How are packaged potato chips and sweet soda available in villages? Why do branded soaps and hair oils reach small towns when measles vaccines don't? The answers to these questions will indicate a huge gap in India's public delivery systems.
Ten years ago when I left McKinsey & Company to plunge into the public health sector, one question haunted me: why can't the delivery of health solutions scale up in India? The country's public health record is shameful. Almost 2 million children die before they are six years old. Over 40% of those who survive are malnourished. Even though the situation has improved in some states, India is still nowhere near the developed world.
But we know the solutions to India's health challenges: child deaths can be avoided with the widespread provisioning of safe vaccines against diarrhoea and pneumonia. Nutrition can transform if the anganwadi delivery system works. Exclusive breast-feeding, widely practised, will make a huge difference if entrenched social barriers are addressed.
But solutions are rarely brought to scale with quality. The outstanding Society for Education Action and Research in Community Health (SEARCH) programme in Maharashtra demonstrates how home-based newborn care can save infant lives. This model is now used in several African countries. But India took more than two decades to warm up to this and even now its usage is far less than its potential.
In public health, we often spend time reinventing the wheel. At the Gates Foundation, my charter was to create a programme - Avahan - that would bring HIV prevention to at-risk populations in six states. We decided we didn't need to create a better condom. Instead, we focused on scaling up the delivery of a set of solutions. At Avahan's peak, we distributed about 13 million condoms a month.
Businesses don't have to be pushed to scale up - it's in their DNA. A few lessons from the world of business can teach us how to scale up public health delivery. There are many rules to do that but let's examine three.
Use of data: Like a salesman knows how many doctors there are in his target area and where he should focus to maximise sales, Asha workers and Auxiliary Nurse Midwives, both of whom function at the village level of the public healthcare system, know the number of pregnant and lactating mothers in the villages they serve. They can pinpoint mothers who have special challenges and need extra attention. These workers keep over 15 registers for data collection but often do not find the information they need. So instead of those bulky registers, why can't we give them hand-held devices? With such devices, right incentives and training, they can assist in frontline data generation.
Generate demand by supplying what the consumer needs: There are too many products and solutions that have been developed by distant donors and these usually don't sync with the ground reality. For example, sex workers don't want HIV prevention as much as freedom from violence that frequently accompanies unsafe sex. In six states, a violence-response programme, which was developed with the help of sex workers, worked pretty well and there was a rise in the use of condoms. Like good businesses, public health programmes can also scale up by listening to their customers.
Ally with the state: Privately sponsored programmes need to use the government to scale up and to become sustainable. In the 1970s, Hindustan Lever allowed the government's Nirodh condom programme to freely use their extensive distribution system and marketing know-how. Hindustan Lever became a good corporate, while piggybacking Nirodh demand created rural consumers. Such innovations and best practices must be scaled up and sustained using the reach and permanence of the State.
Today, we need an institution - private or it can be an autonomous body within government - that brings in the know-how to scale-up government programmes. The new venture should be organised around advocacy and delivery. Certain scale challenges can be addressed primarily through strategic advocacy but other delivery situations need demonstration of how to scale.
Ashok Alexander is former Country Director, Bill & Melinda Gates Foundation
The views expressed by the author are personal