As always, the numbers are very impressive. Under the National Rural Health Mission (NRHM), 8,722 doctors, 2,914 specialists, 14,529 paramedics, 33, 413 staff nurses, 69,662 auxiliary nurse midwives, and 10,995 doctors and 3,894 paramedics practising traditional medicine have been hired to ensure that everyone in rural India - irrespective of where they live and how much they earn - have access to basic healthcare.
Government data also shows that innovative approaches - such as decentralisation, flexible financing, improved management and incentives - have ensured more women were choosing hospitals over home to deliver their babies, bringing the maternal mortality rate (MMR) down from 254 per lakh live births in 2006 to 212 in 2009, and infant mortality rate (IMR) from 58 per 1,000 live births in 2005 to 47 in 2010.
Still, 12.5 lakh newborns and 63,000 women die each year cause of pregnancy-related causes, and Union health minister Ghulam Nabi Azad admitted as much in Parliament last month."Unfortunately, India's IMR and MMR is very bad. As bad that it cannot be compared with our neighbours Nepal, Sri Lanka and Bangladesh. Pakistan is the only country India can be compared with," he told the Rajya Sabha last month in response to a question on infant deaths in state-run hospitals in West Bengal.
The devil is in the detail. An incredible 1.3 crore (11.3 million) women have benefited from the Janani Suraksha Yojana (JSY), which offers pregnant women free and cashless deliveries, including free caesarean-sections, and a R1,400-incentive to deliver in a hospital. In most cases, having a baby in a hospital brings no benefits for new mothers other the R1,400. "There is low-birth preparedness that leads to delays in pregnant women reaching a hospital and getting treated for preventable complications. An analysis of maternal deaths, for example, showed that 13% deaths happened on the way to the hospital and 11% after the women return home, which shows poor management before and at the hospital," said Aparajita Gogoi, executive director, Centre for Development and Population Activities India, an international non-profit that works to improve adolescent and women's health.
What's clearly lacking is quality, said experts at the National Consultation on Safe Motherhood in Jaipur this week. "Quality is lost in the rush to meet targets, such as attaining 100% institutional deliveries. We have the standards, technical tools and the basic infrastructure needed, but still the quality of delivery depends on people, not on standard compliances. The system delivers what the top government asks for, so if quality targets are set for babus, they will be met," said Dr Monir Islam, director, Family Health and Research, WHO South-east Asia region.
Measures of quality include better patient outcomes (fewer deaths and complications), lower infection rates and overall patient satisfaction.
Who's to blame?
"I admit that quality is missing and we cannot continue to take pride in institutional deliveries if it's just taking deaths from home to hospitals. Most government institutions have a take it or leave it approach and don't care if the patients don't like what they offer. This attitude needs to change, which is tough because in this country, we are very tolerant of bad quality. No one ever asks a doctor why he is late or absent from the clinic frequently," said Anuradha Gupta, additional secretary and mission director, NRHM, Union ministry of health.
A major reason for the national apathy to incompetence is that action is rarely taken against erring government appointees, who focus more on hanging on to the job than doing it well.
What will improve quality is better tracking and monitoring to identify and eliminate avoidable cause of death and complications, help identify area-specific problems and ensure transparency. "But the review should not be done by the provider, as it usually happens in India. There is massive underreporting of deaths, with one state reporting only 20% maternal deaths, with the doctors listing the deaths under different pregnancy-related complications, such as septicaemia or organ failure," said Gogoi.
The buck stops here
Someone has to take responsibility for the shortfalls, just as many throng to take credit for the successes. "You need ownership. We have too much participation in India, even cows and dogs visit hospitals. Just as a pilot cannot ask all crew for participative flying of a plane, you cannot have everyone running the show," said Dr Dileep Mavalankar, dean, Indian Institute of Public Health, Gandhinagar, Gujarat.
For the system to deliver, the buck has to stop somewhere.