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By Manipadma Jena At a recent public hearing in Orissa's Jagatsinghpur district, both men and women told harrowing tales of negligence, bungling and lack of facilities in the state's public healthcare system
It’s now 10 years since India and 178 other nations affirmed that they would put access to health services, particularly reproductive health services, centrestage in the struggle for greater equality for women. The pledge was made at the International Conference on Population and Development (ICPD). However, despite slight improvements (as shown in statistical data), public health services in India ’s poorer states remain deplorable. At a recent jan samvad (public hearing), held in Orissa’s Jagatsinghpur district, people from 22 villages in Balikuda block -- mothers-in-law, mothers who had recently lost their infants, even elderly fathers -- voiced their concerns and pleaded for better healthcare services. The hearing was conducted by the State Women’s Commission, Orissa, the Integrated Population and Development (IPD) Orissa project and ActionAid India . Although the reproductive and child health programme was introduced in Orissa in 1997-98, and external donors like the World Bank, the European Commission and the United Nations Population Fund (UNFPA) poured in funds to the tune of hundreds of crores of rupees, Orissa’s health indicators continue to show little progress. The state’s infant mortality rate (IMR), which improved from 96 in 2000, now is the second highest in the country, at 87 (rural: 91). That’s way higher than the national IMR of 64. While the national doctor/population ratio is 1:1,916, in Orissa it is an alarming 1:7,462. When doctors are posted to remote areas of the state, they respond by going on leave. The Auxiliary Nurse Midwife/population ratio (2001) is only slightly better at 1:5,178. Subsequently, more ANMs have been appointed but judging by the complaints voiced at the public hearing in Jagatsinghpur not much had improved at the grassroots level. The reasons are not difficult to come by. As an overwhelming number of testimonies showed, there is wilful neglect at public health facilities and at the hands of government health personnel. These include childbirth deaths, pregnancies that occur after family planning operations have been carried out, babies delivered after abortions, STI and RTI infections and, above all, payment for services that are meant to be free. The public hearing clearly exposed that one of the major reasons for high interest borrowing was expenses incurred to save loved ones from ‘health sharks’.
Orissa ranks ninth among 25 states in maternal mortality rate, at 367 (the national rate is 407), according to SRS 1998. What, however, is cause for concern is that over two-thirds of maternal deaths occur right after or within two weeks of childbirth, from avoidable complications arising out of infections (sepsis and toxaemia) and haemorrhage. Although lack of hygiene and trained care can be remedied, even if slowly, what can be done about wilful neglect? The NFHS-II found that only 19.2% of women in their last two months of pregnancy received visits from health workers. An even smaller percentage -- 11.6% -- of women in the last week of pregnancy received visits. Overall, only 9% received one home visit from a health worker in the 12 months preceding the survey; even they were visited only 1.6 times in the 12 months. According to Dr B K Das, director, department of health and family welfare, more ANMs had already been appointed, and 70 mobile medical vans would soon be deployed for service in remote areas.
How desperately the lack of transport and communication needs to be addressed in the most backward districts is apparent from a telling case study cited in the Christian Medical College Vellore’s alumni journal of September 2002, by Rev J Thomas who works at the Asha Kiran Hospital in Lamtapur (where the primitive Bonda tribe lives) in Koraput. “One mother had retained the placenta after delivery. She would have to walk five hours by foot to the nearest motorable road and a further one hour by road to the nearest PHC. She died of a haemorrhage before her family could mobilise six men to carry her for the six-hour journey.”
