Tribal community takes over the Health center
Sachin Kumar Jain
Paati tribal block of Madhya Pradesh (India) is witnessing a unique example for the implementation of concept of Rights based Community monitoring to ensure that Right to Health care is provided to the most marginalized and poor, especially tribal. For Gucchiya Adivasi, a native of Gupaativadi village, Pati block, district Badwani, 22nd May 2008 was an altogether different experience of attending the local Community Health Centre [CHC]. Since last three years he is regularly visiting here to treat his stomach ache. Every time the doctor would write medicines for him without even properly diagnosing him. Gucchiya has to buy medicines from his pocket as there are no medicines in this hospital, till date he has spend Rs. 1250 on medicines. They are angry but helpless, as they find state system full of unaccountability.
This time not only he was properly diagnosed by the doctors here but was also counseled about which medicine he is supposed to take and at what time? Gucchiya wonders if this behavior and seriousness towards poor and marginalized patient would sustain for long. Analysis of last three month’s prescriptions for Gucchiya shows that he was given medicines for arthritis or scabies to heal his stomach ache! Gucchiya is not the only person having experiences of wrong treatment; almost every native visiting this hospital has gone through the similar kind of experiences.
In this context, the collective decision of initiating community monitoring of the public health services in Pati block by tribal community and people’s organization has played a crucial role in healing Gucchiya. There were agitations for last 2 years but Got exhausted with the dismal state of health services on 19th may 2008 around 1500 natives of this tribal block, most of them the members of village health committee, decided to undertake community monitoring of Pati Community Health Centre, sat in CHC premises for 4 days.
After struggling for four days the administration was made to sign an agreement with the community promising that Janani express and ambulance will be provided in every village, patients would be provided medicines and other medical support in CHC and medical staff would be increased to meet the requirements. Very first and innovative of its own kind this agreement has been put up inside the CHC now and everybody can see it. Madhuri Krishnaswamy of a people’s organization - Jagrut Adiwasi Dalit Sanghthan says it is not an innovative idea, but it is just implemented first time in Madhya Pradesh. They are not only agitating against the corruption in practice but Doctors from SATHI-CEHAT (an organization working on Health Rights) running the ‘People’s Health Information Centre’ and providing a weapon called Information and addressing the violation of Health rights in a technical manner. Besides the intensification of ‘people’s direct monitoring’, one major highlight of this day was the march by village activists to the clinics of all the private ‘doctors’ in Pati town. The reason for being that most of the persons known as ‘doctors’ and running clinics in Pati are known to administer unnecessary injections and saline / glucose infusions on a large scale, even though it was doubtful if they had any degree allowing them to practice modern medicine. The procession of village people marching through Pati gave slogans in Bareli dialect like ‘Sadi hove bimari – nahi lage pichkari’ (if the disease is ordinary, no need for injection) and ‘Saline batli ma kay chhe – nun, sakkar, pani chhe’ (what is there in a bottle of saline – just salt, sugar and water).
Dr. Abhay Shukla of CEHAT (Pune) describes it as a multi dimensional people’s action; on the one hand a group of about 25-30 people visited each of the ten or so private clinics in Pati and requested each of the ‘doctors’ to show their degrees. As expected, almost all of them were administering injections and saline infusions, but only one of them (an ex-medical officer of the CHC) had the qualifications to give such treatment. The other ‘doctors’ included a naturopath, an electro-homeopath, a self-proclaimed dentist, an ex-compounder and a ‘Jan Swasthya Rakshak’ of a distant village. The adivasi activists, most of them non-literate, then explained to all of these ‘doctors’ why injections and saline are not necessary in ordinary illnesses, made the doctor to commit not giving these unnecessarily, and put up pictorial posters in all the clinics on the need to avoid unnecessary injections and saline in each clinic. Based on a rough costing of saline / glucose bottles, I.V. sets etc, the doctors were made to accept that if given in a necessary situation, they would not charge more than Rs. 50 for infusing a bottle of saline or glucose (existing charges vary from Rs. 150 to 250). Posters to this effect were also put up in all clinics, affixed with the signature of the doctor.
On the other hand, to make sure that the administration doesn’t backtrack from its promise two villagers are monitoring the CHC every day. Ramesh Gangaram, native of Kandra village says, “CHC is in dismal state, stinking environment, un-cleaned rooms and toilet, blooded cottons, used dressing items and syringes are throne in open spaces has become an identity of Government Hospital. It is very difficult to explain what we feel, when we are allotted a blooded and stinking bed, how patients will achieve good health here. But we were bound because private doctor charges Rs. 250 for a glucose bottle and Rs. 50 as injection fee. We are heavily indebted due to this. Thus, now it is better for us to forgo our 2 daily wages in monitoring CHC than keeping indebting ourselves”.
