Vulnerable children

Why has infant mortality risen in Mizoram even as it has fallen everywhere else?

The Mizoram government insists the data does not reflect the ground reality.

The fourth National Family Health Survey, conducted in between January 2015 and December 2016 shows that most public health metrics have improvement. For instance, the number of infants dying per thousand live births – a critical measure of human development index – has gone down sharply from 57 in 2005 to 41 in 2016.

Quite significantly, infant mortality rate has declined in all 15 states and union territories surveyed, except one: Mizoram. According to data released as part of the survey, the rate in Mizoram went up from 34 in 2006 to 40 in 2016, an increase of almost 18%.

Is this an indication that Mizoram is facing an impending public health? If so, what is fuelling it?

According to H Lhungdim of the Population Centre of India, who was part of the team that carried out the survey in the state, the primary reason behind the higher number was the use of district-level samples. “Since robust data samples from each of the districts were collected this time the poor performance of the southern districts, particularly Saiha, reflects in the state average,” he explains.

Lhungdim, however, insists that it may not be the best idea to compare the survey of 2006 and 2016 as there were no district-level samples taken in the former. Lhungdim’s explanation indicates that Mizoram’s high infant mortality rate may not be a new phenomenon but was not detected earlier because of bad data and poor representation from the historically backward and minority-populated southern districts.

The centralisation of health facilities in the state capital Aizawl, said Lhungdim, has led to people in the southern districts being deprived. “Most of Mizoram is rural and since the terrain is difficult, quality healthcare fails to reach these people,” he said.

A Scroll.in ground report from Saiha district in 2015 corroborates Lhugdim’s contention. Aizawl’s apathy has pushed Saiha to the margins and the neglect is all-pervasive in the area.

In neighbouring Manipur, almost all district headquarters are bustling centres with comparatively decent healthcare facilities, according to Lhugdim. Manipur has the lowest infant mortality rate in India.

State government in denial

The Mizoram state government, though, does not seem to think that there is a problem. The state’s coordinator for maternal and child health Dr Zochhuan Awmi told Scroll.in over the phone from Aizawl that the data was not accurate and it “depicted Mizoram in a bad light”.

“According to our own live data, the rate has been steadily coming down – it is 22 now,” said Awmi. “We are completely surprised at how they have arrived at these numbers. It seems they didn’t go to the field at all.” Awmi pointed out that even census data, released earlier this year, pointed towards a lower rate: 32.

The data Awmi is referring to is Sample Registration System data of the Registrar General of India. A two tier-approach is employed by the to collect these numbers. A local enumerator keeps record of all births and deaths in a sample set of villages or urban blocks and an independent supervisor carries out a survey every six months retrospectively. While Mizoram’s infant mortality rate was indeed 32 at the end of 2015, according to this data set, it has risen by more than 80% since 2000, when the rate was just 17.5.

A study from Mizoram University in 2015 diagnosed that the high infant mortality rate in Saiha was a direct consequence of food insecurity and malnutrition. The study showed that per capita calorie intake in the region was 1703 kilocalories. The recommended amount is 2400 kilocalories.

Awmi, however, contended that the situation was under control. “Since April 2015, we have been distributing Vitamin D supplements and we have seen deaths come down by almost 50%,” she said. “We refuse to accept the National Family Health Survey.”

Broken system

T Sundararaman, dean of the School of Health Systems Studies at the Tata Institute of Social Sciences in Mumbai, said the National Family Health Survey seemed fairly robust and believable. “State governments tend to underreport data for obvious reasons,” said Sundararaman, who was also till recently the executive director at the National Health Systems Resource Centre in New Delhi.

However, he added, infant mortality rates should always be understood in relation to other metrics like nutrition prevalence since better nutrition levels usually lead to low infant mortality rates.

“The data looks believable because it’s in the same range as the census data and the previous survey,” Sundararaman says. “What happens is simple interventions like women’s education, sanitation, nutrition, etc. can bring down infant mortality rates from say the 60s to the 30s, but to decrease it beyond that requires higher level scientific and medical interventions and special facilities. Since it is unlikely that Mizoram can afford such interventions, the number has probably stagnated or increased, but it has definitely not decreased.”

Mizoram has been on the verge of a health crisis for some time now, owing largely to its over-reliance on central funds in the absence of any other real source of revenue. Even the Janani Suraksha Yojana, a scheme to reduce neonatal and maternal deaths, has suffered major cutbacks due to non-availability of funds.

It is evident that Mizoram’s healthcare system, particularly its maternal and child health services, is broken and requires immediate attention. The government would do well to acknowledge it.

We welcome your comments at letters@scroll.in.
Sponsored Content BY 

What hospitals can do to drive entrepreneurship and enhance patient experience

Hospitals can perform better by partnering with entrepreneurs and encouraging a culture of intrapreneurship focused on customer centricity.

At the Emory University Hospital in Atlanta, visitors don’t have to worry about navigating their way across the complex hospital premises. All they need to do is download wayfinding tools from the installed digital signage onto their smartphone and get step by step directions. Other hospitals have digital signage in surgical waiting rooms that share surgery updates with the anxious families waiting outside, or offer general information to visitors in waiting rooms. Many others use digital registration tools to reduce check-in time or have Smart TVs in patient rooms that serve educational and anxiety alleviating content.

Most of these tech enabled solutions have emerged as hospitals look for better ways to enhance patient experience – one of the top criteria in evaluating hospital performance. Patient experience accounts for 25% of a hospital’s Value-Based Purchasing (VBP) score as per the US government’s Centres for Medicare and Mediaid Services (CMS) programme. As a Mckinsey report says, hospitals need to break down a patient’s journey into various aspects, clinical and non-clinical, and seek ways of improving every touch point in the journey. As hospitals also need to focus on delivering quality healthcare, they are increasingly collaborating with entrepreneurs who offer such patient centric solutions or encouraging innovative intrapreneurship within the organization.

