By: Subhash Mendhapurkar
Himachal Pradesh has achieved much better health indicators than many of its neighboring states in a short span of 30 odd years and this has happened without much participation from civil society groups. No doubt, this has made the health department to feel ‘good’.
It is also true that in North-west India, the growth of Civil Societies is not the outcome of social/ peoples’ movement like in South or Western India. Therefore, there is no history of collaborative efforts of Civil Societies and government departments for the betterment of various services in Himachal Pradesh.
In recent years, under the instructions of Central Government, the state Health Directorate has started collaborating with Civil Societies especially in RCH program, but the experience of most of Civil Societies is not very ‘pleasant’ to say the least. This is due to the difference in expectations – the health department expects Civil Societies to act as ‘extension agencies’ to fulfill its targets whilst many Civil Societies feel that their role is not limited to this, but to raise ‘issues’ and demand ‘quality care’ for the poor. The peculiar topography and demography of Himachal demands that public health care services be available to poor and marginal sections of societies, specially women of all ages, throughout their life cycle. This is a strong point of priority with civil society organizations as well.
On the other hand, the government health care services are concentrating their services to ‘reproductive age group’ and ‘reproductive health care services’. The government is also facing problems in recruiting qualified staff for the interior areas and therefore is planning to follow PPP model where private sector is expected to play (secondary and tertiary services) critical role whilst the primary health service providers is the government.
The private medical providers do not sense the possibility of getting good return on their investments in view of the difficult topography in the state, and are still in their ‘infancy’ in HP, except in the lower Shivalik areas. So any present and future planning of the health sector will have to take into account this factor. We cannot replicate what is happening in Haryana and Punjab, where the private health providers are making more investments (unless HP government wants to outsource people’s health to the private sector on very lucrative terms and conditions without any conscious plan or strategy. It is also true that there seems to be no political will to regulate the private health care services (little more than four years have passed but the state has failed to frame rules for Private Medical Establishment Regulation Act).
Himachal Pradesh, after achieving ‘good results’ in health indicators has graduated to generation-II issues in certain areas (such as TFR) but large interior areas are still facing Gen-I issues (about which I shall speak letter on). In other words, there are groups, the poor, the tribals, the dalits and OBCs and other marginalized groups, who have not ‘caught up’ with others (urban population).
The SRS and NFHS surveys are giving enough warning about the reverse trends in health status of Himachal Pradesh. These data are also showing that the locational gaps in health indicators are yet be bridged, but again there is little sensitivity towards this. Even though the roadmap for Health Development in HP-2008 makes it clear that the objective of the public health services is to `better status of the health of the people leading towards improvement in quality of their lives with main emphasis on equity and access.’
The above statement shows that at least the health department is in agreement that at present their services are not entirely based on ‘equity’; but at the same time the roadmap makes no mention of ‘how the department is going prepare its personnel to do this. There is no mention of what kind of training/orientation the service providers and managers need, how this training/orientation can be undertaken or who shall do this’.
The Mission Statement and objectives of the Roadmap are laudable, but lack of plan for preparing the department to deliver this, is of the concern to civil society sector. Expecting this to happen with quantifiable targets reflects on the Department’s inability to understand the Gen-II issues that the state is facing. The above document doesn’t make any mention of involvement of civil society groups, which is noticeable. Neither it makes any mention of the issues that are grappling the state e.g. declining sex ratio, high locational gap in reach-out and IMR, neo-natal mortality, women’s health status (of which maternal morbidity is only one aspect) rising number of single women, etc.
The self-congratulatory mode that has gripped the Directorate is the main culprit for making any further movements in Health Care Services as well as lack of understanding of Gen-II issues and its long term effect is another reason. This is very evident from the fact that the Health Directorate has planned various campaigns for improving certain indicators without public debate and deliberations with Civil Societies (the most recent example of this is the campaign for reducing anaemic conditions in women- The Manifesto by Vulnerables 2007 published by Civil Societies has demanded a special campaign and program for removing anaemia amongst women and the government initiated the campaign, but it did not felt it was necessary for it to consult the Civil Societies during planning the campaign). ‘We know all and we can do it alone’ is the attitude which needs to be changed if we want any further movements in health care services.
This note is based on the belief that at least the policy makers of health care services have realized that this attitude and way of functioning is not going to make much headway and are looking forward for a constructive dialogue with civil societies. We must recognize that time has come for the attitudinal changes amongst the service providers and managers is the need of the hour. The major issues in health care services:
1. Declining Sex Ratio:
The Civil registration data of the State has shown further decline in girl child sex ratio even after 2001 census was out and efforts made by all. It is so because the efforts made by Civil Societies are limited to small part of the State and the State has recently started taking action against the unscrupulous medical establishments involved in sex detection.
