AKHA (the ship of hope) is the name given to boat clinics that visit the 2,300 riverine islands in upper Assam on the Brahmaputra, serving almost 10 per cent of the population of Assam. The north-eastern Indian state has some of the worst health indicators in India: the infant mortality rate (IMR) is 58 for every 1,000 live births and the maternal mortality rate (MMR) stands at 390 per 100,000 live births, both of which are way higher than the national averages.

With the present IMR at 47/1,000 and the MMR at 212/100,000, India may not be able to meet the Millennium Development Goals target of bringing the IMR to 27 and the MMR to 100 by 2015. The situation across its border, in Pakistan, is no better. However, there are some innovative schemes and projects being carried out in India that need to be scaled up there and worth learning from and perhaps even emulating here in Pakistan.

The case study on the boat clinics is just one of the 23 innovations (chosen from a directory of over 200 models) designed to reach the poor and the marginalised in the area of maternal and newborn health, documented by the Public Health Foundation in the book Innovations in Maternal Health: Case Studies from India. Divided into five sections, the case studies are written in crisp non-technical style, not only making for an interesting read for non-medical people, but also a valuable resource for educating public health professionals in understanding issues related to maternal health and its socio-cultural context. The book would also be useful for those who are advocating for change in the areas of maternal and newborn health. It is accompanied with a set of 16 films.

Reaching out to the Assamese population on the islands was a big challenge, especially during the monsoon season when these islands are cut off from the rest of the country. But in 2005, Sanjoy Hazarika, founder of the Centre for North East Studies and Policy Research came up with the novel idea of using boats to reach out to the island people. Today the centre owns seven boats large enough to carry medical practitioners, supplies and equipment. It also has a basic laboratory for on-the-spot testing. Solar energy is used to power refrigeration. There are eight more boats that can be rented. Apart from the boats that are docked on the mainland, there are several smaller boats that make day trips, ferry medical personnel and supplies to islands away from the mainland to set up day camps, and reach the next island before sunset. There are also transport boats for emergencies, especially pregnancy-related complications.

Perhaps something similar can be considered for the people living in and around the Manchar Lake in the Jamshoro district, Sindh, or for the inhabitants of the villages in the creeks of the Indus delta, namely Kharo Chan, Hajamro, Turshan and Khobar.

Innovations in Maternal Health next takes the readers on a journey south of West Bengal into the islands of Sundarbans that are enclosed by mangroves. The place epitomises poverty, deprivation and acute struggle against geographical challenges. Finding committed medical and paramedical staff to work in those communities is next to impossible. As with the islands in Assam, here too, the only way to reach is by boats.

According to a study conducted by the USAID, one of the major factors hindering people from seeking family planning and reproductive and child health services is the cost. To find a solution to that, a voucher scheme was piloted. One of the case studies in the book documents the Sambhav Voucher Scheme of Uttarakhand (the same scheme was implemented in two other states, Uttar Pradesh and Jharkhand) that provides subsidised access to quality family planning and reproductive health services to those living below the poverty line. It is a collaborative effort of the government of India and the USAID.

These vouchers cover a range of services — antenatal care, delivery, postnatal care, sterlisation, contraceptive pills, condoms, intrauterine contraceptive devices and institutional deliveries including treatment for complications. The objective is to utilise the large but unregulated private sector providers to deliver key health services at greatly improved and affordable standards. The poor in Uttarakhand could, for the very first time, avail these services from any of the designated private hospital of their choice, free of cost.

The book also discusses two emergency referral transport projects delineating the role of transport in saving women’s lives. In fact, delay in reaching health facilities because of not being able to find transport is one of the three delays often cited by public health specialists.

The GVK Emergency Management and Research Institute started operations in 2005 with 30 ambulances across 50 towns in the state of Andhra Pradesh. The same year, the government came on board and today the entire state is covered with 802 ambulances providing round the clock service. They receive 30,000 calls and handle 3,500 emergencies in a day. Twelve other states and two union territories have replicated the initiative.

The services include pre-hospital care, emergency care during transportation and emergency care at the facilities the institute has tie-ups with. The services are provided completely free of cost.

However, while these ambulances may be used for general emergencies as well, 96.7 per cent of the time they are used for a medical emergency. Of these, the largest category is pregnancy related. While the global standard for reaching the patient is around eight minutes, ambulances in India take about 20 minutes.

By disseminating information about these novel yet possible ways of providing healthcare services, the editors of Innovations in Maternal Health make it possible for them to be emulated elsewhere. And that perhaps is the primary reason for compiling these models. In the book’s foreword, the president of the Public Health Foundation, K. Srinath Reddy, states: “It seeks to accelerate pace of innovations by documenting contemporary innovative programmes undertaken to improve maternal and newborn care in India.”

Innovations in Maternal Health: Case Studies from India

(Health)

Edited by Jay Satia, Madhavi Misra, Radhika Arora and Sourav Neogi

Sage Publications, India

ISBN 9788132113102

356pp.