PHCs can be made to work with local solutions
Shree Padre, Mysore
Hura is a sleepy village in the Nanjanagud taluk of Mysore district. There is nothing in its nondescript landscape to attract people to the place. So there are no tourists and only occasional visitors from afar because buses and taxis don’t want to ply the distance.
Villagers in Hura are either small farmers or agricultural workers. Till recently, this region was so backward that women delivered their babies at home. That was the norm. A Primary Health Centre (PHC) existed but it was ramshackle and nobody knew what purpose it served. It was just a building that stood there like a sore thumb.
But that was till the Grassroots Research and Advocacy Movement (GRAAM) arrived in Hura to carry out a research project on public health. GRAAM is part of the Swami Vivekananda Youth Movement (SVYM), an NGO in Mysore with an outstanding social track record.
GRAAM’s project, called Arogyashreni (ranking healthcare), mobilises villagers to assess and monitor the functioning of PHCs. A PHC is ranked according to the facilities and services it provides. As people rate their PHCs, they begin to realise the services it can provide. In the second year, community members told GRAAM that they wanted their PHCs to function better. So GRAAM began training them in advocacy to get the local healthcare machinery to perform better.
A WATER FILTER AND TOILET
With public pressure mounting, PHCs in the Nanjanagud taluk have begun to offer enhanced services and facilities. The Hura PHC today records the highest number of deliveries per month in the entire district. Increased awareness created by an Asha (Accredited Social Health Activist) and a functioning PHC has encouraged villagers yet further to access services here. A water filter has been installed to ensure clean drinking water. A toilet has also been constructed for anganwadi workers with NREGA funds.
In three years, the PHCs in some of the most backward villages in Nanjanagud taluk have begun to slowly turn around. In fact, GRAAM received the prestigious Manthan Award 2013, instituted by the Digital Empowerment Foundation, in New Delhi, for its Arogyashreni project.
“Earlier we did not pay much attention to the functioning of our PHC. Honestly, we did not know the kind of facilities it was meant to provide. Neither were we aware of its various rules and regulations,” recalls Nagarathnamma, Vice President of the Hura panchayat.
“But, thanks to GRAAM, we now have a clear working knowledge of the role of the PHC. Health has become a subject of discussion in the village. We are sad that this useful project is now coming to an end.” The project ended in March.
WITH LOCAL SOLUTIONS
Standing outside the clean, transformed PHC, Dr Jagadish, the Medical Officer, explains enthusiastically: “The community discusses the PHC. They understand the administration’s limitations and problems. To resolve them they come up with local solutions.”
Take, for example, the absence of an ambulance service. The nearest hospital is in Nanjanagud, 26 km away. People had to pay around Rs 500 to take a patient to hospital. Seeing the efforts of the people to improve the PHC inspired Nagaraju, a young auto-rickshaw driver. He volunteered his services. Villagers can phone him and he arrives at their doorstep with his auto-rickshaw. His charges are nominal. In fact, boards stuck on his auto and at the PHC say his services are free for delivery cases.
Arogyashreni has taken local people from being indifferent to engaging with and making demands on government health services.
Getting government health services to perform needs to be a priority. According to the National Family Health Survey (NFHS), 80 per cent of health infrastructure is in the public sector, but only 34 per cent people use it. On the other hand, just 20 per cent of health infrastructure is in the private sector, but 66 per cent of the population uses it.
CLOSING THE GAPS
GRAAM began by closing the gaps in the Union government’s National Rural Health Mission (NRHM). Apart from creating a cadre of Ashas at village level, the NRHM mandated that committees be formed to ensure people’s participation. So Hura has committees for health, sanitation and nutrition. It also has an Arogya Raksha Committee (ARS) and a Planning and Monitoring Committee (PMC).
Villagers were selected as members of these committees. But they didn’t know what exactly they were supposed to do or why they were there in the first place. So, in reality, these committees existed on paper.
It was this gap that GRAAM sought to plug. “Many of our public servants aren’t very clear about why they are called public servants. Similarly, citizens assume that ‘public service’ means services meant for the public. That’s it. In reality, public service means rendering service using the taxpayer’s money. The meaning of democracy would be clearer if this concept was understood,” explains Dr R. Balasubramaniam, Executive Director of GRAAM and founder of the Swami Vivekananda Youth Movement (SVYM). He is a doctor and a social entrepreneur. The SVYM runs the Vivekananda Memorial Hospital, a 90-bed hospital in Sargur, in the backward HD Kote district adjoining Mysore.
“We shouldn’t just stick to the restricted meaning of public service, that getting services from PHCs is our right. We should see things in a wider perspective: how can we strengthen our PHCs to get better services?”
In the 112 rural taluks of Mysore district, GRAAM skillfully used a computer-aided software called the Interactive Voices Response System (IVRS) to capture the people’s perspective of healthcare available in their PHCs. The community is given a card to assess its PHC on the quality of service provided and hence the project’s name – Arogyashreni.