The state government use jargons like ‘community monitoring and participation’ in its every report but blithe efforts have been undertaken to ensure this at the grassroots. Since last one year SATHI CEHAT and Jagrat Dalit Adivasi Sangathan have trained almost 250 persons, ASHA and CBOs for erecting the lopsided health system in 15 tribal villages.
Consequently, community members have come to know about the discrepancies and chaos spread across the CHC. Kutwal Adivasi, a member of community monitoring group got to know after attending trainings that a syringe should be used only one time on one person. He observed that instead of disposing the same nurse was using same syringe on ten people, now one syringe for one patient.
Dr. O.P. Kadam, Block Health Officer, tries to put things under the carpet as he says, “Since there is shortage of doctors and specialists here it’s quite obvious to have problems with diagnosing patients properly”. He shares that out of five sanctioned posts two are vacant. Earlier they used to attend 250-300 patients per day but now this have increased to 700, in last 4 days it is more then this. It is getting taxing on their time devoted on per patient. When asked about why are there private expenses on medicines and health care he expressed his helplessness by saying that pneumonia and bronchitis are the two most popular diseases in this area. Everyday almost 10-20 such children comes but the CHC doesn’t have combination syrup for so. Therefore, the parents are asked to purchase such medicines from outside. He has no answer of the peoples claim that they (Doctors) are normally absent from the chair.
A survey conducted by Jan Swasthaya Abhiyan says that despite 74% children reeling under malnutrition in the area there is no Nutritional Rehabilitation centre has been established for them. As per the state government data 1708 infants died in Badwani.
Dr. Nitin Jadhav, one of the monitoring group members says, “CHC doesn’t have the basic facilities like stethoscope, quinine and pregnant women are not at all receiving pre natal care”. In fact the CHC staff seems to be hand in gloves with the local medical stores’ owners as they keep referring patients to purchase medicine from them.
Behind these sporadic complaints from the native villagers there is a wider issue of lopsided health services and resurrecting infrastructure. This CHC provides services in 110 villages but doesn’t have even basic facilities, like, table for attending delivery case, labour room, etc. In such as case it seems too much to ask for a gynecologist! In the period from February-May 2008 there have been seven deliveries in this CHC, that too on a making table. The norms, provisions, laws and vision for public health in India could be easily seen shattering here. But interestingly Madhya Pradesh Health Department has been very loud for the promotion of Institutional deliveries and as per their claims they have achieved the level of 70% institutional deliveries. Just go and see the Pati CHC!!
As per the Health institution indicators, there is a provision of 30 beds in a CHC but there are just six beds here that too are thrown in the compound. At 45 degree temperature there were ostensible efforts to beat the heat by draping clothes in open compound; this is what care for new born and lactating women means in Pati. Out of the four sanctioned posts for specialists here three are vacant.
Dr. Abhay Shukla, a health rights activist associated with CEHAT (Pune), expounds on violation of child rights when he says, “the state of immunization is pathetic in Pati block. Though full immunization is even less than ten percent in this block the government records present a different story altogether. As per the government records 88% children have got measles vaccination, 123.6% children and 129.4% pregnant women have received iron tablets but the monitoring group have seen the iron folic acid tablet’s boxes been put to fire, it is just nor corruption it is crime”.
The initiative of community monitoring is laudable but the biggest challenge lying ahead is to rekindle community’s trust in government health services. Madhuri, of Jagrat Dalit Adivasi Sangathan says, “Through this monitoring we try to implement NRHM and other health provisions at grassroots in true letter and spirit, this is the only way to push market forces and un-accountable elements out from the Health services”.
Contract points between CHC officials and the Community Monitoring Group
1. No patient will be required to purchase any of the medicines being prescribed at the CHC. All patients will be provided all necessary medicines from the CHC.
2. Patients with ordinary illnesses will be given, as per need, medicines for three days (in contrast to the present practice of people from remote villages being sent back with a single dose or single day’s supply of medicine)
3. Each patient requiring an injection will be given this with a separate needle and syringe (in contrast with the existing practice of injecting upto ten patients with the same needle). The need to minimize unnecessary injections was also stated.
4. Ambulances to transfer serious patients from villages to the CHC, and from the CHC to Badwani district hospital would be available free of charge to all those with ‘Deendayal cards’. In case of patients without such cards, subsidized rates fixed by the RKS would be charged. However any serious patient who does not have a card, yet is unable to pay, would be given the ambulance free of charge.
