‘Problems must be prevented before they become health emergencies’: Ashok Alexander

Ashok Alexander jumped into a career in public health in 2003, when he left McKinsey and Co. as a senior partner, to take up an offer from the Bill and Melinda Gates Foundation (BMGF) to create Avahan, a programme to stem the spread of HIV/AIDS in India.

Avahan remains one of the biggest and most successful private-public health partnerships in India to date and is credited with helping avert 600,000 HIV infections, according to The Lancet journal. It did so by working in close partnership with the Centre, state governments and the affected communities in six states with the highest HIV prevalence.

With the mission accomplished, Alexander left BMGF India after a decade to set up his own NGO, Antara Foundation, which works in maternal and child health in Rajasthan, Madhya Pradesh and Chhattisgarh. Alexander describes the past 15 years as a “continuing adventure that has taken me from boardrooms to brothels, and beyond”, parts of which he has documented in his book, A Stranger Truth: Lessons in Love, Leadership, and Courage from India’s Sex Workers.

In an interview with HT, he outlines how public health issues can be prevented at the community level before they turn into health emergencies.

What according to you are the major public health challenges in India?

India still has some of the worst public health outcomes on many dimensions. For me, the one that stands out is the abject state of health of India’s poorest mothers and children in several northern states. Almost a million children die before they reach their first birthday every year. Of the ones who survive, more than one-third are malnourished. It is important that interventions focus on the first 1,000 days from the time a child is conceived till he/she is two years old.

What are the areas that need immediate attention to improve maternal and child health?

The markers of malnourishment are wasting (weight for height) and stunting (height for age). Malnourishment, especially before age two, affects the physical growth and cognitive development of a child. Malnourished children are being compromised. It is a humanitarian issue, at an individual level. And at the population level, it translates into a compromised workforce.

Is India spending enough on health care?

In India, about 69% of the health spend is still private; a poor man is largely spending from its pocket. Public health spending is still only 1.2% of its GDP. Having said that, the government is taking many steps in the right direction, such as implementing the Ayushman Bharat scheme. Again, Swachh Bharat addresses the issue of sanitation, which has a direct positive impact on health.

There is also a big gap in private giving. Both private philanthropy and CSR spending on the prevention (as opposed to treatment) of maternal and child health problems is low. I’d say less than 2% of total private giving goes to preventive health.

What are the possible solutions?

Health problems must be prevented at the village level, before they become health emergencies at higher levels of the system. The problems seem complicated, but the solutions are actually simple —after all, what is more natural than breastfeeding? The real challenge is ensuring that such solutions are delivered at scale. It is not enough to educate a mother about breast feeding – it’s more important to ask what prevents a mother from breastfeeding her baby.

Here, the barriers are finding the riskiest cases, gender inequality, livelihood compulsions, and more. The essence of scaling up is to manage supply and demand effectively, and work closely with communities to remove these barriers.

Ultimately, these are management solutions because they involve such classic business practices as segmenting the market, understanding consumer behaviour, data-use by front line workers. Much is made, and rightly so, of the shortage of doctors; but as big a problem is the shortage of managers and business thinking.