At the Hospital Leadership Summit hosted by Abbott, some of the speakers from diverse industry backgrounds brought up the role of entrepreneurship in order to deliver on patient experience.

Getting the best from collaborations

Speakers such as Dr Naresh Trehan, Chairman and Managing Director - Medanta Hospitals, and Meena Ganesh, CEO and MD - Portea Medical, who spoke at the panel discussion on “Are we fit for the world of new consumers?”, highlighted the importance of collaborating with entrepreneurs to fill the gaps in the patient experience eco system. As Dr Trehan says, “As healthcare service providers we are too steeped in our own work. So even though we may realize there are gaps in customer experience delivery, we don’t want to get distracted from our core job, which is healthcare delivery. We would rather leave the job of filling those gaps to an outsider who can do it well.”

Meena Ganesh shares a similar view when she says that entrepreneurs offer an outsider’s fresh perspective on the existing gaps in healthcare. They are therefore better equipped to offer disruptive technology solutions that put the customer right at the center. Her own venture, Portea Medical, was born out of a need in the hitherto unaddressed area of patient experience – quality home care.

There are enough examples of hospitals that have gained significantly by partnering with or investing in such ventures. For example, the Children’s Medical Centre in Dallas actively invests in tech startups to offer better care to its patients. One such startup produces sensors smaller than a grain of sand, that can be embedded in pills to alert caregivers if a medication has been taken or not. Another app delivers care givers at customers’ door step for check-ups. Providence St Joseph’s Health, that has medical centres across the U.S., has invested in a range of startups that address different patient needs – from patient feedback and wearable monitoring devices to remote video interpretation and surgical blood loss monitoring. UNC Hospital in North Carolina uses a change management platform developed by a startup in order to improve patient experience at its Emergency and Dermatology departments. The platform essentially comes with a friendly and non-intrusive way to gather patient feedback.

When intrapreneurship can lead to patient centric innovation

Hospitals can also encourage a culture of intrapreneurship within the organization. According to Meena Ganesh, this would mean building a ‘listening organization’ because as she says, listening and being open to new ideas leads to innovation. Santosh Desai, MD& CEO - Future Brands Ltd, who was also part of the panel discussion, feels that most innovations are a result of looking at “large cultural shifts, outside the frame of narrow business”. So hospitals will need to encourage enterprising professionals in the organization to observe behavior trends as part of the ideation process. Also, as Dr Ram Narain, Executive Director, Kokilaben Dhirubhai Ambani Hospital, points out, they will need to tell the employees who have the potential to drive innovative initiatives, “Do not fail, but if you fail, we still back you.” Innovative companies such as Google actively follow this practice, allowing employees to pick projects they are passionate about and work on them to deliver fresh solutions.

Realizing the need to encourage new ideas among employees to enhance patient experience, many healthcare enterprises are instituting innovative strategies. Henry Ford System, for example, began a system of rewarding great employee ideas. One internal contest was around clinical applications for wearable technology. The incentive was particularly attractive – a cash prize of $ 10,000 to the winners. Not surprisingly, the employees came up with some very innovative ideas that included: a system to record mobility of acute care patients through wearable trackers, health reminder system for elderly patients and mobile game interface with activity trackers to encourage children towards exercising. The employees admitted later that the exercise was so interesting that they would have participated in it even without a cash prize incentive.

Another example is Penn Medicine in Philadelphia which launched an ‘innovation tournament’ across the organization as part of its efforts to improve patient care. Participants worked with professors from Wharton Business School to prepare for the ideas challenge. More than 1,750 ideas were submitted by 1,400 participants, out of which 10 were selected. The focus was on getting ideas around the front end and some of the submitted ideas included:

  • Check-out management: Exclusive waiting rooms with TV, Internet and other facilities for patients waiting to be discharged so as to reduce space congestion and make their waiting time more comfortable.
  • Space for emotional privacy: An exclusive and friendly space for individuals and families to mourn the loss of dear ones in private.
  • Online patient organizer: A web based app that helps first time patients prepare better for their appointment by providing check lists for documents, medicines, etc to be carried and giving information regarding the hospital navigation, the consulting doctor etc.
  • Help for non-English speakers: Iconography cards to help non-English speaking patients express themselves and seek help in case of emergencies or other situations.

As Arlen Meyers, MD, President and CEO of the Society of Physician Entrepreneurs, says in a report, although many good ideas come from the front line, physicians must also be encouraged to think innovatively about patient experience. An academic study also builds a strong case to encourage intrapreneurship among nurses. Given they comprise a large part of the front-line staff for healthcare delivery, nurses should also be given the freedom to create and design innovative systems for improving patient experience.

According to a Harvard Business Review article quoted in a university study, employees who have the potential to be intrapreneurs, show some marked characteristics. These include a sense of ownership, perseverance, emotional intelligence and the ability to look at the big picture along with the desire, and ideas, to improve it. But trust and support of the management is essential to bringing out and taking the ideas forward.

Creating an environment conducive to innovation is the first step to bringing about innovation-driven outcomes. These were just some of the insights on healthcare management gleaned from the Hospital Leadership Summit hosted by Abbott. In over 150 countries, Abbott, which is among the top 100 global innovator companies, is working with hospitals and healthcare professionals to improve the quality of health services.

To read more content on best practices for hospital leaders, visit Abbott’s Bringing Health to Life portal here.

This article was produced on behalf of Abbott by the Scroll.in marketing team and not by the Scroll.in editorial staff.