Soumitri Varadarajan, RMIT University, 2010
Maternal mortality is a significant health issue in India. Roughly 20 to 25% of Maternal Deaths on this planet occur in India. A major proportion of these deaths occur among the rural poor. To focus more sharply upon rural health indicators the Government of India has set up The National Rural Health Mission (NRHM). There have been significant improvements in maternal mortality rates (MMR) because of NRHM, though there is still a long way to go to meet the Millennium Development Goals. Currently the discourse in MMR in India is informed by two perspectives; one, the development of state medical infrastructure focused upon health service provision, and two, the public health perspective of connecting medical health practitioners with the clients. In effect the rural is viewed as a neglected condition needing more resourcing. While increasing resourcing is fine as a solution in the short term and to meet immediate goals – it is not sufficient and does not contribute towards the development of a resilient model of universal health care. I argue that the remote rural poor are a unique category of consumer for health services, who are strategically placed to privilege a mode of health service that is uniquely responsive to their particular needs. In this paper I argue a particular service design practice for rural remote poor could provide a resilient ecosystem going into the future.
Late in 2009, I commenced work on a pilot project to explore maternal mortality in Assam to explore how service design could contribute solutions to the problem of maternal mortality reduction. The project was undertaken at a time of a unique rethink and reformation of rural health services in India brought on by its commitment to meet the Millennium Development Goals (Mavalankar, Vora et al. 2008). This commitment has created a condition of unprecedented openness to innovation among government agencies dealing with rural health. The research in the pilot project began with a literature review, a mapping of the stakeholder network, both in the maternal health system in rural India, and with specific focus upon the stakeholder network in the Indian state of Assam, followed by a field-study. The field study was undertaken in two stages: one, interviews with key agencies that were either doing research on maternal health or were actively involved in projects at the grass roots level, and two, interviews in the state of Assam in India with rural families and key stakeholders in the maternal health system in Assam. I was looking at maternal health as a specific category of service delivery. The key findings of the pilot project that are significant here are:
- Urban models of service delivery rely on good infrastructure and often do not work for rural poor.
- Government mandates can have adverse effects. In India mandating 100% hospital births, has de-legitimized midwifery and de-skilled the community.
The pilot project concluded that services for marginalized and remote communities are indeed a separate category of services. A methodology of service design practice in such contexts would need to be; one, inclusive and account for traditions and deep rooted community practices; and two, decentralized, to account for both the need to support and stimulate local economy and to build self reliance as a way to tackle potential marginalizations (Gupta 2007). Such a practice of service design would be situated in opposition to mainstream service design practice that privileges centralization, use of sophisticated technologies and assumes urban consumption practices.
In this paper I first describe current approaches and practices in maternal mortality reduction and point out the need for a multifacteted approach. I then introduce current services design practices and point out their inadequacies to make a case for a special category of service design for resource poor settings. I refer to this practice as “service design for the remote rural poor” to distinguish the key attributes of the community that suffers significantly due to high rates of maternal health deaths.
Current Approaches: Problem Solving Maternal deaths
Current approaches to tackle maternal mortality have three focus areas;
- Focus upon Direct Causes – Medical intervention
- Focus upon Indirect Causes – Public health theory orientated intervention
- Focus upon the Ecosystem – The administration of state service provision
Focus upon Direct Causes: Medical Intervention!
A significant portion (38%) of maternal deaths occur due to Post-partum Hemorrhage (PPH) (See Image 1). An injection – such as Misoprostol, Oxytocin, or Endometrine – can stop the hemorrhage. So it appears the solution could be: Drug to be available at the time of Delivery! In field work in India I was asking the question of whether access to drugs was factor in the mortality rate. I learnt that Oxytocin was easily available in rural contexts as its misuse was widespread in the dairy industry. It appeared then that improved availability of such drugs would not change the situation dramatically. In addition as deliveries in remote areas are not often attended by trained personnel the actual delivery of the injection would be an issue. Therefore though direct intervention looks like a solution the problem could be solved by a focus upon indirect causes too, such as access to institutional care, which is the option favoured by the NRHM. In effect focusing upon drug delivery may not be the appropriate or complete solution!
