A former pediatrician, Dr. Balijepalli Sailakshmi is reducing the child mortality rate among the most poor by raising their access to quality healthcare. To achieve this, she is linking communities, schools, universities, and public providers to public healthcare in order to build health awareness, enhance health seeking behaviors and make care inclusive, accountable, and effective.
The New Idea
While there exists a large network of government hospitals in India, they are failing to provide quality, timely care to patients, especially to children, because of inefficient management and lack of transparency. Dr. Sai is building a supportive and educational system that proves minimal investments in administrative and management practices can significantly improve health outcomes.
Focusing on neonatal and pediatric care, Dr. Sai involves stakeholders such as local governments, educational institutions, and private providers to address the gaps in public healthcare. Taking a partnership approach Dr. Sai gained the trust of the government medical system by offering solutions to the biggest problems it is facing. By intervening from within the system and leveraging existing government budgets and schemes, Dr. Sai addresses the major governance and management failures responsible for the poor quality of care—namely drug supply, equipment maintenance, diagnostic capability, and manpower.
Dr. Sai is also building a health and prevention-oriented system on the ground by educating communities and raising their agency in monitoring healthcare. These measures ensure the timely manner of quality health interventions.
As a result of Dr. Sai’s initiative over the last three years, every district in Tamil Nadu has been ensured access to institutionalized and integrated neonatal care, while she is expanding the program to include overall pediatric care and expand it in other states.
India has more than 900,000 newborn deaths a year which equates to almost 30 percent of the world wide total. While the National Rural Health Mission requires every district to have a Special Neonatal Care Unit (SNCU), most still do not exist.
Nevertheless, public healthcare in India avails significant resources and investments of the government. Mandated to provide care for free or at minimal cost, the public healthcare system has wide reach and sizable infrastructure. Unfortunately, the lack of appropriate administration and governance systems result in its poor performance. To worsen matters, government hospitals typically require practicing doctors to fill in leading administrative roles without any training. As a result, hospitals do not have professional administrators who can play a leadership role in managing the functioning of the hospital. Doctors are typically stretched for time and lack expertise to solve different problems. For instance, a recently conducted inventory demonstrated that 80 percent of equipment in hospitals in the state of Tamil Nadu was dysfunctional. Similarly, there is a severe shortage of doctors in government hospitals. For example, a recent study showed a lack of 500 government doctors in the state of Punjab. Due to this manpower crunch in public hospitals, even the best trained doctors are often unable to save lives. Each doctor may be required to oversee 50 to 80 children at a time, and often can only attend to them once it is too late. Doctors are also forced to make difficult choices on which child to care for due to an absence of life-saving medicines or limited equipment.
For these reasons, public healthcare, although more affordable, is becoming the last choice for poor people. Communities are placing greater reliance on services provided by individual practitioners, private clinics, and hospitals. For instance, the National Sample Survey Organisation Report reflects that the role of private providers in the treatment of illness now contributes to nearly 80 percent of inpatient and outpatient care in rural and urban areas. However, the private sector poses several threats to the health and well-being of communities as insufficiently trained doctors and spurious drugs are common, especially in rural areas. In addition, such services are far more expensive. For instance, costs for inpatient services have been found to be 107 to 740 percent higher (Report of the Task Force on Medical Education). As a result, about 20 million people in India fall below poverty line due to health shocks annually.
The lack of knowledge and appropriate health seeking behavior among communities worsens illnesses and perpetrates ineffectiveness of public healthcare. Without access to information, communities are not equipped to make better choices or demand quality from the providers. Consequently, the poorest patients also end up being the victims of negligence and corruption. In this context, there is an urgent need to reactivate and strengthen the government system in parallel with increasing the role of communities in health.
To pursue her goal to improve access to healthcare for poor children, Dr. Sai founded Ekam in 2009. Through Ekam, she collaborates with the public child care system to address its biggest gaps and evolves grassroots health monitoring and response capacities.
Dr. Sai is focused on activating SNCUs in the state of Tamil Nadu. She began by addressing the need of qualified medical staff to run these units. Dr. Sai convinced the government to outsource to Ekam the identification, training, and hiring of 350 nurses for the units. As the government medical facilities are commonly understaffed and struggle to attract appropriate human resources they were open to collaborating with Ekam. In future, Ekam will not need to provide this service to the government; they will only need to create the linkages with the appropriate service providers.
Another manpower related gap is the need for continuous learning and exchange of knowledge among the medical personnel. To tackle this within the activated units, Dr. Sai created expert committees that connect doctors in remote areas with each other and to central facilities. Utilizing existing funds from the National Rural Health Mission funds, Ekam is now facilitating the creation of processes for these committees to function. Going forward, this is intended to become a common practice and will not require Ekam’s participation.
