Tag Archives: India

Making the Case for a Family Doctor

Kriti (name changed), my co-resident in an apartment I am renting out during the internship is a typical young professional working in the booming software industry in India. The neighborhood we live in is serviced by the best amenities possible including services for health care that range from clinics, secondary hospitals and super-specialty centers. Two weeks into my stay here, Kriti developed a recurring back pain that almost affected her mobility. She knew she had to see a doctor but needed answers to many questions before she chose one – which doctor/ specialist will be right for the problem, how expensive will the services be, will the doctor have time to hear about her entire medical history before he/ she prescribes her a treatment.

Incidentally my study during the internship was looking at this very issue – the rising cost of healthcare resulting from a lack of preventive care as well as lack of information. For example, a lot of Kriti’s problems could be sorted if she could see a family physician. The family physician would perform a preliminary investigation helping Kriti diagnose the problem and also prescribe the preliminary treatment. While the specialists look only at the specific cause of concern, the physicians would view Kriti’s health concerns from a holistic point of view and provide a more comprehensive line of treatment. If need be, he would direct Kriti to the right specialist. On top of all this, seeing a family physician would be much less expensive than seeing a specialist in the first place.

The problem is that the presence of family physicians has significantly dropped in India.  Fewer medical graduates want to follow the stream of family medicine as against super-specializations like cardiology, neurology and urology etc.  More and more people are changing cities frequently for their jobs making it difficult to have a dedicated family doctor. Further, with a rise in income levels and easier access to specialists, there has been a surge in demand for their services. With a diminishing supply of providers, and an inconsistent demand for general practice, the breed of family physicians is nearing extinction in the country.

At the same time, lifestyle related and non-communicable diseases are rising in India. According to a 2010 World Bank report, the percent of out of pocket expenses incurred by households in the country on non-communicable diseases rose from 31.6 percent in 1995-96 to 47.3 percent in 2004. Family physicians who take on the role of health managers and promote preventive health can significantly improve health stats of the population.

A handful of providers are doing just that. Nationwide Healthcare in Bangalore, Ross clinics in Gurgaon and Healthspring in Mumbai are amongst some of the providers trying to revive the family physician model. They are all multi-clinic chains servicing communities in urban and peri-urban areas and working to reestablish the trust for a family physician as the first point of contact for any health concern. More importantly, they are reinforcing the importance of preventive rather than curative care. They are all in the first few years of their operation, and while it may be hard to assess their success at this stage, they offer an interesting study as innovative health care models that are striving to improve the population’s health indices.

ACCESS Health International (AHI), the agency I am interning at is taking an active interest in these models and others similar to them. While here, I am conducting a study of these models to understand their delivery model, document their success stories, and identify challenges they face including support for replicating and scaling up. Going forward, AHI will be working to build a community of practice that will facilitate a collaborative environment amidst the different players interested in the field.



India’s Water Conflicts: Politics over Water

Being here for three months working on watershed issues has indirectly led me to other unstable issues here in India. Water conflicts in India are becoming explo­sive and politicians are working hard to sustain them over a long period of time. Practically every state in India, particularly in the south, has at least one or more conflicts over water distribution with its neighbor. Maharashtra, Karnataka and Andhra Pradesh are at loggerheads with each other over the sharing of the Krishna waters; Karnataka, Tamil Nadu, Pondicherry and Kerala are in conflict over the Cauvery; Kerala and Tamil Nadu are fighting over the 113-year old Mullaperiyar dam. The intensity and frequency of these conflicts are increasing. No doubt that it will become worse with the in­creasing uncertainty of climate change.

Despite having negotiated several settlements with Pakistan over water with the help of mediators, it seems as though it is very difficult for Indian states to han­dle internal conflicts over water. One of the reasons is that there is a lack of an efficient frame­work and mediating mechanism for con­flict resolution, both within the govern­ment and civil society. There are a number of common themes among the conflicts over water in India.  For example, it is common for downstream users to distrust upstream dam building and operation, and this kind of conflict exists within states and between regions, at levels ranging from the village to the basin level. The other important aspect is that India’s systems are not oriented towards building trust. In fact, very often, the contrary is the case, especially when such conflicts overlap with state boundaries.

Another issue I see is that there is a lack of a scientific approach to water management. The science and the policy of dealing with water sharing have both considerably advanced in recent times around the world and especially in the United States. Water manage­ment in India does not seem to have advanced as much. As a result of a lack of communication between scientists and policymakers (ala Copenhagen) river flows have fallen below levels and have disappeared in many important fishing communities. India seems to have its own brand of the “rule of capture”. Dam construction technology has led to a construction race that aims at capturing every drop of water that everyone is entitled to. The complexity of climate change adds another serious dimension to the conflict. While the precise change in rainfall is disputed, all climate models agree on the likelihood of the increase of extreme events – extreme surpluses and extreme shortages.

