Saturday, 26 January 2013

Swadeshi Healthcare

This was originally written for and posted at Healthradii ( now reposted here.

Swa =own, self, local
Desh = country/locality/region

Swadeshi = of one's own country/locality/region

Gadchiroli, Bangs and the wonder of low Infant Mortality Rates


Gadchiroli is a district in western Maharashtra. It is one of the most backward districts in India with a high level of tribal and deprived population. The terrain is tough with forests and floods; what ever little infrastructure suffers poor upkeep. In addition the area is infected with arms, ammunition, explosives with people willing to use these often; Naxalite related violence is a routine feature in the area. Currently there seems only two positive features to Gadchiroli, one of them is a general literacy rate of 74% which is far higher than the Indian national literacy rate of 59%.

The other is Gadchiroli's low Infant and Neonatal Mortality Rate. Clinicians could describe this as a a unique wonder, the faithful could describe it as a miracle. How is it, in an area with a difficult geography, backward population and extreme violence that the Infant Mortality Rate (IMR) is so low that it beats many 'developed' cities in India?

Come explore with me.

The Numbers

Around the year 2003 the whole of India Infant Mortality Rate was about 60 and India ranked 150 (out of 194 countries), Gadchiroli Infant Mortality Rate was 26.5 (which would equal a world ranking of about 100). That means the whole India IMR was a 100% more than Gadchiroli.

What is really interesting is in 2010 Indian Urban IMR was 31 with Delhi Urban IMR at 29. This means that the remote Gadchiroli had a better IMR in 2003 than Indian cities including India's capital have in 2010.

The neonatal mortality rate (NMR) in Gadchiroli in 2003 was 25. The neonatal mortality rate in 2010 for the whole of India is 33 (for urban India the 2010 NMR is 19).

Those are the basic facts highlighted.

How was this achieved?

Localism and operational research

By long persistent and consistent effort. It may be still be a wonder but it is certainly not a miracle. The research was detailed, hypothesis was based on local data and its analysis. The action that ensued was closely followed by continuous operational research and there was sequential building of hypothesis relevant to the local situation.

This means there was no direct transplantation of clinical pathways, technology or treatment from any so called best practice. Principles of public health research were rigorously followed to create locally optimum methods. The principles are universal but the data, analysis, hypothesis, action, pathways, care delivery methods were all local and specific to Gadchiroli.

Who did it?

Abhay Bang and Rani Bang; a husband and wife team both physicians with public health qualifications from Johns Hopkins decided to test and put theory into practice. Both have long family histories of concerning themselves in the matters of improving the lives of others. Just Google their names and be inspired.

What was the approach?

A holistic bundled approach. It is important to remember that these bundles were created on the basis of local data analysis. To put it precisely the Bangs for example found that local data showed sepsis/pneumonia, prematurity and hypothermia as the top causes of death. After a further analysis found in order of priority dealing with sepsis, asphyxia, hypothermia and feeding problems will reduce mortality with management of sepsis alone is likely to contribute to reduction of neonatal mortality by 50%. Tools for management was created after consulting with local population and delivered by village healthcare workers. The village healthcare workers were local resident literate women who were provided with a total of 12 months on the job training.

A 16 item Home Neonatal Care intervention package including management of asphyxia by bag and mask ventilation, injection of vitamin K, thermal care, early diagnosis and treatment of sepsis with two antibiotics (injected gentamicin and oral co-trimoxazole) were implemented. You can see the mind blowing results in the charts above. Over 15000 injections administered by these village healthcare workers and there have been no complications.

Every shred of evidence was local, every intervention was agreed with and co-designed by the local users, care was delivered by local people. No imported best practices, no national guidelines, no experts, no experienced care providers, no external or governmental monitors, to working to imaginary targets/predictions, no high technology, no huge amounts of money.................

The bundle approach did not stop with care delivery for neonates. Women's health was a closely inter-knit issue with child health and that was part of a bundle. Public education especially on healthcare issues was a part of another wider bundle. There have been equally immense successes in those areas.

A good quality of life is enabled by good personal habits and Gadchiroli happens to be one of the few areas in India where the public have recognised alcohol as not conducive to healthy living and hence demanded prohibition and help to keep the prohibition going. This is part of the public health bundle championed by the Bangs. I am positive if there was any way that they could reduce the violence in the area, if they had any power or influence on it they would have, I suspect they might have already explored it.

The Importance of the Bangs, SEARCH and Gadchiroli to the world of healthcare

When we think of healthcare in India most of us will be aware of Apollo in the corporate sector, Aravind Eye Care for brilliant innovation in ophthalmology, some pharmaceutical companies who produce affordable drugs for India and Africa, recently we think of Dr Devi Shetty's volume based quality improvement models; there are many more commercial names we could think of. We may think of medical tourism, we may even think of some traditional Indian healthcare systems such as Ayurveda and general health system such as yoga. While those are examples at the better end of the spectrum, we would probably avoid thinking of a greater cohort of diverse providers and their dubious ways.

We never think of Gadchiroli or the Bangs who have taken on a whole district with the poorest population and produced amazing results with meagre resources in an clinical area where everyone else in the whole of India finds it daunting. They are a triumph of public health, they are a victory of scientific principles of operational research, they are a beacon of localism.

Yet when I speak to many doctors in paediatrics, public health and operational management they are blissfully ignorant of this leading example. When I speak to paediatricians in India and paediatricians of Indian origin in UK, most of them are totally unaware of this.

It will be essential for every doctor in India and in every developing country to be fully aware of the Bang's Gadchiroli experience. When we talk of developing or delivering alternative models of successful healthcare that are specific to local needs there is no other learning resource better than Dr Abhay Bang's published material which clearly describes the principles of how to do it. These should be taught very seriously as a part of the public health curriculum in medical schools in India.

Aping the west, urban Indian healthcare providers should eliminate their mental block against anything local; they must develop some discipline in following the scientific principles of improvement and vision to own and deal with population health rather than client/customer health; that might help them improve the quality of healthcare in India. If you are Indian you have certainly heard the Gandhian word called 'swadeshi'; Abhay and Rani Bang are probably the greatest proponents of Swadeshi in healthcare, being Gandhians themselves that is hardly surprising what is relevant is that swadeshi has given India some top class results and lessons worth emulating in every area of Indian healthcare.

This is the Indian rural version of what Intermountain Healthcare does at Utah. I recommend the Bang method for India's healthcare improvement. I also recommend a Bharat Ratna for the Bangs.

Follow me on twitter @HemadriTweets


Dr Abhay and Rani Bang's SEARCH website:

India Infant Mortality Rate graph generated from the longitudinal data at


Paul Levy said...


(I've linked my blog to yours, by the way.)

M HEMADRI said...

Thanks Paul for your comment and your support.

Your blog was one of my early inspiration to start writing.

Manish Kushe said...

Amazing....I know other couple who got inspired from Dr Bang. Dr Prakash amate is another example.

Kavitha Madhuri Thumuluru said...

Wow. It is both humbling and a matter of pride that not a system but 2 doctors who care can make a positive change! Hats off to them and thanks to u Hemadri for informing u

M HEMADRI said...

Manish, Dr & Dr Mrs Amte are extraordinary human beings.

Kavitha, what is also remarkable is not only they have created a great system but they have documented it scientifically and published it for anyone to learn.

JK said...

It is sad that our learning is quite prejudiced towards the western world. Anything which has seen success using alternate methods is looked with suspicion.