Friday, May 25, 2007

Women's health on the AIRwaves

AIR’s 14 radio stations in Madhya Pradesh ran a 15 to 20 minute episode daily on the issue of women's health.

Anil Gulati in Bhopal

Ten percent of maternal deaths in India take place in the state of Madhya Pradesh. Maternal death audits as undertaken by the state reveal that how timely medical attention still is a challenge for many pregnant women. Lack of awareness on recognition of danger signs, issue of transport, access to proper medical facilities, poverty are still some of the many challenges which needed to be overcome. Though the Government of Madhya Pradesh has launched many schemes to promote institutional deliveries and to combat maternal mortality, with special focus for below the poverty line and those belonging to scheduled castes and tribes, but a lot remains to be done.

Media and civil society are helping to raise concern and create awareness on the issue. All India Radio with its vast network in the state particularly in rural Madhya Pradesh contributed its bit by using air waves for the cause by addressing issues of immediate concern to its audiences.

All India Radio in collaboration with the state government and UNICEF, supported by Department of International Development (DFID), strategically used its programme options to engage communities on the issue of safe motherhood and help voice their concern by its people - policy interface. It also used its news network to give voice to state and civil society on the issue. Content analysis of last few months i.e. June 2006 - Feb 2007 AIR news reports tell us that the issue has been in focus and is spread evenly. News pertaining to government proclamations, schemes, and events took the major share but the news network also relayed statements of various experts and people working on the issue, which is a positive trend.

AIR has a strong presence especially in rural areas vide its fourteen radio stations across the state. It ran a 15 to 20 minute episode daily in form of a series from its network of radio stations on the issue of women's health. 35 such programmes were aired. Each programme had a local expert, often a medical professional to answer the questions and issues that were raised by the people from the district. It also provided information on how to recognize danger signs in pregnancy, stressed on the need of institutional delivery, care including nutrition of women during pregnancy, and issues related to anaemia. The purpose was to provide information and answers to the questions to the community by a local expert.

In addition to the same, the radio network also aired a series of seven one-hour live-phone in programmes on its afternoon prime time slot each month. It was a 'people - policy maker interface'. As part of the same programme a political representative or a representative from the state department was present in the studio to answer questions raised by callers on the issue. For the first time the issue of maternal health was addressed in this forum. The initiative by its very nature strengthened the community - system interface.

In the first programme the State Health & Family Welfare Minister answered questions from various rural parts of the state. Callers from far off villages in districts like Rewa, Tikamgarh, Sagar and Hoshangabad, brought to the notice of Health Minister the problems they face when it comes to the functioning of the health delivery system at the primary health centre level. The common grievance was that the doctors and nurses were absent from the duty. Questions were also raised the benefits of schemes not accruing and the types of health schemes available. On similar lines representatives from State's Women Commission, Human Rights Commission, Women and Child development department, Rural Development and Public Relations department were involved. Fifteen to twenty questions were asked in each programme.

In the last of the series the Chief Minister of the state answered queries of people in the state on the issue. Though the programme focused on women's health and safe motherhood, issues of education especially of girls, grant of scholarships to girls as provided by the state and violence against women also came up. In turn the programme offered an opportunity for people to get answers to their grievances by their elected representative on issues which many times get neglected in the political process.

Sunday, May 06, 2007

A comment on two years of NHRM

Dr Sanjit Nayak at One World South Asia

Health being a state subject, states have used their own discretion to interpret and implement the National Rural Health Mission (NRHM). While this has resulted in some activities being implemented the broader goal of the NHRM to empower local communities has been lost. This has lead to the dilution of the agenda of placing people's health in people's hands. The current government approach is to mandate community participation by issuing government orders to its functionaries at the district level. In rural areas, village and district action plans based on community need assessment have remained a non starter and in urban areas the poor remain marginalized from this process. The NRHM talks about health sector reforms but the specific objectives of the reforms appear unrealistic and unlikely to result in the improvement of the health status of the individual or the community. In effect the Mission remains more target oriented with a disproportionate emphasis on inputs rather than focused on output or performance. The concept of Accredited Social Health Activist (ASHA), which forms the core through which the NRHM will be operationalised, cannot be described as being an innovation but rather is old wine in a new bottle. In earlier versions of the health programme similar human resource mechanisms have been proposed - for example the community health worker, link worker, multi- purpose worker amongst other things. In India, the polices, plans and schemes have often been comprehensive but the implementation has remained poor and as a result the desired result as envisaged by policies and programmes has never been actualised. The ASHA as has been mentioned earlier forms the core implementation mechanism for NRHM, who will undertake the bulk of the activities at the community level.

Inspite of playing this critical role, women who are selected are seen to be volunteers and the programme itself does not define any type of financial compensation for the work they will undertake. Recent findings show that it is proving to be extremely difficult to motivate individuals to undertake the work where no remuneration is forthcoming. As part of the ASHA scheme an incentive system has been proposed under the supervision of Sarpanch and Auxiliary Nurse Midwife. This has lead to non-integration (architectural correction) of all the other health programmes at the community level. Furthermore, there is an extremely high expectation from ASHA whose envisaged work profile does little justice as a part time worker.