The second case Thomas cites illustrates the rot that has set into the public health system. “The mother was in labour for three days and then carried to the nearest PHC at Khairput. From there she was referred to the Koraput District General Hospital , 120 km away. The nearby Malkangiri District General Hospital , though manned by obstetricians, had no operating facility or blood bank. The relatives made arrangements to transport the mother to Koraput. When the mother arrived at Koraput, her relatives reportedly were asked to pay Rs 15,000 in advance. The dismayed relatives returned home with the mother who was by that time in shock. She died soon after reaching her village. The cause of death was ruptured uterus sepsis, also avarice and corruption in our medical system,” writes Thomas. What infrastructure development or which modern medicine can cure this disease? After their firstborn son, Rita and Prafulla Rana, from Chanarpur village, waited four years before having their second child. Rita, 21, had six check-ups during her pregnancy at the community health centre (CHC). When she went into labour, in the ninth month of her pregnancy, Prafulla immediately hired an autorickshaw and took his wife to the CHC. Fortunately, there was a doctor present. But he said Rita’s labour pains were false and that she should go back home. Prafulla decided to stay the night at a relative’s house near the CHC. Sure enough, at 9 pm , the labour pains returned in earnest and, at 4 am , Rita delivered a baby boy. But the mother was not doing too well. The doctor said she was “just weak and would be all right if fed properly”. He prescribed Horlicks. A nurse, however, told Prafulla: “She is trying to attract attention. Take her home, give her rice and she will start working in no time.” Although Rita’s condition worsened the doctor insisted on her being taken back home. The nurse’s behaviour too was becoming more and more abrasive. Prafulla decided to take his wife to the district hospital where he was told she had jaundice. She was referred to the SCB Medical College and Hospital in Cuttack -- the largest medical facility in Orissa. The hospital confirmed that Rita had jaundice as well as malaria. Prafulla bought all the medicines the doctor prescribed, but Rita’s condition did not improve. Rita died before all the reports came in, leaving her husband to raise their six-day-old child. When the CHC doctor heard about Rita’s death he returned the Rs 500 he had taken as a fee to Prafulla. A daily-wage labourer, Prafulla ended up spending Rs 3,300 on his wife’s treatment, of which around Rs 2,000 went towards medicines, pathology tests and doctors’ fees.
Mamina Choudhury from Tandauni village, Kalio panchayat, suffered the same fate; only, she is alive today. For 10 years after her marriage, Mamina could not conceive a child. When she finally did, she had twins. But, of the two male infants born at the CHC, one died during the operation, the other within two days. She blames it on negligence. What’s more, the doctor allegedly demanded Rs 1,000 for the caesarean section operation. Five months after losing the twins, Mamina has frequent stomach and back pain and her body swells up. She is severely depressed and has stopped speaking.
After giving birth to two daughters, Laxmi Naik opted for a family planning operation at a health camp. A couple of hours after the operation her husband put her on his cycle and rolled it gently the four kilometres to their village. Within nine days, the stitches turned septic and the local doctor refused to treat her. Laxmi was only able to return to her job as a daily wage labourer a month-and-a-half later, after taking countless medicines and injections. She was not paid for the time she spent away. Laxmi’s experiences have only served to put the other villagers off sterilisation altogether.
Thirty-year-old Charulata Sahu from Godida had her third child after (what she presumed was) a family planning operation in 1999. When she conceived she confronted the CHC doctor who offered her a strange explanation. He said: “We could not locate your fallopian tubes. Since you were the first in the queue at the family planning operation health camp, if we had announced this the other women would have refused to go ahead with their operations. So we did not tell you that you were not operated that day. If you bring your husband along, I will do a MTP anytime.” Fearing further bungling, they refused the doctor’s offer. And they did not get their Green Card. Countless other women tell the same story. Swarnalata’s has a twist in the tail. When she attended the family planning health camp she mentioned to the doctor that she had missed her menstrual cycle by a month and was probably pregnant. The doctor assured her that he would do an abortion a month later, but insisted she get operated right away. When, after a month, Swarnalata approached the doctor for the abortion he said it could not be done at the CHC. She went to another doctor who demanded Rs 100 and warned her that he would not be held responsible for any subsequent complications. Illiterate and confused by the behaviour of the two doctors, Swarnalata went ahead with the pregnancy and had a fourth child -- she now has three daughters and a son.
Orissa ranks 18th out of 25 states in institutional delivery, with only 22.6% of births taking place at public and private health facilities. As the Koraput case studies show, many PHCs are inaccessible; emergency transport support is poor, as is road connectivity. Women with obstetric complications have to be carried in baskets from remote areas to health centres. When poor people do manage to make it to public institutions, as was the case with Mamina, the ‘treatment’ they receive does not inspire much confidence in the public health delivery system. After launching its IMR mission to reduce the number of infant deaths, the state claims the number has inched down to 87 from 96 in 2000. The state government is also poised to launch Vision 2010 -- an action plan that, among other things, aims to actively involve the community in health services.
It is important to note that this sorry state of health services exists in Jagatsinghpur district, which records a literacy level of 79.6% (the second highest in Orissa). Female literacy too is a high 69.14%, compared to the state average of 51%. The district has one district, three community, 38 primary and 178 sub-health centres. It has 16 specialists, 50 doctors, 16 staff nurses, 32 female health workers, 212 ANMs and 56 MPWs (the requirement is for 115). (Manipadma Jena is an independent journalist based in Bhubaneshwar, Orissa. She reports on development issues.) InfoChange News & Features, December 2004
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