The Manifesto by Vulnerables 2007 has demanded that the State be declared as Demographically Challenged one and thus dedicate itself towards developing an Integrated Policy for restoring pro-gender population (which is what was in Himachal till 1981).
To restore the natural sex ratio, there is a need that the community owns up the issue and start action. This can be done by the Civil Societies by helping the Mahila Mandals/SHGs to understand the implications of declining girl child sex ratio and ensure their participation. This is much effective as Civil Societies have a better rapport with Mahila Mandals/SHGs than the departmental personnel. The work done by SUTRA in this regard has given results, which are well documented. We consider that whilst the government work on supply side; Civil Societies should work on demand side. The better the harmony between the both, quicker shall be results.
2. Locational and gender gaps in IMR:
Himachal Pradesh has achieved very good results in reducing the IMR from 134 in 1971 to 47 in 2007.
But the fact is that there still exists vast chasm between rural and urban IMR. An important locational gap.
Year Rural Urban
2001 62 37
2007 49 25
This Locational gap is not merely due to the lack of proper and efficient service provision, but is also due to the peculiar topography and hostile climate of the State. Another reason for this is the dieing institute of Dais on one hand and on the other hand majority of women preferring to deliver babies at home.
Under RCH Program, many Civil Societies have motivated families to have Institutional deliveries with great success, but the experiences of women who went to Health Institution to deliver babies was not very pleasant, to say the least. The quality of care was lacking as well as expertise was also lacking. The large number of stillbirths taking place in Institutions is also a worry. If Locational gap in IMR is to be bridged then we need to take different approach, which should be suiting, to topography and certain political realities.
The political reality is that the State Government shall never be able to make Female Health workers to stay at Sub-Center whilst topography and hostile climate shall not encourage people to undertake Institutional deliveries. We need to find a solution and it may lie with development of village-based cadre of Dais well trained and their work rigorously monitored. Selection of Dais may pose a problem because the expectations of becoming `sarkari mulajhim’ are very much alive. One solution is to ask Civil Societies to select Dais, department taking up the responsibility to train them and the joint monitoring of their work can be undertaken. We need this to be debated.
The second but equal worry is the emergence of negative gender gap in IMR. Till 2004, Himachal was the only state north of Vindhya where gender gap in IMR was positive. But since 2005 SRS data has shown that this positive gender gap has become negative one. In other words more girls are killed in the womb, but those who are allowed to live are also not being treated humanely.
Year Male Female
2001 56 44
2004 47 51
2007 45 49
One of the reasons may be that the second successive girl child is allowed to die as the families wanted to have male child. Another reason may be the increase in discrimination after birth (there is discrimination before birth which can be taken care off by implementing PC-PNDT) and this discrimination can be removed through social movement which is what Civil Societies are expected to initiate.
It may take some time, but unless we built up pro-girl child environment, we shall never be able to bridge this gap.
The Civil Societies can be motivated to built up this environment through Mahila Mandals/SHGs as well as quickly arranging postnatal services. One must remember that such a gender gap is not the result of `remoteness’ of villages it is the outcome of `discrimination after birth due to girl child’s birth order. We can say this with certain confidence because there were more remote villages prior to 2004 in Himachal but we had positive gender gap in IMR. As the infrastructure and mobility of Himachalis is improving, there was expectation that this positive Gender gap in IMR shall not be only maintained, but improved. But opposite is happening and therefore we believe that this is due to induced discrimination and not the one which is prevalent in India. Therefore the solution lies in social action followed by quick response from the Health department to provide quality of care during post-natal period.
Other locational Gaps:
To find out the reach of the Health Services to Tribals, poors, Dalits and migrant workers, we need to have data. But field experiences show that these services are not reaching to them – especially to large number of migrant labours who are from plains and move alongwith their families. qThe nutritional status of children according to NFHS-III is another worry. Though NFHS-III doesn’t provide data based on locational (rural-urban), it is presumed that these reverse trends are mainly occurring in rural areas because of lack of nutrition and in urban areas because of change in life-style.
The lack of knowledge of spacing methods among the rural, tribal, Dalit and less educated population makes them dependent on sterilization, whether male or female. This is a major locational gap. They may not even be aware of these options. This is certainly a Generation I problem. Only the urban population and the well off and educated rural population have gained from their knowledge of the various methods of contraception and their ability to access these services, so we are chasing a non-inclusive strategy of population planning and feeling very proud that we have achieved replacement level of fertility.
