Healthcare in rural India

Outlook carries a series of articles about doctors working in rural areas of India. The header article provides an overview of the kinds of efforts that are underway and the unique challenges doctors face in rural areas. This particular para caught my attention as I was guilty of this kind of thinking as well.

"What also angers doctors working in rural areas are misconceptions that are rife about the healthcare needs of "simple and hardy" rural people. Rural poor, they point out, are prone, not just to the worst communicable diseases, but all the so-called "lifestyle diseases" lazily correlated only with urban excess, and never with rural poverty and stress. For instance, the rural poor show up, far from obese, with diabetes so advanced that diagnosis and amputation happens in a single session. Yet, affordable access to insulin is a dream when even getting a basic malaria test is hard."

There are several short profiles (Chattisgarh, Tamil Nadu, Uttaranchal) of doctors who have given up lucrative careers in cities to go work in villages. Finally there is an opinion piece that makes the case that the rural medicine should be a separate medical specialization in itself as it requires some very specific and unique skills. The following quote from this article hints at just how imbalanced health infrastructure in India really is.

"Seventy per cent of our population lives outside the cities but eight out of ten doctors and a shocking 80 per cent of all hospital beds are urban. Every preventable malady, like tuberculosis, malaria, diarrhoeal diseases, is many times more prevalent in rural India; so are infant and maternal mortality."

Uses of internet in villages

Washington Post carries a long article about how internet access through cellphone (connected to a computer) is making life easier for the people of a village in Bangladesh. Here are some of the uses listed in the article

1. Making sure that a doctor will be available before making a long and expensive trip to the city
2. Make up for the lack of access to books
3. Call relatives abroad using VoIP at dirt cheap rates (11 cents vs $2)
4. Getting married on webcam !!!

These cellphone powered internet centers are being set up by Grameen Phone which is partly owned by Grameen Bank of Muhammad Yunus fame. To the best of my knowledge 3G hasn't arrived in Bangladesh yet. So that means the cellphone based internet can provide dialup speeds at best. I didn't know you could do VoIP or video conferencing over dialup!

Right now a number of initiatives are going on to make computers available at extremely low cost. Assuming atleast one of these initiative will succeed, this story illustrates how a combination of dirt cheap cellular rates and availability of computers can improve the quality of life of people.

Global hunger index

Outlook carries an article about a Global Hunger Index developed by the International Food Policy Research institute. Some of the key findings from the index are here.

• India ranks 23rd (1 being most afflicted by hunger).
  
• Malnutrition in India is worse than that in Sub-Saharan Africa but child mortality rates are less.
  
• The custom in many households for women to eat what's left after men have had a go is an important cause for child undernourishment.
  
• Good news is that India's Global Hunger Index has fallen dramatically from 41.23 in 1981 to 25.73 in 2003.
  
• Bad news is that the index was 25.73 in 1997. So in this one aspect nothing has improved during 6 years of torrid economic growth.
  

There is also a short and interesting comparison between the poverty alleviation efforts of India and China over the past 30 years.

Charity is selfish

There is a thought provoking article on Slate which claims that charity is selfish. Well, I guess intuitively that makes sense. After all we volunteer because it makes us feel good (or less bad).

"If people really were altruistic, there would be much less volunteering. ... It would almost always be more effective to volunteer less, work overtime, and give more. A Dutch banker can pay for a lot of soup-kitchen chefs and servers with a couple of hours' worth of his salary, but that wouldn't provide the same feel-good buzz as ladling out stew himself, would it?"

But then given the fact that all humans are selfish isnt it better to channel your selfishness towards volunteering than say designer shoes? Some U of Chicago economists (who else) have conducted an experiment which shows how little altruism has to do with many charitable donations. Some findings as presented by the Slate article

"Using controlled trials to compare different methods of door-to-door fund-raising, professor List's team discovered that it was much more effective to raise funds by selling lottery tickets than it was to raise funds by asking for money."

"More effective still was simply to make sure that the fund-raisers were attractive white girls rather than a dowdier assortment of males and females representing all shapes, races, and sizes."

Now I know why I am not so good at raising money :)

For me the most interesting part of the article is where it talks about how we allocate our charitable dollars.

"Someone with $100 to give away and a world full of worthy causes should choose the worthiest and write the check. We don't. Instead, we give $5 for a LiveStrong bracelet, pledge $25 to Save the Children, another $25 to AIDS research, and so on. But $25 is not going to find a cure for AIDS. Either it's the best cause and deserves the entire $100, or it's not and some other cause does. The scattershot approach simply proves that we're more interested in feeling good than doing good."