Says Dr Balasubramaniam, “We thought just giving grades won’t suffice. The PHCs should be ranked. This is because comparison makes health providers think critically about why they are lagging behind.”
Basavaraju, Deputy Director of GRAAM, recalls that when they started in 2011 the PMCs (Planning and Monitoring Committees) existed only in name. “We wanted to ensure community participation in health services and provide policymakers with practical evidence to improve services at the grassroots.”
There were doubts, however. “We wondered whether rural communities would be able to use technology to transmit their views. We also wondered if they could bring in the changes that were required,” says Chandrika Shetty, project coordinator.
GRAAM’s office in Mysore has a staff of 17 and nine resource persons in the field. After a great deal of research and discussion, it was decided that the views of the community would be systematically and periodically documented. The IVRS digital technology was created by the Bengaluru based Mahiti Infotech, an organisation that develops technology and communication for social change.
To assess the PHC, five members from each of the PMCs were selected as Arogyashreni representatives (ARs). An awareness meeting was organised of the ARs from all 112 PHCs. In answering the questionnaire these selected members were to visit the PHC, monitor the available services and understand the issues bedeviling the PHC from the doctor and the PHC staff.
A toll-free number service for the IVRS was installed. The selected members were to call up this number through their mobile phones and record their answers by pressing numbers on the phone. For instance, 1 if the answer was yes, and 0 if the answer was no.
A set of 36 questions was given to them. These included: “Is clean drinking water available in your PHC?” “Is ORS given to children suffering from diarrhoea?” and “What are the emergency services provided?” There were questions on reproductive and child health too.
Based on the answers recorded PHCs were ranked. Printed rank cards were sent to ARs, PHCs, gram panchayats, NRHM officers, MLAs and the MP. This process was repeated every three months.
In the second year of the project, people began telling GRAAM that they didn’t just want to answer questions about PHCs. They wanted their PHC to improve. So GRAAM added advocacy training to the Arogyashreni project. It created a forum for PMC members to discuss with doctors the problems facing PHCs and how these could be resolved. Eventually 34 PHCs were selected for the advocacy programme.
Asha workers, village elders and political activists were also involved. In these workshops, they were informed about the facilities that the PHC should provide and what the rights of the people were.
“We simply pointed out the democratic options in front of them. We never advised them on what they should do,” says Chandrika.
Periodic and intensive capacity-building workshops were conducted for GRAAM’s resource persons working in villages. Printed handbills with appropriate information were distributed to them and they kept updating PMC members.
After discussions with the PHC staff, PMC members found that three issues plagued PHCs: an acute shortage of doctors and staff, of medicines and of infrastructure. Their persistent lobbying with the district health administration and the panchayat began to yield results.
“Thanks to community engagement 25 out of 34 PHCs have been successfully improved,” says Chandrika.
N. Shivakumar, a resource person with GRAAM, coordinates 13 PHCs. “Earlier there was no interaction between the community and the PHC staff. Now the PMCs meet once a month and a lively discussion takes place between the two.”
The PHC in Mulluru village, for instance, was declared a 24x7 one under the NRHM. It was supposed to provide emergency services like deliveries and accident cases. But they didn’t have a single dedicated doctor. At the advocacy meeting, the in-charge doctor, Haleem Pasha, explained that he had a tough time attending to two PHCs, an anganwadi and various field visits. He appealed to the PMC members to demand a permanent doctor. The members lobbied with the zilla parishad and the health administration. A permanent doctor was eventually appointed. Medicine for an emergency like snakebite wasn’t available at the PHC. It was bought with ARS funds.
Hanasoge in KR Nagar taluk is another 24x7 PHC. Deliveries are conducted here regularly and neonatal care is available. During discussions PMC members found that the PHC required a baby warmer. Power shortage was another problem. There was a shortage of nurses and ANMs (Auxilliary Nurse Midwives) and of routine medical supplies like cotton, ointments and so on.
The PMC held an advocacy meeting with the doctor and members of the gram panchayat. A baby warmer was bought with the ARS fund and so was a UPS to run the baby warmer and preserve vital medicines. Dog bites are a problem and now anti-rabies medicine is being kept in stock.
Bettadapura, another 24x7 PHC, faced an acute scarcity of water. “When deliveries take place a lot of water is required. This problem was raised at a gram panchayat meeting and Rs 30,000 was sanctioned. A bore well was dug. But it was a failure. Finally, the gram panchayat arranged water supply from a public pipeline,” says Ravi C.S., community coordinator, GRAAM. “This is a significant change. Earlier, health issues and PHCs were not subjects for discussion at gram panchayat meetings. Drainage, housing and so on were the only things discussed.”