Population Displacement in India Due to Climate Change: Why 3 Feet Equals 125 Million People

Climate change activists in northern India

Climate change activists in northern India

Climate change is increasingly understood to be a human induced phenomenon, greatly accelerating natural cycles. By now we have heard over and over again, that in it’s latest research the Intergovernmental Panel on Climate Change has confirmed that accelerated climate change – global warming – is taking place. No surprise there. But, what may be a lesser known fact is the impact climate change is having on sea-levels.

A 3-feet rise in sea-level will inundate 3,700 square miles in India, of which Mumbai, Kolkata and Chennai will be the major cities being affected. This would mean losses of billions of dollars in infrastructural, social, physical assets and capital.

According to Indian climate scientists, 125 million people are likely to migrate in the coming century of which 75 million will be from Bangladesh. The people from Bangladesh will most likely migrate to India in addition to their own 50 to 60 million people who will be displaced due to sea-level rise and resulting water source scarcities.

Mumbai, Kolkata and Chennai are the largest cities on the coast of India, on an average elevation of 5-30 feet, which is in the Low Elevation Coastal Zone, an area that falls under 30 feet of coastal elevation. Approximately 50,000 square miles of land fall under this zone in India – this includes a population of over 60 million. Fifty percent of this population are in urban regions comprising approximately 31 million people.

These are sobering numbers that leave these predictions in the hands of local institutions. The question is whether these institutions are capable of managing or containing these problems.

One industry that will be hurt the most are the fishing communities, which live on the coast and are the least resilient to climate change. Livelihoods will be lost and  forced to move inland in search of alternative work.

Erratic rainfall, climate changes, water shortages and food scarcity will push the vulnerable communities of landless laborers, small farmers, into worse conditions forcing them to migrate to the cities in search of new livelihoods. Economists believe that the adaptive capacities of these communities are extremely low considering that they are already affected by negative trends of globalization.

If these trends continue and no major policy changes are made then the displacement will be around 50-60 million. Too high a number for the Indian government to not take action.

Watershed Development Programs in India: Impacts on Equity and Resource Management

At the moment, I am calculating a water balance (rainfall versus water use) on a watershed and farm level in a village in the state of Gujarat, India to determine the efficiency of the central government of India’s Watershed Development Program. In general, the Watershed Development Program is designed to help poor farmers in villages in semi-arid regions of India. The program aims to generate jobs through building rain water harvesting structures, promoting gender and caste equity, and advocating natural and water resource management policy.

As part of an interdisciplinary team that includes hydrologists, economists, rural development experts, and social scientists, we hope to generate awareness of the affects (positive or negative) the watershed development has on the livelihoods of the rural poor.

Having a scientific background (hydrogeology), my way of thinking about solving problems has changed. For example, development programs are not and cannot be a purely scientific exercise. I have had the great fortune here at GIDR to go out to villages and talk to heads of villages, tribes, and various caste members of how the government’s water policies affect them. Interacting with various groups and stakeholders (in different languages no less) has proven to be challenging and rewarding at the same time – human impact from government policies and climate change are clearly expressed.

Being in the semi-arid region of western India has proven to be the best experience when it comes to the issues of climate change, rural development, and water policy.  It provides a challenging task of combining natural phenomenons with socioeconomic conditions of a unique population. Gujarat is a unique state unto itself as it contains vast deserts, dense forests, highly urbanized areas, rolling hills, and millions of acres of farmland. As a result, development strategies change throughout the state.

Hello from India!

Good evening from the 113 degree heat of Ahmedabad, India. I am interning with the Gujarat Institute of Development Research (GIDR) where I am evaluating watershed development programs that were initiated by the central government to sustain productivity of dry and semi-arid regions of the country by adopting more efficient production and conservation techniques. This research effort, undertaken at GIDR for evaluating these watershed development programs, is known as the “Forum of Watershed Research and Policy Dialogue”. The forum focuses on watershed development sustainability, gender and caste equity, and democratization in rural India.

At the moment I am primarily conducting field investigations to determine the spatial distribution of groundwater withdrawal scenarios by farmers in select rural watersheds, (2) collaborating with an evaluation team in analyzing the collected field data and determining the program efficiency on three scales (household level, farm level, and watershed level), and (3) evaluating the impact of technology on the economic welfare of households in the select watersheds.

We basically want to answer the question of  “What impact do watershed development activities have on rural areas, especially groundwater resources, agricultural production, and socioeconomic conditions?” The ultimate goal is to help policymakers create guidelines for the watershed development programs in the state.

I’m hoping that with my background in hydrology and environmental science I can bridge development scenarios with water management with technological advancement and water policy. Stay tuned!