State of Indian work force

Rediff has an article about an employment report on the Indian labor force. This report is for the 2004-2005 year. Given that the topic is not related to movies or cricket or how people in Bangalore and Mumbai are buying a gazzillion BMWs, I was surprised to even find it on Rediff. This report was commissioned by the 'Ministry of Statistics and Programme Implementation' (just the name makes me want to work there). Don't let the name fool you. Their Press Release of this report is very succinct and informative. A must read in my opinion. Here are some interesting tidbits with emphasis added by me.

"About 11 per cent of households in both the rural and urban areas were headed by females. Compared to all households, they had, on an average, a relatively smaller household size and a much higher sex-ratio."

Confirms anecdotal evidence from Kerala.

"About 42 per cent of the population in the country were usually employed. The proportion was 44 per cent in the rural and 37 per cent in the urban."

58% of the country is not usually employed! Think about it. In the US when the unemployment rate reaches 10% there is a national crisis. Are they counting different things?

"The unemployment rate (number of person unemployed per 1000 persons in the labour force), according to usual status (ps+ss), was 17 in the rural areas and 45 in the urban areas. The unemployment rates for females are found to be higher than that for males, and highest among urban females."

Say what? There is more employment in rural than in urban India?

"In both the rural and urban areas, unemployment rate among the educated (secondary and above) was higher than that among those whose education level was lower than secondary."

Oh, now I get it. Our distaste for manual labor.

"In rural India, the proportion of ‘all’ male workers engaged in the agricultural activities declined gradually from 81 per cent in 1977-78 to 67 per cent in 2004-05. For ‘all’ female workers, the decline was less - from 88 per cent in 1977-78 to 83 per cent in 2004-05."

So women are taking up agriculture work as men move to cities?

Spend to Save?

Reduce, Reuse, Recycle. The mantra of conservationists. In this world of limited resource, this is what every responsible person should do.

But are they really the right thing to do in the long run?

Consider the case of oil. a limited resource that is set to run out in the not-too-distant future.

Lets say a significant portion of us decide to cut down on our dependence of oil and its products. Of course, there will always be savers and spenders amongst us. What would happen?

Oil, like every other commodity, is priced by supply and demand and perceived future supply and demand. The supply would outstrip demand. Prices would drop. The spenders would find this ever more reason to be carefree in their spending habits. Perhaps enough (since there are likely to be more spenders) to undo all the savings.

Not exactly what the savers wanted!

Now, on the other hand, what if the savers did the exact opposite? Went on a spending spree. And drove prices up. Wouldn't that provide the economic incentive for some bright soul to come up with a viable alternative to the internal combustion engine? Or atleast force the spenders to rethink their spending?

P.S. Hopefully the bright soul will be successful before we are thrown into the chaos that is inevitable if a major oil shortage were in sight.

P.P.S. Doesn't this sound a bit lie the current energy price situation where developing countries are waking out of their slumber and starting to bid for an increasingly larger piece of the global resource pie?

Ultra cheap pc from, where else China

Slashdot links to this techfreep article about a $125 PC planned by a company called 'ZhongKe Menglan Electronics Technology Co.' in China. At first look the specifications of this PC look pretty good for the money. Infact (and I am a bit embarassed here) it's almost as good as my old, still very much in use PC.
RAM - 256MB (same as mine)
Hard Drive - 40-60 GB (more than mine)
CPU - Godson-2 800Mhz-1Ghz (mine is a Pentium4 2Ghz)
The CPU ofcourse is the issue in ways more than one. There have been some concerns that it's a rip off of a MIPS chip from MIPS Technologies.

"However, the chip’s architecture has gotten attention around the industry for its similarities to the MIPS chip from MIPS Technologies Inc. According to market research group In-Stat, the Godson-2 is about 95-percent compatible with the MIPS R10000, which was introduced in 1995. BLX claims that similarities between the Godson and MIPS are strictly coincidental."

Well, we had heard similar accusations when Huawei and ZTE initially got into the Telecom infrastructure market. I don't see anyone talking about that anymore. So lets see how the CPU part of this saga plays out.

