Inside the primary health centre at Gharuan village in the north Indian state of Punjab, a family is excited about its newest member. Ram Kaur looks fondly at her grandson, barely hours old, lying beside his mother. Although she herself had given birth at home, she encouraged her daughter-in-law Karamjeet to give birth at a health centre. "Many women die in childbirth because they do not make it to a hospital or a health centre in time. I did not want that to happen in my family" she says.
Karamjeet is fortunate. In India, only 41% of births take place in a health facility and only one in seven babies born at home is delivered by a skilled birth attendant, according to the most recent figures. Still, thousands of women die every year in childbirth or just afterwards across this vast country of 1.2 billion because they live too far from a health facility to get antenatal care and because they can't afford the transport and other costs linked to hospitalization. Also--unlike Ram--family elders often have more faith in traditional birth attendants, who are not always able to handle obstetric emergencies.
A community health worker convinced Karamjeet's family of the benefits of institutional delivery. Such workers are vital for improving health in communities with little education. "In the beginning, I was scared," says Karamjeet. "But after a few visits to the health centre for check-ups the fear disappeared." She smiles after receiving her US$ 15 (700 Indian rupees) cheque under the Janani Suraksha Yojana (Motherhood Protection Scheme), a federal government cash assistance programme which requires recipients to undergo at least three antenatal check-ups and give birth in a health facility.
The health worker who persuaded Karamjeet's family is one of a national cadre of village-based workers (accredited social health activists). These workers also advise villagers on sanitation, hygienic practices (including hand washing), contraception, immunization and other health issues. They form the backbone of a flagship government programme launched in 2005 known as the National Rural Health Mission.
The Planning Commission, the government agency responsible for the federal budget, has pledged to spend more on health in the next Five-Year Plan, which begins next year. And, as funds for health are set to increase, public health advocates are calling for more to be spent tackling the social factors that determine health.
"While some initiatives have been taken to address the social factors that impact health ... the government has not adequately invested in employment" says Mirai Chatterjee, the director of social security for the Self-Employed Women's Association. "Since 1990 we have seen mostly 'jobless growth'. This has led to increasing inequalities" she says.
For Nata Menabde, the World Health Organization (WHO) Representative to India, despite the fact that the health system is there to serve everyone who needs it, the rich often have better and easier access to services than poor and vulnerable populations. "This is, among other reasons, because the poor have reduced access to information and take more time to find their way to needed services within the system. Therefore, having services available to all is not enough. Extra efforts are needed to ensure that all people can benefit from them in an equitable manner."
"A significant body of evidence shows that living conditions and poverty in a broader sense are important determinants of health. Can WHO improve health without addressing poverty and living conditions ? Although poverty has many dimensions--not all of which fall within the scope of WHO's mandate--WHO can contribute to concerted actions towards poverty reduction by bringing evidence to the attention of policy-makers and making them aware of the links between those determinants and health outcomes," Menabde says.
"There are promising signs of change," says Chatterjee, who was a member of the Commission on Social Determinants of Health, a group of policy-makers, researchers and activists set up by WHO in 2005. …