How an innovative boat clinic programme is bringing health care services to underserved riverine communities in Assam.

The islands along the Brahmaputra River are known as ‘chars’ and ‘saporis’. Beautiful and remote, they are hard to access, a problem compounded by annual flooding in this part of the North East. This poses problems for the inhabitants of these islands - who make up 10% of Assam’s population - when it comes to accessing healthcare. In most parts of India, we’re used to quick, convenient road access to medical care. The islanders of the Brahmaputra have to depend on unreliable boat services, taking them through choppy waters to distant hospitals on the mainland. Fortunately, an innovative program using boat clinics and community workers is changing how these remote communities access healthcare.

Annual flooding places tribal communities at risk

Assam is located in the northeast region of India. The Brahmaputra River, the longest river in Asia, flows through the state. The river is navigable for large boats for about 6 months of the year and is prone to flooding during the rainy season. Flooding causes extensive damage to crops and livestock.

Disruptive Healthcare Innovation using community workers and boat clinics

The eminent author, filmmaker and journalist Sanjoy Hazarika conceptualised the innovative rural healthcare programme called the Boat Clinic, which has taken shape into an established, successful programme today.

In 2004, C-NES was selected as one of the 20 finalists in the World Bank’s India development marketplace competition in New Delhi. C-NES’ design was lauded by the judges for its innovative approach to solving problems in rural areas, and C-NES received a cash prize of $20,000. The prize money enabled the building of the first boat clinic, which was designed by MIT’s design team, local boat builders and local river surveyors. The vessel was named Akha (Asha), meaning hope in Assamese.

“Soon after the boat clinic programme first took off in May 2005, UNICEF came forward to support the Dibrugarh health outreach initiative in July 2006 with an emphasis on improving immunisation coverage of children and pregnant women. Health care delivery system on curative and preventive care was also streamlined. UNICEF is not directly involved with the Boat Clinics which is totally supported by National Health Mission, Assam under the Public Private Partnership mode,” says Sanjoy Hazarika.

Assam Government and UNICEF: collaborating to bring healthcare to remote communities in the North East

UNICEF India had already been working in the state since 2006, providing basic health care to children under five years old. The government of Assam wanted to expand access to healthcare to all citizens. A unique Private Public Partnership (PPP) agreement was signed by NHM and the Government of Assam in February 2008.

C-NES has a team of doctors, nurses, pharmacists and lab technicians to run its operations. Boat clinics visit different riverine communities on a regular schedule. During their stay, they share information about prevention of diseases, and healthy habits, and provide curative support if required. The COVID-19 pandemic is no exception. Boat clinic members shared information about COVID-19 focusing on hand washing, social distancing, cough etiquette, hygiene etc. Information about the next scheduled visit is shared with residents prior to the clinic moving to the next location and in an emergency, C-NES provides transport to the nearest district hospital

Boat clinics operate on two systems. In units where specially designed boats like Akha models are present, the teams travel on trips of 4-6 days (including night halts) at a

stretch, conducting one or two camps per day. Where larger boats are not available, country boats are hired and adapted to provide the basic provisions, including an OPD and cabin for ANC check-ups.

Focus Areas of the Boat Clinic

C-NES and NRHM have recruited both technical and non-technical staff to work on the project. Each district will have a total of 15 team member including one District Programme Organiser (DCO), two Medical Officers (MOs), one General Nurse Midwife (GNM), one Pharmacist, one Lab Technician, two Auxiliary NurseMidwives (ANMs), three Community Workers (CWs) and four Boat Crew Members (BCMs). There will also be a staff of nearly 200 people including doctors, nurses, lab techs, pharmacists and coordinators who work directly with district and state administration and nearly 3 lakh people are treated every single year.

“Boat clinics established by NHM Assam with technical support from UNICEF are stellar examples of contextually relevant health innovation addressing an unmet need in the community. These boat clinics have also been vehicles of transformation. Natural calamities such as floods disrupt routine health services delivery and the vulnerable populations are most affected by such disruptions. NHM has mostly used it for RMNCH and routine immunization. It definitely can be used for all essential health services, there is scope for incorporating NCD services to ensure continuum of care,” says Oommen John from the George Institute of Health.

Kerala Model

Kerala has had a long history of using medicine boats. These boats were first introduced in the 1980s and were in vogue until 2017. Lourdes hospital, a medical institution based out of Ernakulam, has relaunched the services for the residents of Thanthonni Thuruth.

SIMILAR MODELS

Was Hazarika inspired by any of these models? “As I child, I remember reading about a hospital ship which worked, I think it was in Africa. The Boat Clinics were inspired by a life changing experience while making a documentary on the Brahmaputra with the renowned filmmaker Jahnu Baruah. While in Majuli (the largest river island in the world), I was moved by learning of an incident where a young pregnant woman died because she could not travel to the mainland hospital on the other bank on time. As I researched the issue of the high maternal mortality rate in Assam, at that time the highest in the country, it struck me that the only effective way of taking health care and other services on a sustained basis to the islands was by boats. That's how the boat clinic idea began and grew. At flood time, it takes health care right to people’s homes. That way, a major gap is met with the partnership of the National Health Mission - without which this could not have worked because you need the involvement of the stakeholder, that gives a programme sustainability, inclusivity, reach and financial support. The State has the capacity to cover the last mile. It is our job as informed citizens to enable it to do just that,” he explains.

Measuring an Innovation

How effective is the programme? A study conducted by the Regional Resource Centre for North Eastern States (RRC-NEE) in 2013 found that the frequency of coverage of particular areas varied from 6-24 times in a year.

Here’s a link to the study: http://www.rrcnes.gov.in/study_report/Boat%20Clinic%20Evaluation,%20Assam%202013.pdf

Performance of Boat Clinics

Source: https://nhm.assam.gov.in/schemes/boat-clinic

The success of the Boat Clinics bodes well for the future of healthcare among island communities in Assam and the North East. It is also a realisation of the ideals of the Twelfth Five Year plan, which set forth the goal of universal health cover and high standards of care. Having negotiated the turbulent waters of the COVID-19 pandemic successfully, the Boat Clinics of Assam are a positive test case in the power of innovative, locale-specific programs to improve outcomes for previously underserved communities.

Bridging the Healthcare Divide on the Brahmaputra with Boat Clinics