Anyway, back to the PC. Initially it will be priced at $160-$170 and used in schools and government offices in China. It will hit the $125 price tag if the initial rollout goes well and it goes into mass production. The PC will come preloaded with Linux and the free goodies that come with Linux. I wonder if a person who has never used a PC before will find Linux user friendly. My theory is that a lot of 'user-unfriendliness' of Linux can be attributed to our collective addiction to Windows, a problem which a completely new user wont have. But that's just idle speculation. I can't prove anything.

On similar lines I came across some old articles from DQIndia about the Rs10,000(~$220) PC that are being marketed by Xenitis India. The article in June 2005 makes it sound very promising.

"A quick comparison with some of the branded competitors brings out the magnitude of Xenitis' achievement. For an under 10K price tag, Xenitis provides a PC fuelled by a Cyrix 1 GHz chip, with 128 MB RAM; a 30 GB hard disk drive; a 52x CD drive, a floppy drive and a 15 inch color monitor. The software is Red Hat's Enterprise 3 professional version of Linux, which comes on 9 CDs that include the Open Office suite, database, e-mail tools and a browser."

But in another article a few months later it documents the practical problems involved in actually buying such a PC. A good read if you need convincing that just technically reducing the cost of something is not enough. The eco system (suppliers, distributors) to make it available also needs to be in place.

I am in full 'Kiva'

This post started out in the comments section in response to Kuriakose's comment. But then it got too big :)

Jokes aside, the concept behind Kiva which Kuriakose correctly refers to as the '...attempts to opensource the supply side (where the cash comes from) of microfinance...' is so amazing that I felt it deserved its own post. They partner with microcredit institutions in developing countries, get profiles of credit vetted entrepreneurs from them and then enable the general public to give micro loans to them. Yes, loans not donations. By taking out commercial banks from the money raising part of the microfinance chain, (I hope) their partners can offer better interest rates to the end users. From a donor perspective, this enables people to actually see their money in action and a high probability that they will get their money back (and just lose out on the interest). I know from personal experience with Asha for Education that it's always easy to raise money through Support a Child programs as donors prefer to donate to a real person instead of to anonymous recipients. So I can imagine this program (if it can build trust) having the potential to raise lots of money. But how well it can scale will depend almost entirely on how many honest and able microcredit partners they can tie up with. Even though they are just 2 years old , they already have tie ups in about 12 countries. So that's a pretty impressive start.

The reason I am so excited about Kiva is that it's an example of how technology (in this case internet) can be used to have an real impact (making capital available) on people in the developing world. I plan to sign up as a small donor (or capital provider) just to see how it works. I will report back with details about my experience later.

PS: If you think the subject is cryptic, look up the meaning of Kiva

Microfinancing continues to spread

This article in Businessweek tries to make the case that microfinancing in India is slowly going mainstream. For more details about the concept of Microfinancing check out the Wikipedia entry or better still go to the Grameen Foundation website. In short it's a system in which financial institutions give very small loans ($20, $100 you get the idea) to people who wouldn't normally be given loans by banks because they are too poor. This idea originated from the efforts of Dr. Muhammad Yunus to extend credit to poor women in Bangladesh. Grameen Bank, the bank he founded for this purpose continues to be the biggest microfinance institution around.

Anyway, back to the Businessweek article. According to the article mainstream banks like ICICI, HDFC, HSBC etc. have started concentrating on this sector as the urban markets are getting saturated. The good news is that this push is not being driven by lofty ambitions but rather by pure financial needs. This is good because if banks can indeed profit from microfinancing, then it will spread way more rapidly than if it were a social service initiative.

The scale of the microfinance market is so big that banks, even big ones like ICICI cannot possibly handle it on their own.

"Since 2003, ICICI has doubled the size of its rural banking activities to about $3.44 billion and has outstanding microloans of some $538 million.

FIVEFOLD GROWTH. It has set up more than 100 tie-ups with small-town lending specialists and has about 3.2 million low-income customers. HDFC hopes to follow suit. Earlier this year, it created a microfinance unit with more than 100 employees and aims to double its lending levels in rural India to $22 million."

Therein lies the potential problem. As the article states, banks are relying on 3rd party agencies to reach out to people because they simply don't have the infrastructure to do it themselves. Whether or not microfinancing will be able to make a positive difference will depend to a large extent on how closely these small agencies are monitored by the banks. Because it would be very easy for local money lenders to form an agency, keep charging exorbitant rates and maintain the depressing status quo. This is one of those places where access to information is so vital. That way the end consumer can shop around for rates and not be beholden to the local agency.