The ASHA work under severe constraints with regard to infrastructure as a result ASHAs often have to resort to referring their patients to private service providers. In addition, ASHA has replaced the male health worker. ASHA's work profile is different and primarily to support the ANM. The numbers of male MPWs is already reduced and it is likely that their role will soon be written out of health programmes. It is important to point out that MPWs have a key role to play in other programmes e.g. prevention of communicable diseases and undertaking surveillance, none of which can be undertaken by ASHA. As part of the reform process of the health sector, which remains an important component of NRHM, the strengthening of public-private partnership has been mooted.

However, many health activists feel this is the governments' way of shirking responsibility to provide health services in particular primary health care as has been envisaged in the Constitution. The government is now trying to even privatize primary health care and does not want to invest in improving the public health sector. Upgrading infrastructure, especially PHC to FRU/ UPHC in un- served and underserved areas with doctors unwilling to provide service will further privatise primary health care. Contracts to private practitioners will be the only solution to man these PHC. Indian Public Health Standards (IPHS) to provide quality health care in the public health system by ensuring minimum requirements of infrastructure, accountability of doctors, the need for standard treatment protocols and social audit through rogi kalyan samiti (RKS) has been a non- starter. This has been the scenario previously as such policy directions have not translated into action. T

he guidelines for IPHS do not address the real issue which requires an analysis of failure of previous schemes. An attempt was made by the National Commission of Health and Macro-economics but its recommendations are gathering dust. NRHM aim is to reduce infant mortality and maternal mortality by improving access through the ASHA and the Janani Suraksha Yojana (JSY) scheme by strengthening Community Health Centres. The emphasis is on technology alone. It has failed to address the correlates to nutrition and thus to poverty. The belief that reducing total fertility will reduce infant mortality ignores the links between the socio-economic status of the community especially that of women and health of an infant. It is important to note that access to care is also linked to discrimination as well. Additionally unskilled human resource and poor infrastructure in un-served and under-served areas compound the problem. Targets to reduce infant mortality rate (IMR) and maternal mortality ratio (MMR) by only increasing health sector expenditure needs to address issues of equitable distribution and resource allocation. Conceptual problems do exits in NRHM. Much of NRHM today depends on public- private partnership and not on strengthening the public health system. By outsourcing and contracting we have subscribed to privatisation of the health care delivery system. It is also difficult to comprehend how ASHA can bring about inter- sectoral coordination. In conclusion the link between poverty and ill-health are cursorily mentioned and are ignored in the actual implementation plan laid out as part of the NRHM. Based on the above analysis it might be fair to say that attainment of the goals envisaged by NRHM by 2012 remains wishful thinking.

The author is a public health specialist with the Population Foundation of India New Delhi. The views expressed are that of his owns as an activist and not that of the foundation

Maternal Deaths In Madhya Pradesh Denial Is The Best Policy

by Sachin Kumar Jain

Village Sarari Khurd, Sheopur - has a primary health centre but no doctor. Since when it does not have doctor, even villagers can't remember the same. The centre is opened by hardly fours days a week by local nurse. It neither has any facility nor any equipments and hardly has been cleaned ever. This is not the situation of one health centre, 20 kilometers of Sarari Khurd is Karahal. Karahal has community health centre. Though it opens every day but three positions out of the four to be posted there are vacant. Karahal block officially has a facility of mobile health van to reach out to inaccessible areas. But it has just one mobile health van. If the same works daily it will reach the same village after a gap of 35 days (please note if it works daily). And there is nothing to take care of a pregnant women and children. Even in case of unavailability of medicines, village level health staff is sailing the various kind of medicines to the Villagers.

There are 533 villages in the Saheriya primitive tribe dominated Sheopur district with a population of 5.60 lakhs. The total number of bed available at the one district hospital and other hospitals is only 166, of which 148 beds have not been changed during the last 13 years. During the last two years, several big claims have been made about promoting safe motherhood but just like last six years, three out of four posts of doctors in the Karahal block are still vacant. There was no improvement in the medical facilities during this period and even a single gynecologist and obstetrician could not be posted.

Anganbadi worker from Gothra Kapura village of the district, Bilasi Devi speaks from experience and asks as to why should one go to hospital? No one even speaks properly there and everyone right from doctors to nurses to sanitary workers asks for money to take any action. Government claims that anyone going for institutional childbirth would get Rs 1700 worth financial aid, transport fare and free medicines, but Babhuti was taken for childbirth to a hospital and her family had to pawn their land for completing the process.

In such situation, the Government of India has recently released figures related to maternal mortality for the first time since 1998, which claims that the Maternal Mortality Rate (MMR) has gone down from 498 (per lakh childbirth) to 379 during the period. But the report of the GoI (Maternal Mortality in India: Trends, causes and risk factors - 1997-2003) is itself facing some basic technical questions. The biggest question is as to whether the government is trying to veil the ground situation by some statistics under some pressure.