Image 1: Causes of Maternal Deaths
Image 2: Evidence based interventions
Focus upon Indirect Causes
Most maternal deaths occur among women in remote and rural communities, often among the poor. These women do not have access to complete and continual care from the public health system. While physical, socio-cultural (gender, culture, religion and resultant lifestyles) and economic barriers (poverty) affect women’s access to institutional health services, youth pregnancy, anemia and medical history further compromise their ability to have a safe pregnancy and delivery. It is therefore entirely possible tha some deaths can be prevented through proper preparation before labour and delivery. Three case studies that highlight the possibility of improved health outcomes through non medical intervention are described below:
SEWA Rural in Tribal areas of Gujarat: This is an example of an NGO realizing improved health outcomes. With 75% home delivery, SEWA Rural could reduce MMR by 40% and NMR by 45% in three years with specific interventions at community level backed up by a functional FRU. Some of the features of this project were:
- Empowering TBAs/ Local women volunteers ensuring satisfactory Birth Preparedness/ Complication readiness
- Clean and Safe normal delivery ensuring critical new born care and post natal follow up
- Timely identification of any complications during delivery and ensuring prompt referral to SEWA Rural’s functional FRU
- Professional provision of basic and comprehensive emergency obstetric care by SEWA Rural FRU
Department of Health Tamil Nadu: This is an example of an improvement in maternal health outcomes through a systematic improvement in the practices of a state health system. Characterized by 90% institutional delivery the Tamil Nadu health system is a case study of best practice in systemic transformation.
The Boat Clinics of Assam: The Centre for North East Studies (CNES) runs a boat clinic service in Assam. The program comprises a fleet of 15 boats and has the support of the state NRHM. This is a story of coverage and a whole population living in the riverine areas of Assam has been brought into the ambit of the NRHM in Assam. While the improvement in health outcomes is yet to be reported upon in the maternal health space, the potential for overall health improvement and education impacting upon health outcomes is a real possibility.
Focus upon the ecosystem
The Government of India recognized that the health care service delivery in urban contexts was better than that available for rural populations. Their response, The National Rural Health Mission, attempts an ‘architectural correction’ by focusing separately upon the rural with a new and different design of the service. A key feature of the project’s focus upon maternal mortality is its three-tier strategy of separating states with high rates from those with moderate and low rates (MMR). Additionally the project has instruments such as: State level program-proposal development (to enable bottom up decision making), Program evaluation reports (to enable transparency) and Public Private Partnerships (to encourage diverse service provision models).
A key strategy within the project is a scheme called the Janani Suraksha Yojana (JSY – Safe Motherhood Programme). Bearing affinity to the global Safe Motherhood Initiative the JSY programme integrates the cash assistance with antenatal care during the pregnancy period, institutional care during delivery and immediate post-partum period in a health centre by establishing a system of coordinated care by field level health worker. The goal for the NRHM-JSY is to meet the Millenium Development Goal #5 target of an MMR of 100, a reduction from the 2009 Maternal Mortality Ratio (MMR) figure of 212 per 100,000 live births.
In the current scenario the efforts by the various state governments are to address the gaps in service delivery. Specifically the gaps in the NRHM focus upon MMR are:
- Insufficient resources in NRHM focusing upon JSY
- Reliance on Accredited Social Health Activist (ASHA)
- Field Data not accurate and so interventions not effective
- Quality of service, and skills available need improvement
In 2012 it’s the end of one phase of the JSY program – and there is a lot of reporting on the way the system has been rorted. Yet there are also success stories. Overall a key to improvement in maternal health outcomes will be improvements in the state health service provision. The following two stories illustrate the complexity in the situation and the need for both strengthening the state health system and building demand for the system. I highlight two significant aspects of the remote rural health condition as being one, access to Quality of Care and two, access to EmOC (Emergency Obstetric Care) Transport.