What the world thinks - does it matter?

Outlook magazine is running a series of articles and the results of a couple of opinion polls under the theme - what does the world think of India? The inevitable question ofcourse is, why does that matter? But if you can ignore that question for a while there are some good reads there. There is an interview with Amartya Sen where he makes some interesting observations which I can't resist from quoting here.

On a question referring to India's socialist past.
"... I'm not sure what you mean by India's socialist past. A country that failed to achieve the most elementary progress that most socialist countries in the world achieved easily (despite their failures in many other fields), namely universal schooling and basic education supported by the state, primary healthcare for all provided by the state, comprehensive land reforms and so on which pre-reform Russia, pre-reform China, Cuba, Vietnam and other socialist countries achieved, can hardly be described as a socialist country...."

On a reference to Indian diaspora's contribution.
"...It's also important to recognise that India's success as a functioning democracy, with a relatively free media, regular multi-party elections and a lively civil society has also helped the diaspora gain respect and acceptance abroad...."

On a reference to India's growing 'power'.
"...We have to think more critically and more fully about exactly what powers we want, in what sense, and precisely what we want to do with power. Having more power is not a virtue in itself."


There are articles from among others Dominique Lapierre, Ayaz Amir, Gurcharan Das and of all people Donatella Versace!

As for the opinion poll, it was conducted in New York, London and Beijing where people were asked various questions geared towards getting their opinion about India. Well I generally use opinion polls for entertainment purposes. They failed to correctly predict the results of both the American and the Indian elections! How the hell can they be true guages of the opinions of entire countries? So in the spirit of entertainment I am quoting 2 results from this opinion poll.

How apt are the following attributes describing Indians?

Hard-working and disciplined

91(NY) 82(Lon) 44(Beij)


Do the following things about India interest you? (Affirmative responses given below)

Hindi cinema/ Bollywood

33(NY) 30(Lon) 76(Beij)

At least the Beijing wallahs like our movies :)

Mission 2007, no really

When I first read about Mission 2007 on rediff I had a sense of deja vu. An initiative for rural development with a grand sounding name. Hasn't this been played out a million times before? Lofty ambitions, grand launches and then complete silence. But as I went through the Mission 2007 website I realized that this initiative was not being launched now. It was launched in 2004. For whatever reason rediff chose to highlight it now. Which is a bummer because we are learning about it just 1 year before it ends. But in a way its good. Now that the end of the mission is not that far off we can atleast remember to follow up and see what worked and what didn't.

Btw, for those of you too lazy to click through the links, the mission statement of this Mission is

“Achieving sustainable human security is a priority task. This will call for harmony with nature and with each other. Knowledge connectivity within and among countries will help to achieve this goal. This is why we should make 'Mission 2007: Every Village Knowledge Centre' a success.”

It's easy to be cynical about an initiative that is run out of a Govt Secretariat and I am fighting hard not to fall into that trap. After all even if this is a half-hearted Babu driven initiative it will probably touch more people than we ever can - such is the power of Govt agencies. So who am I to complain. But (you knew there was a but right :)) I couldn't help but notice that the milestone page has a list of launches and conferences instead of real statistics like how many people in how many villages have they been able to touch so far. I hope it's a cultural oversight. They have a concept of partner organizations of which there are 242 as of today. Though it's a bit late in the game we might decide to join it. If that happens there will be more reports on this topic.

Solar powered Wi-Fi

Uber tech blog GigaOm links to an article in news.com which talks about an effort to make internet access a reality in underdeveloped regions. This project named Green WiFi is being run by a couple of employees from Sun (one former and one current). They have developed a prototype with a grant from the $100 laptop project and are now getting ready for a field deployment in Uttar Pradesh.

At a very high level, enabling internet access comprises of 2 distinct challenges. Having a high bandwidth broadband backbone in place and getting people access to this backbone - the so called last mile problem. The wires that cable companies put, the phone lines that dsl providers use and the wi-fi access that hotspots provide all address the last mile problem. Simple WiFi won't be able to solve the last mile problem for Indian villages are they are usually no where near a broadband backbone. So the Green WiFi project is going to use a series of routers - each connected wirelessly through 802.11b/g (wifi) - to connect the end user to the backbone and hence the internet. Their innovation is that they are coming up with a cheap and robust solar power charged battery set in order to provide power to these routers and more importantly they are coming up with a way to do elegant degradation when the router starts running out of power.

