My first two days at Prayas have been great. Dr. Narendra Gupta, the leader of the project, is a very interesting and cool guy. He's very much into medicine pricing type advocacy right now, so we had a lot to talk about when I arrived. He had me over to his house for dinner, which was very nice of him. Food here is on the upper range of my spice tolerance, but I'm fine if i have something milk/sweet like after.

Also, some young dudes who speak English showed up, so I actually have people to hang out with! This has been a welcome change. That being said, it slightly detracts from my impetus to keep studying hindi, so I have to be disciplined.

I've spent the first two days learning a lot of about the current medical/public health system of India. The Indian government does somewhat ascribe to the idea of ensuring medical care for all. With the launch of the National Rural Health Mission (NRHM, http://mohfw.nic.in/nrhm.htm) the current set up is roughly as follows (some of this was in place before the NRHM, but it modified the system a bit): each village has an ASHA, or Accredited Social Health Activist, who is a member of the village chosen to be the liasion between government and village health. She also gets minor reimbursements for finding sick people and bringing them to the appropriate treatment place. For every few villages, their is a Sub-Center, which employs an ANM, or auxilary nursing midwife, who is trained to attend births and do a few other things. Above this there is a Primary Health Center, which employs two doctors (one in allopathic, one in AYUSH - ayurvedic, yogi, unani, siddha, or homeopath), a few ANMs and some support staff. Above this is the Community Health Center, which has a wider range of services, then the District Health Center, where you start seeing true specialists and a high-tech hospital format. The only thing above this is academic medical centers linked to medical colleges, where you might see leaders in a field or subspecialists.

This format seems logical, but its unfortunately drastically underfunded. There's a decent amount of absenteeism from staff at various positions along this hierarchy, and otherwise attempts to extract money. Also, about a year after the launch of NRHM, it was decided that they would allow staff to charge user fees (http://mohfw.nic.in/NRHM/RKS.htm). Only the state of Tamil Nadu has banned all user fees, realizing that this would probably be a terrible idea when you're trying to expand access to healthcare for super poor people. Which gets back to that article from my earlier post, which says Tamil Nadu is a model.

Check out this graph, which breaks down public vs. private spending on healthcare as a percent of GDP for various countries or groups of countries. Its taken from the 2008 World Health Report from the WHO:
India's public spending as a percentage of GDP is super low. I think it's only comparable with like the Democratic Republic of Congo and a couple of other countries that are really poor or struggling with unstable governments or both. Other interesting things to note are that external resources (essentially donor funding) play a miniscule role in India, and not as large as I would have expected for other low-income countries. Also note the outrageously high overall spending in the USA. The public spending is on par with other G8 countries, but private spending is huge. Our health outcomes are also way worse than most G8 countries.

Anyway, one consequence of this lack of India's public funding is that even if poor people go to government health clinics listed above, there's often not enough medicine for them, and they have to buy it out-of-pocket from a chemist. Dr. Gupta has been doing a bunch of research on pharmaceutical pricing, and has found that there is, expectedly, an enormous mark-up in pricing. An Indian pharma company will sell pills to the local chemist for 8 or 9 rupees, but the pricing on the bottle will say to sell it at retail for 70 rupees. I'm not sure if the local chemist actually captures a whopping 7 fold profit, or if some of this kicks back to the pharma company after sale to a customer. Whatever it is, this level of mark-up is clearly a huge burden to patients. (By the way, these are prices for generic medicines produced by India's generic companies - see earlier post. There's probably a different story entirely for brand-name multinational pharma companies operating in India).

Dr. Gupta has gone through estimates of Indian disease burden in every disease category, the rough amount of medicine needed to treat this burden, and the price of the medicine if procured at the 8-9 rupee price sold to chemists and government bodies. He has estimated that it comes to something like 6600 crore, which is actually a small amount when compared with the entire budget the government is putting into the NRHM. It would also likely drastically increase the success of the NRHM. So he's been doing government advocacy on that front recently.

Another thing that is part of the NRHM is a community monitoring program, where Village Health and Sanitation Committees (VHSCs) in each village give quartly report cards on the various services the government healthcare providers are supposed to be supplying. This is a pretty cool idea, but difficult to implement. The gov't is teaming up with local NGOs to help in the training of VHSC's, and Prayas is one of these NGOs. I hung out with the group that's doing this yesterday, and helped one of them flesh out a research study that is evaluating the training programs. The study will be his dissertation for his master's program in health management.

I think I might be going off to one of Prayas' projects in a remoter district for a few days, so I'll try to take some pictures for a more colorful next post.