Of the two cases one was an instance in a remote tribal community of a home birth that went wrong. As narrated by the women who worked on the delivery the placenta could not be extracted and the woman was in distress though not bleeding. She was placed on the khatiya, a wooden bed with rope webbing, and carried by the men for kilometres to the local sub-centre. On arrival she was referred to the hospital, the ambulance was called and she was taken to the hospital some 50 kms away. By this time hours had gone by. At the hospital it is unclear if the personnel in attendance were qualified as no attempt was made to extract the placenta. She did not survive till the morning. In this case the community spoke of their reluctance to call the 108 Ambulance which was located 40 kms away, beyond some pretty poor potholed roads, to come to the aid of the woman who then had to be transported just 3 kms to the sub-centre. Home births are common in this community and the women spoke of their confidence in handling deliveries. When questioned they said a specific category of Dai’s (traditional birth attendants- TBAs) did not exist as any of the older women folk could be pressed into service at delivery. The capacity for ‘normal delivery’ (a phrase they used repeatedly) was considered to be widely prevalent.
The second case was the wife of a sub-inspector in the police. This was a hospital delivery that went wrong. As told by the family and corroborated by the community the delivery was carried out in the local PHC/ subcentre by an AYUSH, Ayurvedic, doctor who normally is not trained for western medical practices and specifically not for performing deliveries and surgical procedures. In this narrative he picked up the forceps to extract the placenta, and the ANM claim they asked him not to use the forceps, and as he used the forceps he set off profuse bleeding. She was rushed to the hospital and died on the way. I was told that there had been unsuccessful campaigns by local communities and NGOs to get this particular doctor to stop performing deliveries. Apparently he is to retire in a few years and there is an absence of administrative and political will to act on this doctor.
The interventions in this instance could be enhancement of skills available at both home and hospital settings. In the remote tribal community it was the woman’s sixth delivery and this could have been flagged as a high-risk pregnancy which then makes a case for risk assessment.
- Risk Assessment possible in one case of home birth
- Delivery by untrained person in hospital setting – lack of capability in infrastructure. Need for zero tolerance on Quality of Care
- Two approaches could be – facilitate home births and improve capacity in hospitals.
SERVICE Design is not perfect
The current practice of service design fails when used to develop services for poor and marginalized communities. Service design is currently centered around urban and affluent contexts. Service design theory has evolved with a focus upon privileging expert discourses in a predominantly urban context (Shostack 1982; Normann 2000; Leadbeater and Cottam 2008) This form of practice is focused upon redesigning existing services to either reduce cost, or improve customer experience and is predominantly targeted at urban, educated and affluent consumers of services (Frug 1998; Glaeser, Kolko et al. 2001). Service design theory has two main themes:
- Affordances and technologies of interaction.
- Increasing ease of access to services.
Historically, a greater focus upon technology has suppressed the discourse of access (Candi 2007). In health care projects, service design has benefited the client, often a publicly owned organization (Cottam and Leadbeater 2004). Extending such a paradigm of practice, producer-side thinking, into disadvantaged communities often leads to unintended consequences such as the exploitation of rural-poor communities. (Goodman 1968; Whitehead, Dahlgren et al. 2001; Wagstaff 2002).
Current global practices in service design use a mix of methods added on to conventional system design practices (Manzini, Vezzoli et al. 2001; Morelli 2002; Stickdorn and Schneider 2011). These new tools and methods are in the main drawn from contemporary software development practices in the field of interaction design (Manzini 2009). By becoming significantly integrated into retail business practice discourses, service design has had a significant and visible impact upon society (Cottam and Leadbeater 2004). The goal of this form of design is to improve ‘ease’ of customers’ access to services, improvement of ‘customer experience’ by the innovative use of internet and telecommunications infrastructure that is common in urban contexts (Hollins and Hollins 1991; Varadarajan 2009). Service Design projects in health service delivery have validated inclusive practices such as ‘co-creation’, through examples such as the RED project of the Design Council UK (Cottam and Leadbeater 2004). Significantly RED and other milestone projects in service design have been urban projects.
