always translate into practice. Uttar Pradesh (U.P.) is one of India’s most densely populated states with over 220 million inhabitants. This is roughly five and a half times as populous as Kenya. This high density should translate to a high quantity of sub centers, PHCs and CHCs. It should also mean that the geographical distance between these sub centers, PHCs, and CHCs is dramatically reduced, ostensibly translating into more alternatives for patient care within a closer radius of patients’ homes. Yet this is not the case.
Most facilities are non-functional either due to real resource constraints like staff shortage, or limited-availability of drugs, consumables and essential equipment caused mostly by systemic factors. A public health foundation survey in 1999 indicated that more than three-fourths of CHCs have inadequate equipment, and only one-third of PHCs actually provide care. Consequently, Uttar Pradesh lags on most if not all of the major health and development indicators with the highest infant mortality rate, second highest crude death rate, and third lowest life expectancy rate, predominantly amongst low income communities.
Furthermore, private healthcare alternatives in U.P. are not doing enough to close the service gap. Expensive and confined to one or two larger cities in the state, private health providers often lack quality standards as well. Some of the country’s scariest stories surrounding unconscionable health practices come from this region. Additionally, incentives to live and practice medicine here are few, creating shortfalls in practicing medical professionals. Within this context, finding an innovative model to serve the needs of these communities is a strong focus for many, particularly to us in the India team at Acumen Fund.
The beginning of my visit started with speaking to team members of the organization and customers alike at their urban hospital facilities. As previously expected, we noticed that a large number of the lower income patients had traveled an average of 80-100 kilometers by public transportation for a simple health check up, owing to the lack of trustworthy options in their respective home villages. So, with a general idea of where the mapped PHCs and CHCs were for the district, accompanied by new friends, I decided to go to one of the more rural districts about 120km away to see the available options for myself.
An expected two hour journey turned into a four hour wild goose chase trying to hunt down a working PHC facility. We drove around a village in circles, asking anyone we would pass if they could point us in the direction of the government health center – and no one knew. A man driving past us on a tractor gestured to his left, and we went for it, only to find an empty cement structure with children playing on hay. Finally, we located one of the villages that was supposed to have three functioning PHCs to be greeted with a chain and lock around its gate.
Furthermore, behind the locked facility was the construction of two new extensions. Nearby individuals told us the whole facility had been locked since its inauguration by a local politician and that this construction had been going on for the last four years. Given that over the last several years over 15 crores (~$3.3 million) has been sanctioned for the upgrading of PHCs in this district, some progress had to be shown towards these purposes. However, nobody seems to know where this money goes. As a result, here was a glaring example of what happens in so many regions across India and the world, where a lack of oversight only disables the needy patient. The result, however expected, was jarring.
Through our investments at Acumen Fund, we try to find entrepreneurs who seek to provide dignified, affordable and quality alternatives to existing products or services. The value lies in the simple freedom of choice provided to the end user or patient, by removing self-selecting factors like price, quality, or location. Often, improving the quality of the health system begins with physical access to facilities.
Every state in India, every district even, presents a different set of ecosystem challenges in addressing these factors, but here was one of those times that I was confronted with the fact that for the surrounding villages in this district, there was no available choice, let alone a poor one. In places like this, we hope to be able to use our capital more than ever.
Manasa Tanuku is a Portfolio Associate in Acumen Fund’s India office.