3. Taking NRHM beyond JSY
If one studies NRHM document carefully, one understands that Institutional deliveries and JSY are a minor but critical part of the whole program. The NRHM aims at providing Health Care services on Life cycle approach to women. Unfortunately the department has brought it down to mere Institutional deliveries (this is not happing only in Himachal, but the situation is same across the country).
The =mute question is: can all the problems be solved by `Institutional Deliveries?’ We agree here that the HP Health Services are not to be blamed for this (putting all eggs in one basket) but taking into consideration the topography and hostile climate, we needed to take NRHM at a much higher level.
Even if we accept that Institutional deliveries may provide answers to some of the locational gaps (in IMR) but the number of stillbirths that are king place during Institutional deliveries needs explanations (refer data provided by HPVHA and SUTRA).
There are no evidences that due to Institutional deliveries, MMR has lowered or there is less maternal morbidity – if it is available with Health Directorate, the Civil Societies should give serious thought to it.
This exclusive approach to women’s health needs is adversely affecting the quality of Life. The rise in Anaemia not only amongst women but also amongst children is one indicator apart from many others that are available in NFHS.
Secondly, we need to understand that the percentage of Single women in Himachal is roughly 17% (to ever married women). For these women, at present there is no space in NRHM (the way it is implemented) and this is the most vulnerable section of the society. State cannot leave them at the mercy of Private sector due to various reasons mentioned earlier. Therefore, we need to initiate a process to enlarge NRHM to include Single women.
As far as Adolescent Girls are concerned, the approach shouldn’t be `they are tomorrow’s mothers so let us inform them about Reproductive Health’ but instead the approach should be `they are tomorrow’s citizens and thus they should be knowing their Reproductive Rights’.
Another fact we need to understand that as age at marriage is increasing, pre-marital sex is also rising. It is estimated that atleast 10% maternal deaths are amongst the adolescent girls (the recent suicide by a young girl on the mall of Shimla is just one the incidence). This is due to our inability to `educate’ adolescent girls and boys on the use of contraceptive and also making the same available to them. This also raises the question of educating adolescent girls and boys regarding HIV-AIDs and other RTIs/STIs.
We need to take comprehensive approach towards adolescent health.
The Right based approach to provision of Health Care Services needs a big internal preparedness of the department, the Roadmap document is silent on this. The Civil Societies can play a very important role in this venture. They can create enabling environment for these section to access the health care services either through Health Insurance or through community mobilization and also help the department to undertake preparations for changing the mindset of its personnel to accept the Right based approach.
The problem with most of the Health Insurance policies is that they provide insurance against only Hospitalization, but no support for minor illnesses which, in fact need low but continuous cash-outflow which is hard to find for Single women, many of them surviving on a mere Rs 300/- social security pension per month.
Himachali population is also suffering with another problem called ageing – majority of aged population is women and they are perpetually starved of cash. The State cannot abandon them even though their sons have done so. It is so because these women have contributed significantly to the growth of economy. Moreover, the Hon Chief Minister has assured publicly to the Ekal Naree Shakti Sangathan that there would be free Health Care services for all the single women living below Poverty line. The Department is duty bound to implement this but this shall not be possible unless the it seeks help from Ekal Naree Shakti Sangathan. Civil Societies can bridge the gap between front line Health Care Service Providers and Managers and make services accessible to single women. One must remember that for single women, the major issues are related to mental health and we have not developed our capacities to provide the same.
The Civil Societies can play a significant role in bringing primary health care services to these women at doorstep- they need to sit together with the health department to work out the modalities. There shouldn’t be any disagreement that this vulnerable section needs state support so that they spend their last years of life with dignity.
4. Lessening maternal morbidity and related health issues:
It is true that there is increasing maternal morbidity even though we do not have enough data, but anecdotal data proves it. There two major reasons for this, one is vasectomy operations are done on women at an early age (between 24-26) and secondly facilities for safe abortions are lacking in the State.
The problem most of the women are facing in mid 30s is the disturbed menstrual health and the medical fraternity advices them to go in for hysterectomy. All over the world hysterectomy is performed on young women only when there is a danger to her life, but as we do not have any law regarding this, large number of women undergo these operation and suffer psychosomatic diseases such as `loss of something’ or `tiredness’ etc. This is directly related to maternal morbidity.
This also indicates the failure of the State to convince women to use contraceptives as temporary methods of family planning – it is due to lack of faith on `regular supply’ of the same and men’s unwillingness to use condoms. I have mentioned this also in paragraph on Locational gaps.
In the name of `men’s involvement’ what state is showing is the increasing number of NSVs. Instead of this, the real involvement of men would be higher use of condoms and that is where the role of Civil Societies can become critical. The use of terminal methods for family planning either by men or women has also shown on effects on demography as there is increasing number of `only male child families and Himachali society is becoming more masculine.
