Assam’s quiet health revolution

Pallab Bhattacharyya

(Pallab Bhattacharyya is a former director-general of police, Special Branch and erstwhile Chairman, APSC. Views expressed by him is personal. He can be reached at pallab1959@hotmail.com)

For much of the last two decades, Assam presented one of the most intriguing paradoxes in India’s public health landscape. The state steadily expanded its healthcare infrastructure, strengthened institutional mechanisms, recruited thousands of frontline workers, and implemented nearly every major maternal and child health programme launched by the Government of India. Yet maternal and infant mortality indicators remained distressingly high. Hospitals were built; health centres multiplied; Accredited Social Health Activists (ASHAs) reached villages; and schemes such as Janani Suraksha Yojana, Janani Shishu Suraksha Karyakram, POSHAN Abhiyaan, Pradhan Mantri Matru Vandana Yojana, SUMAN, LaQshya, and Pradhan Mantri Surakshit Matritva Abhiyan sought to ensure safe motherhood and healthy childhoods. Despite these efforts, Assam continued to record some of the highest Maternal Mortality Ratio (MMR) and Infant Mortality Rate (IMR) figures in the country.

The roots of this challenge lay deep in Assam’s geography, history and social structure. Large sections of the population lived in riverine char areas, tea garden settlements, remote tribal regions and flood-prone districts where access to healthcare remained difficult despite infrastructural expansion. In the past, families and communities viewed childbirth as a communal event rather than a medical one. Traditional birth attendants often enjoyed greater trust than trained healthcare personnel. Poverty, low female literacy, poor nutrition and deeply embedded cultural practices further complicated efforts to improve maternal and infant health outcomes.

The National Rural Health Mission, launched in 2005, marked an important turning point. Assam, identified as a high-focus state, received substantial financial and administrative support. Maternal mortality, which had once exceeded 490 deaths per one lakh live births, began to decline gradually. Institutional deliveries increased and antenatal care coverage improved. Nevertheless, the pace of improvement remained far below expectations. By 2018–20, while India’s MMR had fallen to 97, Assam still recorded an alarming 195. Similar concerns persisted in infant mortality figures. The existence of healthcare facilities did not automatically translate into their use.

The central problem was not merely the availability of services but the willingness of communities to engage with them. Studies repeatedly demonstrated that many women delayed their first antenatal check-up, missed follow-up visits, or failed to seek institutional care during pregnancy and childbirth. In several districts, healthcare workers encountered resistance, scepticism and indifference. Advice provided by ASHAs was often ignored. Women frequently depended on informal sources of information and local customs rather than professional medical guidance. A significant trust deficit existed between the health system and the communities it sought to serve.

Equally important was the absence of continuity of care. Many women might visit a health facility once during pregnancy or even deliver in a hospital, but postnatal follow-up often remained inadequate. High-risk pregnancies were not always identified early. Warning signs were missed. Behavioural barriers and social norms frequently overpowered medical advice. It became increasingly clear that healthcare outcomes could not be improved solely through infrastructure, incentives or administrative directives. Human behaviour, social relationships and community confidence had emerged as the missing variables.

The decisive shift came in July 2022 under the National Health Mission, Assam, with the appointment of Dr M. S. Lakshmi Priya, a 2014-batch IAS officer and medical doctor by training, as Mission Director. Having served in several districts of Assam and having earned recognition for innovative community-based interventions, she brought a different perspective to public health administration. She rooted her work in a simple but powerful principle: sustainable health outcomes emerge when communities actively participate rather than remain passive beneficiaries.

Her earlier initiatives had already demonstrated this philosophy. During the COVID-19 pandemic, she developed Project Mili Juli in Bongaigaon, which relied heavily on community participation and local social networks. Subsequently, she launched Project Sampoorna to combat child malnutrition. The programme introduced the concept of “buddy mothers,” pairing the mother of a healthy child with the mother of a malnourished child. Through shared learning, emotional support and practical guidance, the initiative achieved remarkable success and received the Prime Minister’s Award for Excellence in Public Administration.