""What we bring to the table is an intelligent charge-controller. We put the router on a diet," Pomerleau said. The controller sits between the battery and the router and regulates power to the router depending on the charge level of the battery and the amount of incoming sunlight."

Absolutely critical for this idea to succeed in Indian villages.

The pilot project in Uttar Pradesh would be able to flesh out the technical abilities and limitations of this model. But the possibility of widespread deployment would depend on how far the internet backbone is from a typical Indian village. The cost of the router has been capped at $200 (Rs. 9000). The news.com report says that the wifi router nodes can be 1kilometer apart. I am not convinced about that being true in real deployments. But anyway quibbles aside, greater the distance from the backbone more the number of routers that have to be used and more the cost. WiMax which has a longer range would be a better fit for this kind of an effort. But we won't be seeing commercial WiMax before late 2007. WiFi is already here. So if this model can bring high speed internet access to atleast those villages which are close to the backbone, that would be a great achievement.

Cell phones in Indian villages

Businessweek has this article about the growth of cell phones in rural India. Businessweek has a history of gushing over the latest fad in town and this article is part of the India, China series. Since I don't live in a cave I am well aware of the explosion of cellphones in urban India. The extent of this explosion can be gauged from this little statistic from the article.


“…India's mobile phone user base has exploded to 105 million today from 5 million in 2001…”

But the story, as always, had been different in rural India. Since the beginning of this year wireless circles have been abuzz with stories about the $4 billion BSNL mega contract. A chunk of the 60 million GSM lines that BSNL is planning to roll out are meant for underserved rural regions. According to this article other Indian wireless operators are also planning huge expansions.


"...Another major India telecom, Reliance Infocomm, is expected to invest around $550 million through the end of the decade, mainly outside of major urban centers.

Tata Teleservices will spend $214 million this year on infrastructure, network expansion, and transmission, according to CEO Darryl Green. On top of that, Bharti Airtel, India's largest wireless player, will devote $1.8 to $2 billion in 2007 on similar expansions...."

The good news is that call rates are so low in India (2 cents or 90 paise per minute) that wireless service will be within the reach of all but the extremely poor in rural India. Bad news is that handsets are not all that cheap.

"Nokia, for instance, sells about 45 models in India. Yet its biggest seller, accounting for 15% of sales in India, is the basic 1100 model for $44 that is turning heads in villages like Latur. Motorola will launch a handset for under $30 in October. "

Even $30 (Rs.1350) is not an insignificant amount of money. The monthly salaries of instructors at a school funded by DridSankalp are in the Rs.3000 range. So buying a cellphone even at these highly reduced prices would be equivalent to buying moderately expensive furtniture for an engineer in the US. Not something that can be bought on a whim. And these instructors would fall in the rural middle class category. For poorer people even a $30 handset would be extremely expensive. I hope some service provider will be smart and brave enough to provide phones on credit. I also wonder if it would be possible to recycle used handsets from Indian cities for around $10-15 dollars.

Ofcourse, having a cellphone or being able to make a call is not an end in itself. How beneficial will this access to communication be? Apart from the obvious benefit of being able to be in touch with friends and family, can this increased access give rise to new and novel applications completely unique to rural India?

First things first

We are a group of accidental engineers interested in figuring out how to use technology to facilitate social development in India. We are interested in all aspects of the social development process which could be improved by technology. What follows is a representative but grossly incomplete list of ideas we are interested in
- Increasing awareness by improving access to information
e.g. ensuring access to computers and the internet
- Ensuring better allocation of resources
e.g. moving books, computers, furniture etc. from places where there is a surplus to places where there is scarcity
- Lowering overheads during the raising and disbursal of funds
- Ensuring better accountability

We are not experts in this field. So as we stumble along towards our goal, this blog will serve as both, a catalogue of our journey and a repository of what we have learned. It's also our hope that through this blog we will be able to network with other individuals and organizations whose interests lie in the intersection of technology and social development. So we would be delighted if you could share your thoughts with us or if you could point us to resources (articles/books/blogs/people) dealing with low cost technology, social development or both.

While talk is important what ultimately matters is action. So we have set up a non-profit organization called DridSankalp (roughly translates to 'strong resolve') through which we will put our money where our mouth is and actually implement some of the ideas discussed here. If interested you could find more details about this organization here.