Thus use of temporary contraceptives has large number of advantages and the propagating the same is needed two pronged approach- lessen the pressure on frontline staff for family planning cases and involvement of Civil Societies for propagation of temporary contraceptives with assured supply specially in the interior areas. One also needs to look at the `method’ adopted for distribution of contraceptives either through sub-center or Depot Holders. Culturally, we shouldn’t expect women (adolescent, married or single) can openly access the contraceptives where their names and addresses are noted. Why can’t we develop innovative methods for distribution of the same (like condom box that was adopted in Nepal which became very successful).
Another reason for rise in maternal morbidity is lack of facilities for safe abortions for women. The existing facilities at district hospitals are excellent, but there is a problem of confidentiality. The hospitals are so crowded that no one feels any `privacy’ and still in this country, women would like to have complete privacy when they want to access abortion services. It seems that private sector is quite capable to provide the same. But the question of `affordability’ comes – how many poor women can afford to have safe abortions at private clinics- these establishments are not regulated, so charges vary according to the needs of the women. We suggest we should separately discuss this and plan out our strategy to provide safe Abortion services that are acceptable and affordable to women specially from the interior Himachal.
Accessing unsafe abortion services, lack of proper post-natal services (resulting in prolapsed uterus) all are adding to maternal morbidity and Civil Societies must come forward to help women to get back healthy maternal life. Health department must come forward to provide technical support to Civil Societies for achieving this goal.
5. Involvement of Panchayats
If we want to make NRHM successful, it can not be done without the creative involvement of Panchayati Raj Institutions– history tells us that without the involvement of GPs neither the Health nor Education Department in Himachal would have achieved the present status. It is true that GPs took keen interest in opening up institutions as well as providing infrastructure facilities in 60s and 70s.
The involvement of Panchayats can be at various level – at governance level, at agency level and at support level.
Let us look at each one of these:
a. SUTRA’s experience confirms that Panchayats are keen to get involved in the movement for `restoring natural sex ratio’ if they get enough information as well as space for deliberations. Many Panchayats have raised this issue in their Gram Sabha as well as they have organized Mahila Gram Sabhas for this purpose. Therefore providing information, helping Panchayats to organize Mahila Gram Sabhas are the activities that the Civil Societies can undertake and the Health Department can provide information on PC-PNDT as well as collect information from people to know where are the unscrupulous medical establishments working so that it can take legal action against the same. Panchayats should be legally empowered to take action against the Zola type Service Providers or other private service providers. When the Bill for Regulating Private Medical Establsihment was discussed we suggested to hand over the power to take legal action against Private medical Establishment to Panchayats. Not merely under the PC PNDT Act, but in other ways. This needs detailed discussion. We strongly feel that Panchayats should be legally and administratively empowered to deal with the supply side, not merely the demand side. We need to make this issue as an issue of governance.
b. The Panchayat leaders can also be motivated to get women undertake early registration of pregnancy and also in creating `support group’ for the women who are forced to go in for sex detection and sex selective abortions, if needed.
c. Under NRHM, the Panchayats are expected to provide all the support to Health Department to achieve the NRHM goals and also undertake community monitoring.
Unfortunately the experience of the Panchayats is that, in the name of support, the Health Care Service Managers treat Panchayats as mere `extension agency’ and keep on giving them `responsibilities’ without providing any `authorities’ which is not liked by the Panchayat leaders like any other people’s Representative and that is why there is vast chasm between Panchayats and Health Care Service Providers/ Managers.
The Health Department also is not keen to work with Panchayats on the issues of Governance and monitoring. This may be because the Health Service Managers feel that their knowledge base is much superior to that of Panchayat leaders. It may be true, but they must remember that Panchayats are essentially Constitutional Bodies and their supremacy must be accepted. If they lack their `knowledge base’ then it is our duty to provide the same. The Civil Societies can help them to built up perspective and can provide critical support when there is a Community Monitoring which is lacking as of today.
Involvement of Civil Societies beyond Extension Agency:
Involvement of Civil Societies beyond a mere implementing agency is a need of the hour. The reputed Civil Societies or their networks can provide human resource to Department to undertake training/orientation to service providers/managers to change their attitude and initiate Right Based approach to Public Health Care Services.
It must be mentioned that about a decade ago, with the support of UNFPA, the State did initiated training/orientation program for front line managers (Medical Officers at PHCs/CHCs), but unfortunately it failed to integrate the pilot training / orientation that were conducted into its annual plan of action.
We strongly suggest that, the State must involve the Civil Societies in organizing such training / orientation for its front line service providers/managers.
(The writer is coordinator of Sutra)