- Service design fails when used to develop services for the rural poor.
- Emerging service design theory is intimately tied to improving urban ‘customer experience’.
- A project of re-conceptualisation would extend service design theory by including service provision for the rural poor.
Services for marginalized and remote communities are indeed a separate category of services. A methodology of service design practice in such contexts would need to be; one, inclusive and account for traditions and deep rooted community practices; and two, decentralized, to account for both the need to support and stimulate local economy and to build self reliance as a way to tackle potential marginalizations (Gupta 2007). Such a practice of service design would be situated in opposition to mainstream service design practice that privileges centralization, use of sophisticated technologies and assumes urban consumption practices. Such a practice would be a separate category of Service design – Service Design for Remote-rural-poor (SDRRP).
Service provision for rural poor is a unique field characterized by neglect and poor performance of public services (Sainath 1992; Louis 2007). Approaches to the poor and marginalized in design have been characterized by a discourse of social engagement and social entrepreneurship (Jegou and Manzini 2008). While a focus upon the rural poor (Papanek 1985) has found form as the practice of social design (Margolin and Margolin 2002) with a strong focus upon artifacts (Rawsthorn 2007) the main paradigm is still one of pushing from the centre to the periphery (Er 2001). Service provision in health, universally viewed as a state subject has two key problems; one is the focus upon increasing access to and compliance with state services in remote areas (Humphery, Weeramanthri et al. 2001) and two is that “provider pluralism”, where different forms of service providers are allowed to operate, often goes unrecognized and is marginalized in state plans (Ministry of Health and Family Welfare 2005). To summarise, service provision for the rural poor is a complex context for design which demands that service design theory needs to move beyond: one, the urban context and reliance on infrastructure to become more widely applicable, and two, privileging the needs of a client and move towards working ‘creatively with messy and sometimes contradictory realities to achieve better outcomes’ (Standing and Bloom 2002).
The rural poor have not been the subject of a case study thus the practice and theory of service design has had little impact beyond the urban (Varadarajan 2009). While service designers have worked with the public sector on health and their projects have included service delivery to the poor, these have been mainly to redesign services to achieve better customer satisfaction. The poor in rural areas are often not reached by these public services and so ‘are much more likely to be at the purchasing end of shoddy or dangerous goods and services’ (Standing and Bloom 2002). In a key work dealing with service provision for the rural poor, Standing and Bloom speak of a ‘a failure of conceptualisation’.
The recognition of the neglect of the rural poor in health service delivery is contained in the preamble to the Indian National Rural Health Mission document, which advocates an ‘architectural correction’ of the health care services in India (2005). The problem of government health service provision in India, being focussed upon urban populations, has meant that health indicators for rural populations have been consistently poor and this is manifested in the high incidence of maternal deaths (Bajpai, Sachs et al. 2009; Padmanaban, Sankara Raman et al. 2009). With three more years to the 2015 Millennium Development Goals it is expected that the project of maternal mortality reduction would continue to be a location for intense scrutiny of service delivery (Mavalankar, Vora et al. 2008).
Its three years to the target date of the Millennium Development Goals and the question reprised in the media in India is “will India meet the target?”. A lot of money has been poured in and a huge effort has been made to transform the ecosystem. The key question therefore is – has it worked. Yes the system has been rorted, but is that a phenomenon only at the periphery and limited to certain specific geographical areas. Could the NRHM intervention therefore be largely seen to have worked to transform health outcomes for pregnant women? If yes – then this is the first step toward an large improvement in the health service system.
The future however has to contain a strategy addressing the problem of maternal deaths in remote rural areas by addressing both direct (medical) and indirect (social and systemic) causes. Service design can make a significant contribution in both areas – however the possibility of service design thinking contributing in the social and systemic space is the subject of my current and future research explorations.
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NRHM National Rural Health Mission
EmOC Emergency Obstetric Care
ASHA Accredited Social Health Activist
ANM Auxiliary Nurse Midwife
 TBA – Traditional Birth Attendant
 FRU – First Referral Unit