Mr. Gopi Gopalakrishnan is the President of World Health Partners (WHP) and has over 20 years of experience in implementing large-scale service-delivery programmes in low-resource settings. We recently had the opportunity to interview him for his thoughts on the status of Maternal and Child Health (MCH), family planning and health care in India.
WHP was founded in 2008 by Mr. Gopalakrishanan.It is committed to delivering health and reproductive health services to rural and marginalised communities in the developing world. Utilising existing social and economic infrastructure, as well as innovations in social franchising and marketing, they have developed a holistic, scalable, replicable model that can be applied to low resource settings. The WHP model links the informal and formal sectors through a cost-efficient, referral-based, multi-leveled, service delivery network and provides underserved communities access to high quality, affordable health services.
Mr. Gopalakrishnan has been a member of India’s Population Commission and has advised the Ministry of Health and Family Welfare and numerous national and international organisations on large-scale cost-effective service delivery. Prior to WHP, he founded and managed the Janani Programme in Bihar from which includes a number of WHP’s current core management members. Janani is a non profit organisation that provides family planning and comprehensive abortion care services in the states of Bihar, Jharkhand and Madhya Pradesh. It has won national and international acclaim for its innovative and creative management that enables the program to serve some of the poorest communities in the world on a sustainable basis.
Here are a few of his thought provoking responses to some of our questions:
- There is really nothing to be proud of about health in India. In fact, we are doing worse than Bangladesh and in some fields, even Nepal.
- Bangladesh is poorer, more unstable and more conservative but when its health standards are better than India, there is something very wrong.
- The system has become very corrupt, lethargic and dysfunctional. The system has to be redesigned so there are metrics collected at arm’s length which will allow incentives for good work or equally -disincentives for poor work. This is where the private sector succeeds because it collects its metrics by linking to the monetary system so that performance can be measured.
- Over a period of time, I hope we can get enough bandwidth to also start exploring robotics. I would like to imagine a doctor sitting in Delhi performing a surgical procedure on a patient who is located in one of the interior villages of the country. It is very possible. This will be an expensive project, but that’s the future.
Section A The following questions are related your views on the status of health in India.
1.According to you, what should be the top three health priorities in India?
The first health priority would be to improve access to health care facilities in rural India. Currently, there is a vast gap between the services available in urban and rural India despite the villages being home to 75% of the population. Some states have shown improvement in recent years mainly due to improved connectivity between the urban and rural parts in those states got better. We must realise that both in health and education, improvements and sustainability are crucially dependent on strong connectivity of rural parts with the urban centres.
The second would be stronger focus on preventative health care. This is very crucial and it goes far beyond medical services to cover social, cultural and physical aspects that support good health. The questions then turn out to be: Do we have good water management and sanitation systems in place? Do we know what happens to the sewage water that is collected from homes? Because a cesspool of dirty water is as much a health concern as an infection.
The third is a strategy to harness and manage all the resources in the country has irrespective of whether they are in public, private or NGO sectors. Experience over the past six decades shows provision of health care services cannot be left as a public sector responsibility. Public sector has distinct advantages—it is inherently sustainable because taxation power of the government pays for its role. This is not the case with the private sector. The private sector also focuses more on profit garnering curative services rather than less profitable preventative. There is a need therefore to identify the right kind of health care models for both sectors. It indeed should not matter whether the care that is being provided is by the private or public sector but that it has to be good care for all with provisions to deliver quality to all segments. For this we need to explore financial instruments such as insurance and vouchers so the poor are protected even if they received the care from the private sector.
2.What makes you proud about health in India?
There is really nothing to be proud of. In fact, we are doing worse than Bangladesh and in some fields, even Nepal. The only satisfaction is that we are doing better than Afghanistan. In India, malnutrition is not necessarily because of the non availability of food but also because of the low immunisation rates and poor sanitation . It emerges that in some aspects we are in fact doing worse than some of the poorest countries of Africa. If the majority of the population in a country finds basic health care an unattainable luxury, then what is there to be proud of? Bangladesh is poorer, more unstable and more conservative but when its health standards are better than India, there is something very wrong.
3.Where is India falling behind the world?
I think there is an increasingly over intellectualisation of simple problems. In weak infrastructure- low resource areas, the programme manager’s ability to deliver good health care hinges on his or her ability to read the current situation in the local context and find a solution accordingly. This calls for close engagement with the community. The academic driven approach tries to find text book solutions which are often divorced from the local mores and cultural norms. This disconnect is leading to many of the problems.
4.Are there examples where other fast-growing economies are handling health problems better than India?
