Thread by @prashanthns

1/ Few days back, a 5y old girl with congenital heart disease from a remote village inside #BRHills got operated at Jayadeva Bengaluru, a govt tertiary hospital; kudos to the ped. cardiology team, but a thread on barriers to care BEYOND free schemes & health insurance

2/ Although an amazing feat to perform cardiac surgeries on children, hospitals like Jayadeva in fact routinely do this; this "technology" is available to "some of us" for decades, yet its access is not as per need; money is DEFINITELY a barrier, but perhaps the easiest to solve

3/ Gowramma's father grew up in #BRHills; from an Adivasi community; took extraordinary efforts to motivate him to agree to go to Bangalore; mother was nursing a 1y old; both daily wage earners; "free care in Bangalore" was not exactly the greatest gift of the State for them;

4/ ASHAs, NGO hospital staff, neighbors, Adivasi leaders and caring healthcare staff at her village YET his misgivings; previous govt hospital experience had not been "great" (to put it mildly);

5/ Arogya Mitra from #AyushmanBharat was only a small peg and social network of the local doctor who triggered a call to a "high official" & the "high official" who amidst her million things cared to oblige were crucial in securing "safe" care albeit free

6/ Another Adivasi woman fully eligible for AyushmanBharat suffering severe pain due to GallBladder stones requiring possible surgery waited a full day at a distant taluk hospital for the ArogyaMitra to produce a referral letter (after a minor bribe);

7/ my social networks with the dt coordinator couldnt secure family's trust; despite "on-paper" access to care, they settled for a local Dr suggested by a neighbor whom they could trust and feel safe;

8/ for now she'd rather endure pain locally than depend on a "free scheme" that she & others routinely experience through its lack of access to their kin; husband tells me that the "scheme planners" have never seen ground realities; possibly true, we all access pvt care anyways

9/ These are not rare instances; for many of the families we work with, these free schemes DO NOT work by themselves, but only through social networks; and as always its the elite in any group that have access to such priviliged social networks;

10/ Health policies & systems cannot function based on priviliged access and we must make fundamental corrections in these schemes

11/ Communities like Adivasis (but also many other rural poor and disadvantaged) struggle to reach higher centers in time not only because they cannot pay direct costs (hospital chages) & indirect costs (wage loss, single woman families, no relatives in Bangalore/cities), but...

12/ Also cos of limited trust & faith in public services; while many "middle-class" choose our care in the "open market" looking for ratings or call a cousin or uncle "who knows people", many others outside of these caste & class networks do not feel safe enough

13/ Anyone who has sought healthcare knows that it is not only about "science" & "evidence" that people look for; people also seek care, comfort, dignity, respect and safety; and while govt services fail on these counts (not only because of overworked staff but systemic)

14/ Private services - by design - provide these for paying customers (perhaps no fault of theirs but that of their regulation - or lack thereof); health & healthcare systems are instruments for equity & social justice;

15/ We must (a) commission meaningful & participatory evaluations of schemes keeping equity & justice in mind (b) include reps from disadvantaged communities in scheme oversight bodies, (c) go beyond SCHEMES to universal healthcare systems