Bilugali village has a Primary Health Unit that is now called a PHC. It had a little laboratory facility inside its small premises. But the lab wasn’t working because the lab technician was transferred to the taluk hospital that was facing a shortage of technicians. During discussions, the doctor explained to PMC members that he couldn’t do anything about the non-functioning lab. PMC members called up the Taluk Health Officer (THO) and requested him to allow the lab technician to visit their PHC lab at least twice a week. The THO agreed and the Bilugali laboratory now functions twice a week.
The Badagalapura PHC in Heggadadevana Kote taluk is one of the oldest. It was started in 1943. Sahukar Lingayya, a local zamindar donated land and money for the building. It caters to 32 villages. A substantial number of these are tribal villages.
There has always been a sense of local ownership at this PHC because of its unusual history of the land coming by way of a donation.
It was past 6 pm when one visited the PHC. Predictably, it was closed. But within minutes villagers appeared and opened the PHC for us. That unusual act symbolised the good relations the community had with the PHC staff.
“Out of Rs 1 lakh our ARS receives every year, Rs 75,000 is spent on various development purposes,” said B.C. Ravi, member of the PMC.
A compound wall was built around the PHC at a cost of Rs 4.5 lakh under NREGA. To prevent trash from being dumped in an open well, villagers got together and built iron grills to close the well’s opening.
After discussions, the PHC has been helped to equip its laboratory. It has bought blood and sputum testing equipment. If there is a shortage of medicines, they are bought from the ARS fund. “As the quality of service has improved, the number of patients accessing the OPD has increased from 15-20 to 60-70 a day. There are days when this PHC handles as many as 120 patients per day,” says B.C. Ravi, PMC member.
The PHC also conducts a religious ritual called seemantha for women in late pregnancy stage. They are given an allowance of Rs 750, bedsheets and a kit. Says B.S. Gangadhar, a PMC member, “For the first time we got 60 beneficiaries from tribal colonies for this function.”
There is a critical shortage of staff, transport and roads to take patients to district hospitals. Villages like Badagalapura are located near dense forests inhabited by wild elephants and tigers. At night, people avoid driving down this route. “The ambulance service is 40 km away and the roads are pretty bad. By the time the ambulance arrives and picks up the woman, she delivers the baby in the ambulance itself,” said a villager.
Faced with a staff crunch – in Mysore district alone, 40 per cent of doctors’ posts and 35 per cent of ANM posts are vacant – villagers suggested ‘doctorless’ facilities. “Send us a doctor once or twice a week from the PHC in the next village and we’ll gather all the patients on those specific days,” was one suggestion. As a result, four PHCs started getting doctors twice a week.
“We can have a demonstrative effect,” says Dr Balasubramaniam. “But filling vacant posts is the government’s responsibility.”
Says N. Shivakumar, “The major visible change in the mindset of local communities is that they have started considering the PHC their own property and have begun realising the importance of keeping it well-equipped and efficient.”
PRIVATE OR PUBLIC?
Dr Balasubramaniam’s advice is not to privatise public health, especially PHCs. “Don’t hand over PHCs to the private sector,” he warns. “Instead, infuse the system with social accountability. This is not for profit. The public health system can be more efficient. After all, the government hires only qualified doctors, nurses and other staff.”
At least 70 per cent of routine ailments can be successfully treated by PHCs if they are well-equipped and efficient. Patients can be sent to the district hospital only if further investigation is required. This saves time and trouble for villagers and reduces the workload of district hospitals.
“Clinical medicine is different from public healthcare. Out of the eight major responsibilities entrusted to PHCs, clinical care is only one, let doctors attend to that. Healthcare doesn’t need doctors.”
Dr Balasubramaniam points out that two government cadres are needed – one for public health and the other for healthcare. “We had such a system 20 years ago. We are now lobbying with the government to revive the public health cadre and appoint District Health Officers and Taluk Health Officers. Though some colleges offer a two-year Master of Public Health (MPH) degree, only doctors are eligible.”
“We are lobbying with the government to demystify these courses the way the US did and allow science graduates to apply for public health courses,” he says.
Getting doctors for rural PHCs is a major headache for the government of Karnataka. It recently issued an ordinance making rural service mandatory for MBBS graduates. The ordinance has been awaiting the President’s assent.
“Don’t legislate, provide incentives instead,” says Dr Balasubramaniam. “You can start a three-year course on primary healthcare. Assam has a four-year course for rural doctors. Tamil Nadu provides an incentive to attract doctors to rural areas. Medical graduates who serve for five years get preference in the quota of post-graduate seats in medical colleges. Kerala has introduced a similar incentive.”
GRAAM’s project also has wider connotations. It could be used to assess other public services at the grassroots, for instance, ration shops and schools. “It’s cost- effective, fast, has very low error margin and can be done without much manpower, as compared to manual surveys,” says Dr Balasubramaniam.
In fact, Karnataka’s Commissioner of the Department of Food, Civil Supplies & Consumer Affairs is interested in conducting a similar exercise in Raichur district, says Dr Balasubramaniam. “The bureaucracy has taken note and wants this experiment to go ahead. This is a real sign of recognition.”