One important point is that this study of MMR has been conducted by considering only limited number of cases in specific situation. The survey was conducted over a period of six years and the low MMR is reported in MP and Chhattisgarh (365) although during this period about 103000 cases of maternal mortality were reported in the two states. The second point is that all these cases (365) are those that have been registered in official records while analyses tell that only one out of three maternal deaths get officially recorded. The problem is that in the district hospitals, community health centers and the lower level of health set up, the deaths during childbirth are recorded as general mortality.

The next question is that the Madhya Pradesh Government (GoMP) had in 2003 pointed out through the State Family Health Evaluation made it clear that in the rural areas of the state, the MMR is as high as 763, which clearly tells that the situation is far graver than the analysis by the union government. This study by the GoMP was done on 25 percent populace of each district and not only a selected group yet the union government is releasing contradictory figures for the same period.

The controversy should not remain limited to statistics because the health facility condition in state clearly brings forth the ugly face of the situation. The analysis of recent efforts of state government does not bring any good news.

In the state, only one hospital bed is available per two villages. Total 17 lakh childbirth occur in the state every year and 40 percent of state populace is below poverty line, yet the government provides only Rs 150 per person per year as health budget of which Rs 126 is spend on salary-allowances and other infrastructure costs. Only 137 posts of gynecologists and obstetricians are approved in entire state and of these 38 are vacant since several years. After a long battle, the government started the process of filling up the vacancies last year but no doctors are willing to take up government jobs owing to lack of facilities including diagnostic implements, medicines and general sanitary facilities. In such situation, doctors often have to face the wrath of the family members of the patient in case of death.

Government started the process for filling up 78 posts of gynecologists and obstetricians but only 31 applications were received. A total 112 posts of anesthetists were to be filled up but only 12 took up the job. Corruption at all levels is making conditions far more dangerous for the pregnant women. Corruption has begun in the medicine purchase under the new medicine policy, as now in the new medicine policy all the purchase will be done centrally and the Rs 700 of financial support under Janani Suraksha Yojana is all spent in giving bribe to the local health staff.

Despite unreliable data, statistics say that out of 1.47 lakh maternal deaths in the country every year, 97000 are contributed by the five BIMARU states and the three newly carved states. The World Health Organization also accepts this. The half of the maternal deaths in South Asia are contributed by the states of Rajasthan, MP, Bihar, UP and Orissa in India.

In such situation the statistics need to be manipulated to show lower MMP so that the policies foreign investments and privatization of services could be justified. MMR is directly related to social disparity, exploitation and poverty. The government has limited the scope of poverty around hunger and this has limited the rights of the women for safe motherhood. On one had health services have been hugely privatized and on other government's accountability for rights of community to health has reduced. Due to poverty, more than 40 percent below poverty line families are not able to seek benefit of private health services.

Actually this is the time to sincerely implement the efforts for safe motherhood. A political debate has started on the issue but lack of commitment is easily perceptible. The fear is that the rights of women might get entangles into a web of schemes. Government provides cheaper food grains but it is ironic that a women suffering from childbirth pains has to prove that she is poor as per government guidelines to get free medical care and medicines. The government needs to chalk out a comprehensive policy and coordinated effort for child and maternal health and not keep churning out irresponsible and discrepant schemes just to please some political leaders.

Saturday, May 05, 2007

Hospital negligence claims woman's life in Bhopal

Story on

Salamat Ali is inconsolable. His 25-year-old wife Tajbunissa died at the Indira Gandhi Gas Relief hospital in Bhopal on Thursday afternoon and he wasn't even told until the evening.

Tajbunissa, two and a half months pregnant, had gone for an abortion and a tubectomy. But after the surgery, she never regained consciousness.

Salamat is sure his wife died due to negligence of the doctors.

''After the tubectomy operation, she never gained consciousness and when she started bleeding form her nose and mouth, I desperately tried to call the doctors but there was no one,'' said Salamat Ali, victim's husband.

Hospital authorities claim Tajbunissa died of pulmonary oedema or fluid in the lungs, followed by a cardiac arrest.

Callous attitude

An FIR has been filed and the police are investigating the death. Salamat also says he was asked to take his wife's body away without making a fuss. He says the hospital even offered him a compensation of Rs three lakh.

Other patients at the hospital say the incident has exposed the irregularities at the hospital where the staff is greedy and careless.

''Over here even the guards ask for money. Nurses say 'Give me Rs 500 only then I will change the bottle,'' said Avinash Jain, patient.

There are six hospitals in Bhopal to cater to all those affected by the Bhopal gas tragedy. There are also seven mini dispensaries.

But patients say most of them are severely understaffed and lack even the basic amenities.

''The gas relief hospitals are going form bad to worse. This is not simply a case of negligence or even criminal negligence, it's a case of criminal offence,'' said Abdul Jabber, Convener, Bhopal Gas Victims Organisation.

Already suffering from the after-effects of a disaster, these people seem to get little but apathy at these hospitals set up to help them.