The inventory of equipment in SNCUs, conducted by Ekam, has shown that most equipment was broken and not in use. To ensure optimal utilization of resources, Dr. Sai has recently tied up with the state government for full equipment maintenance in the state. In collaboration with an engineering firm for technical support, she is evolving a mechanism to ensure that maintenance requests are responded to in a timely manner.
Dr. Sai has also created a helpline connecting all the SNCUs in the state. The helpline will manage the requests from the units regarding equipment, drugs and lab investigations, and possible emergencies. It will connect medical professionals in remote areas to the resources they require in an efficient manner to save the lives of their patients. As the next step, Dr. Sai is going to evolve a management system for drug supply. The system will help track the most essential drugs and ensure their availability in the hospitals, both on a regular basis and in emergency situations.
Leveraging her expertise and experience, Dr. Sai creates solutions to improve the overall performance of the system. To achieve this, she intends to work on holistic governance reforms in hospital administration. Through this, she will be able to integrate the processes and standards that have evolved into the modus operandi of the public healthcare system. She is also looking at addressing underutilization of funds due to a lack of clarity of regulations and lack of initiative among the administration. Dr. Sai plans to tap into government insurance schemes, patient welfare society funds, hospital maintenance funds, and contingency funds so that eventually all of these activities will be operationally and financially absorbed by the system.
While Dr. Sai continues to influence systems in the long-term, she is committed to ensure that immediate need for care is not compromised and lives at-risk are saved. She creates collaborations among actors in healthcare by bringing them together with the shared purpose of saving the lives of their patients. Dr. Sai saw an opportunity to involve private sector hospitals to fill up the gap and make their services more inclusive to marginalized communities. At present, Ekam has a partner network of fifty private hospitals. These hospitals provide support at several levels: they provide subsidies of 30 to 50 percent to marginalized patients, extend credit lines for payment, rent medical equipment, and provide drugs in emergency situations.
Dr. Sai is also evolving mechanisms to increase awareness and participation among communities in collaboration with grassroots citizen organizations. Schools are also a part of this system, through Health Clubs, teachers and students monitor the health of children. On one hand, this aims to promote home-based maternal and child care, good nutrition practices, basic life support, and health-related rights. On the other, more health savvy communities are better equipped to keep the public system alert and accountable. Dr. Sai intends to build grassroots institutions to link communities to government officials and medical staff at the village level; with three local committees already established.
Dr. Sai was born into a family of doctors, and when she was young she also dreamed of becoming one. She completed eleven years of studies in pediatrics and child health.
Dr. Sai has always been driven by an instinctive need to respond to problems she witnessed. For instance, when the state of Gujarat was affected by an earthquake that killed 20,000 people, Dr. Sai left for relief work missed her postgraduate entrance exams. Similarly, upon graduation in 2008, she missed a job interview to work for the flood relief in Bihar. It was here that she met Ashoka Fellow Anshu Gupta, who became her mentor and later a board member of Ekam.
During several years working in government hospitals, Dr. Sai observed the inequality in healthcare. She witnessed how many children were becoming the victims of the inefficiencies of the system and saw doctors increasingly accepting these deaths as a routine problem. These observations and an internal resistance to submit has pushed Dr. Sai to search for solutions. Initially, she assumed the role of a proactive doctor visiting orphanages around her hospital to identify, refer, and treat sick children. Later to achieve scale, she created a project that connected eighty private doctors to orphanages around their hospitals.
Feeling more and more involved, Dr. Sai left her medical practice and dedicated herself full-time to Ekam. Her experience as a doctor had made her conscious of the fact that mortality rates were high among children due to their delayed diagnosis, and there was a need to build caretaker capacity. Since most vulnerable children came from adoption agencies, Dr. Sai started by training caretakers to identify sick children quickly, provide emergency care, and improve nutrition.
Later she expanded her work to the government schools, as most orphaned children studied there. Dr. Sai saw that although doctors were required to visit schools for regular health checkups, it did not happen due to administrative inefficiencies. Ekam began to bridge this, by raising funds and arranging for doctors to visit the schools.
Eventually this network covered 80,000 children in Chennai. Witnessing the need for effective follow-up treatment, she also started school health clubs. Teachers assumed a role in distributing prescribed medicines and ensuring compliance. The teachers found this initiative to be rewarding and important for them because they were observing improved productivity in children. Dr. Sai’s idea to involve diverse stakeholders for health on district health committees, emerged from the experience of school health clubs.
Dr. Sai later became cognizant that mortality was highest among younger children and poor children who did not go to school. Seeking to directly reach migrant workers and communities in slums, she started community-based work on preventive neo-natal and child care; to raise the agency of mothers in children’s health. Ekam also created a community children’s insurance scheme.
Eventually it became clear to Dr. Sai that irrespective of this support, private care, especially in acute cases, was simply not for poor families. Children were often transferred to the government hospitals when families had no more resources. Closing the loop, Dr. Sai knew she needed to go back to working with the government system, as with smaller investments, one could witness greater impact.