When Dr Lakshmi Priya assumed leadership of NHM Assam, she adapted this community-centred philosophy to maternal health. Her team learned about the real world by going to many places in the districts of Nagaon, Morigaon, Cachar, Kokrajhar, Dhemaji, Golaghat, Karbi Anglong, and Dhubri. Rather than imposing a rigid policy from above, the programme evolved through continuous feedback, retraining and adaptation.

The Buddy Mothers Model, which came out of Project Saubhagya Plus, changed the way mothers’ health care worked. The model paired two pregnant women together and assigned a mentor mother, usually a lactating woman from the same community who had recently experienced pregnancy and childbirth. The women attended check-ups together, reminded one another of appointments, discussed concerns, recognised danger signs and provided emotional reassurance. Healthcare ceased to be an individual responsibility and became a shared community experience.

The brilliance of the model lay in its simplicity. It did not require expensive infrastructure, additional bureaucratic layers or major financial commitments. Instead, it leveraged existing social capital. Advice coming from a neighbour, friend or fellow mother often carried greater credibility than instructions delivered by an outsider. The mentor mother represented lived experience rather than institutional authority. This helped bridge the trust gap that had long undermined public health interventions.

Importantly, the initiative did not replace existing systems. It complemented ASHA workers, Anganwadi centres, primary health facilities and established maternal health programmes. By integrating behavioural change with institutional healthcare, it strengthened rather than disrupted the existing ecosystem. Simultaneously, NHM Assam introduced regular reviews through Swasthya Manthan, conducted district-level assessments, expanded special health camps and intensified monitoring of high-risk pregnancies. Together, these measures created a culture of accountability and responsiveness.

The results were extraordinary. Assam’s maternal mortality ratio declined from 195 in 2018–20 to 167 in 2019–21, then to 125 in 2020–22, and finally to 84 in 2022–24. For the first time in history, Assam’s MMR fell below the national average of 87. A state once synonymous with maternal mortality emerged as a model of public health transformation. Infant mortality also showed consistent improvement, declining steadily to 29 deaths per thousand live births by 2024.

Assam’s experience finds important parallels across the world. Nepal’s Female Community Health Volunteer programme demonstrated how trusted women from local communities could significantly increase antenatal care attendance and institutional deliveries. Rwanda’s network of community health workers played a crucial role in reducing maternal and neonatal deaths through community engagement and local accountability. Ethiopia’s Health Extension Programme similarly relied on community participation and peer networks to improve maternal and child health outcomes. Bangladesh’s group-based antenatal care initiatives showed that women were more likely to adopt healthy practices when supported by peers facing similar circumstances. Across these diverse settings, one lesson emerges repeatedly: trust and social connection are often as important as medical infrastructure.

The sustainability of Assam’s gains now depends upon the collective responsibility of all stakeholders. Governments must continue investing in healthcare infrastructure, training and monitoring systems. Health administrators must remain responsive to local realities rather than relying solely on statistical targets. Doctors, nurses and frontline workers must strengthen compassionate engagement with communities. ASHA workers and Anganwadi personnel must be empowered through regular training, timely incentives and institutional support. Community leaders, self-help groups and civil society organisations must promote awareness and challenge harmful social practices. Families, particularly husbands and elders, must recognise maternal health as a shared responsibility rather than exclusively a woman’s concern. Most importantly, communities themselves must continue to nurture the culture of mutual support that made the Buddy Mothers initiative successful.

The story of Assam’s maternal and infant health journey ultimately offers a profound lesson in public policy. Merely constructing buildings, allocating budgets, or launching schemes does not lead to development. People achieve development when they trust institutions, and institutions, in turn, trust the people. Assam’s remarkable turnaround was not simply a triumph of healthcare management; it was a triumph of community participation, behavioural change and social solidarity. The state’s experience demonstrates that when healthcare moves beyond hospitals and enters the fabric of everyday community life, even the most stubborn public health challenges can be overcome.