A Trek into the Margins of Public Health

According to the latest National Family Health Survey (2019-21), 89% of births in India now occur in healthcare institutions. Sounds promising! Yet, this figure can obscure the challenges still faced by families in remote areas, where access to quality health services remains out of reach. For many in the remaining 11%, each small improvement in health access demands tremendous effort—a phenomenon like the law of diminishing returns. The effort required for even slight improvements becomes monumental as we approach full access. It’s like the difference between raising a grade from 92% to 93% in school—that last one per cent takes extraordinary work.

I thought about this effect a lot on a recent visit to Barwani, Madhya Pradesh. It’s a place where small gains come at a significant cost, and where physical and systemic barriers converge, making every inch forward a battle:

I was accompanying our team, whose work centres on counselling pregnant women and helping them prepare for safe deliveries, often in circumstances where institutional care might not be a viable option due to a mix of structural, social, cultural, and economic barriers. Our plan included visiting Pati block (a block is an administrative cluster in India of 200-250 villages in a district) to counsel two pregnant women on planning for institutional delivery and following up with a mother who had successfully delivered at the nearest public health facility—a small victory in a pilot project underway in the district.

In areas like Pati in Barwani, where nearly 60% of deliveries have historically taken place at home, the situation has improved but remains challenging. We trekked up to a family’s home perched atop a hill. They’ve chosen to stay here because of their ancestral land, where they grow corn. Education, healthcare, and other services mean little when weighed against the ground that sustains their family. Just this year, network access reached their hilltop. My colleague, a local who’s proud of his region, shared with excitement that it would take a rigorous 90-minute three-hill trek to reach them. We managed it in 40 minutes!

This house, in the most picturesque setting, is alive with the laughter of children and the scent of freshly harvested corn. While we waited for the woman we’d come to meet—a recent mother who had gone back to work in the fields just days after her institutional delivery—I learned her story. Only a few weeks ago, she was carried down three hills in a makeshift palanquin during the night, with her husband and three neighbours carrying her down as my colleague lit the way with his phone torch. At the base, an ambulance awaited to rush her to the nearest Community Health Center (CHC) for her delivery. When she finally arrives, I step aside to give her space as my colleagues, fluent in the local tribal dialect, try to understand why she had yet to receive the government incentive for her institutional delivery—a benefit under Janani Shishu Suraksha Yojana, meant to encourage safe births in healthcare facilities.

This family faces tough choices every day. The nearest school is five kilometres away, but due to the threat of wild animals, they don’t feel safe sending their children there. The local health clinic is barely accessible, practically a dot on the horizon from their hilltop view. An Anganwadi Centre (a government-run local creche in a village), a school, an accessible clinic—this place needs them all, yet access feels like a distant reality.

My phone buzzes—I get a notification that an Amazon package has been delivered to my home in New Delhi. The irony isn’t lost on me. Here I am, trying to build the digital health portfolio for a grassroots NGO dedicated to maternal and child health, and even reaching people, let alone integrating them into the public health system, feels monumental.

My mind wanders to another woman we met before coming here: pregnant for the twelfth time, with an abysmal survival rate; only five of her children have lived. She had spent nearly nine years of her life pregnant and despite that, was still wary of healthcare interventions. Her fear of needles (pichkari she calls them) meant she avoided checkups and never registered herself in the public health system for antenatal care. The Community Health Officer (CHO) with our team, a young woman herself, approached the pregnant woman gently, hoping to perform a Fetal Heart Rate (FHR) check. When the woman hesitated, the CHO, with an empathy that can’t be taught, demonstrated the FHR check on herself first, reassuring her it involved no needles. Gradually, the woman’s defences eased and she was quite excited to know her gestational age and hear her unborn child’s heartbeat.

After the checkup, the CHO used this newly built trust to encourage her to take iron and folic acid tablets. Imagine—five months into her twelfth pregnancy, this woman had finally connected with the public health system. As the CHO filled out her information on the Mother and Child Protection (MCP) card, her eyes met mine, silently saying, “What more can we do?” I felt the weight of her question. Recognition, incentives, or awards can hardly capture the worth of what this CHO achieved that day. She didn’t just administer care; she brought someone into the public health system who had been overlooked. As we wrapped up there, we gathered for a group photo (which has become a ritual these days for some odd reason). I felt almost unworthy to sit beside this courageous pregnant woman, surrounded by her children, one on the way, smiling for the photo-op.

The chatter of my colleagues brings me out of my thoughts, and I find myself sitting outside the house on the hill. It is time to leave the “success story” of the mother who descended three hills to reach an ambulance and had her first institutional delivery. The lives of this mother and the pregnant woman we met are marked by resilience but also by a separation from the opportunities that so many of us take for granted. They are left behind, as far as their homes reach from ours and perhaps even further.

I rise to leave, our visit now over, and the descent awaits. My team tells me that it will be easier going down, and I suppose it will be. Because at the bottom, I’ll step back into my world, my privilege, my bubble.