I would like to share a lesson that I learnt in Vietnam where I worked for three years before moving back to India. The Vietnam health model is probably not one we can follow in India but there are some broad lessons. As a communist country, it set up a strong intelligence infrastructure but currently uses it to keep a check on the standards of care that are delivered. So the takeaway lesson is the role that monitoring plays in programme implementation. This is equally true in China and Iran. In fact, one of the reasons for Bangladesh’s performance is its ability to generate reliable metrics.
India, instead of focusing on actionable metrics, adopted what is loosely called the Nehruvian Consensus in which the government is inherently virtuous and can do nothing wrong. That is applicable from the top most levels of government right down to the health worker in the field. Therefore, they are not supervised and we are now paying the price. The system has become very corrupt, lethargic and dysfunctional. The system has to be redesigned so there are metrics collected at arm’s length which will allow incentives for good work or equally -disincentives for poor work. This is where the private sector succeeds because it collects its metrics by linking to the monetary system so that performance can be measured.
5.If you think about India in 20 years time, what will the citizens of 2034 wish that we had done in 2014? (Why?)
If in 2014, we can set up a good monitoring system which will help programme managers with real time intelligence to assess performance and correct course when necessary, 2034 should have a healthy population.
Section B These next few questions are on health and telemedicine.
1. Recently, some experts have said that India should try to replicate Brazil’s primary care infrastructure. Do you think this will work?
Learning from any successful programme is a good thing but in India the major problem is supply and demand do not connect. In India, we have the consumers who need certain services, but they do not have access to those services due to physical and cultural barriers. The demand is already created, there are ample resource available but the supply is not happening the way it should. Even for programmes such as family planning, the difficulty is not people want to have unplanned pregnancies. The unmet need for family planning in Bihar, the state with the highest fertility rate in the country, is 40%. But services are not reaching.
But using family planning as an example, the caveat of the current demand is that the client needs to be counselled, service should be available close to the homes and there should be adequate follow-up care. The system is not able to fulfill these.
2. A lot of recent work has suggested a growing gap between the number of primary care doctors needed in rural and disadvantaged areas and the numbers who are being trained. Is India doing enough to deal with this?
In order to reduce this growing gap, we need to address two challenges in the rural areas . Firstly, it is important to understand why we have such a shortage of trained manpower in rural areas .If I were a doctor- I would not want to and live in a village that has no electricity, water, school, or entertainment. I have educated myself and want to enjoy certain comforts that come with modern urban living. So, in order to place more doctors in rural areas, it is necessary to first create an entire ecosystem that will enable a doctor to settle in a conducive environment.
Secondly, doctors in India need to have a combination of both medical and people skills. We have focused primarily on the former. It is time we also spend our resources on training them on the latter.
3. Compared to its neighbours, India does not have a great record in reducing maternal mortality or improving child survival. Are there things that the country should be doing?
We need to evaluate what is not working and fix it- be it the quality of the interactions or provision of health services. Let me share an example about Uttar Pradesh . Here ANMs are used from the public sector in the private facilities with a government sanction to provide family planning services such as insertion of IUDs. In the public sector, the failure rate in the insertion of an IUD is very high, sometimes up to 80%. This is because ANMs just give it away without proper instructions as they have a daily target to meet and they misreport as well. Whereas in the private facilities – when the same ANMs are used, the failure rate is less than 3%In a private facility, the ANM does not have other tasks of record keeping and interacting with the community. She is just responsible for her clinical work and the rest is done by other staff members. Thus, we need to install mechanisms in place to catch and then correct what is going wrong.
4.Is there a lot of ideological hostility to private sector solutions to community health problems?
No there isn’t any hostility. In fact, we have found them very welcoming. Especially when we are going there with solutions to some of the problems that they are facing. In one of our programmes – Janani which focuses on family planning, I never faced any problems in implementation. Even when we were interacting with men and women in the community, the openness with which they discussed personal issues was fantastic. That showed a good level of trust.
5. How does WHP utilise the latest advances in diagnostics and medical technology to establish large scale, cost-effective health service networks ?
WHP uses its strong network base called the Sky Social franchise to help deliver essential services in some districts of Bihar and Uttar Pradesh. In Bihar, the network is used to generate awareness on childhood diseases like pneumonia and diarrhea. In Uttar Pradesh, it is used to deliver family planning services to the local population. The Sky network consists of a bottom level of SkyCare Rural Health Providers and the higher tier Sky health centers. The former forms the foundation of the WHP network as the first and often only point of contact for the majority of clients. SkyCare informal health providers already live in the villages and are identified and selected based on their entrepreneurial and social skills. WHP equips them with training and low cost mobile solutions that enable them to perform tele-consultations, referrals (usually to SkyHealth Centers), and diagnostic, symptom based treatments. SkyCare providers charge for their services and earn a commission for each referral.
Telemedicine Provision Centers called SkyHealth Centers are operated by an entrepreneur with a health background, and serve as tele-diagnostic and SkyCare support and coordination hubs. Each SkyHealth Center has 7-10 SkyCare providers underneath it that refer patients requiring more sophisticated care. SkyHealth Centers are thus situated in larger, more centrally located villages. Modern tele-medicine services located at the SkyHealth Centers connect patients with doctors at Central Medical Facilities via the ReMeDi system.
Based on tele-diagnostic consultations, SkyHealth Centers may either refer patients to Franchisee Clinics, or provide them with transportation to a hospital.The investment in technology is sustained through the providers vested interest in providing services and maintaining the systems as he is earning some profit.
6. What technology has till now given WHP the maximum benefit with regards to improving access to healthcare?
There is no one technology. It will always be a combination of technologies and interventions that made the maximum difference and rightly so. In fact, I feel if you start focusing only on one kind of technology then you are putting too many eggs into one basket. In a sector such as this, which is full of complexities and uncertainties, you will have to create enough solutions and backups for the challenges and redundancies within the system.
7.Which technology (current or upcoming) are you most excited about?
Over a period of time, I hope we can get enough bandwidth to also start exploring robotics. I would like to imagine a doctor sitting in Delhi performing a surgical procedure on a patient who is located in one of the interior villages of the country. It is very possible. This will be an expensive project, but that’s the future. The experimentation needs to start soon. We need to have a good vision of what is possible. A lot of the vision may be absolute conjecture, but at least there are some definitive steps we can take to even realise that the vision is possible.
8. What do you think will change about health in India over the next five years? What sorts of trends do you see?
All of it. It is going to be a bit of everything. People are also getting very aspirational with the explosion in media and have started making demands from their politicians, which is fantastic. That is how a society matures. Especially democratic societies where thru their vote, people can then select representatives who can enable them to achieve those aspirations. I see in big change in India in the next five years and not just in one sector but overall in the country.
Section C We would like to know about you and your work:
1.Why WHP? What about this organisation excites you?
My personal philosophy is that this is nothing more than a job that has to be done. In any organisation a large amount of people are working simply because they need a job. If tomorrow instead of working in WHP, theyget a job in a beauty parlor because it is better paying, they will take it. And there is absolutely nothing wrong with it. Now I take a position in a self righteous way using words like passion and commitment, I am going to create a division between me and the ones for whom the motivation is to earn a livelihood. Such division is perhaps the worst schism that an organization can be subjected to. That is why I always say this is a just a job. Let it be driven by the organisational purpose rather than an individualistic purpose.
2. What do you enjoy most about working in the health services field? Are there many challenges ?
It is an incredibly interesting field. Challenges are always there and they are part of the territory. In fact, I would worry if there were no challenges, because then something is not going right.
3. What’s the best thing to happen since you started working in this field ? Is there any experience you have not enjoyed?
Memorable moments are all those little joys and we have had many. I would not say there is only one big moment. For example, the day we got a grant from the Gates Foundation was a very memorable moment.
As an organisation becomes intellectually more sophisticated, the senior members of the team also start becoming incompatible. So, is something I have not enjoyed dealing with. Humility and modesty are important qualities to have and I do not know why people do not cherish these.
4.What might someone be surprised to know about you?
I grew in a village called Kondappanaickenpatti in Tamil Nadu and went to a local school. We had five classes in one abandoned temple and one teacher. It was a government school where everything was taught in Tamil. I went to that school till the 11th grade. When I came to Pilani, I could not speak a word of English and I was 16 years old. I could not speak Hindi either and I had to learn these languages. This was one of the most difficult phases of my life. But it helped that I was very good in mathematics, as one does not require any language skills to studythat. But when you are studying calculus and linear algebra in class, you need have to understand what the teacher speaks and that was difficult. The first book on calculus that I had to study was written in English and I could not even understand the first page of the book. So, I performed badly in college. So, when I tell anyone this story, they get surprised.
5.What do you do when you are not working?
I am an avid gardener. We live on the outskirts of the city and I love it . I am also an internet junkie. So, I sit in the garden and the whole place is wired with the internet. I love it.
–END OF INTERVIEW–