Pit

t r r " . 1 .. . i

p 7f ,,':i'i,,iil:

(.Atli

Pre natal care of the pregnant mothers is one of the important pfolfammes caf' ried out among the preventive services. This includes vaccination of pregnant women against tetanus and supplying them vrith iron folic tablets. However, like other preventive programmes, this programme too, we found, suffered from incompieteness, particuladf in Dumka' While 70 percent of the women in Birbhum reportedll, received tetanus iniections during pregnancy the figure for Dumka v'as only 26 percent. Concerning the receiving of iron folic tablets the picture was more upsetting' Only 46 pefcent of the pregnant women in Birbhum reportediy received the iron folic tablets. For Dumka the figure was only 27 percent' A PHC in-charge in Dumka pare hule hain' Yet, he admitsairl that there was no deatth of iron folic tablets - bhare ted, most of the pfegnant women wele not covefed because (1) it tr"as difficult to make these tablets available to all pregnant mothefs as the numbet of health workefs was much less than required; and (2) even when tablets v/efe supplied to the beneficiaries they did not bother to consume them out of simple negligence. Hower,'et, a female health worker presented it differentiy. First of all she cofltradicted the doctor's view about the availability of s.ufficient stocks of the required me medicines. "PHC me reh sakta hai, magarcentre nal:in aata they may be available at the PHC level, but not at the sub-centles". Secondly, she said that the negligence of pregnant mothefs as legafds consuming iron folic tablets stems from ignorance' pata ki iska maltakya@a hai - they ale unawafe of the importance of the "wnko /<ya iron folic tablets". And the enofmous iob profile of the gfass-{oot level health workers did not allow thern to do the consistent counselling required. Ar,zilability of vaccines at the sub-centre level, both in Birbhum and Dumka, was ^ gre tptoblem. The sub centres in the rural areas suffer from the problem of storage, as most of them are ill equipped (some of them wete running in dilapidated buildings without doors and windows). Even the PHCs, particulady in Dumka, suffered from stofage problems. In a Block levei PHC of Dumka, the in-chatge showed us a refrigerator, which accofding to him, "could best be used as an a/mirab", as the supply of electricity was exrfemely erratic (power cuts for 14 to 15 hours a day was normal and sometimes there would be no powet fot three to four coflsecutive days)' Hence, the non-availability of the required vaccines at the fight times and places hgh cfeates a vacuum that is futther increased by the ignorance of parents caused by and by the levels of female illiteracy (in both the distticts but particulady in Dumka) programme' absenceof a coherent a-r/areness-generating Ant {: r r*f.nei t NG p,,\il t\ f.t 1 part Creating awafenessamong people, particularly among mothers, is an essen'tial parof the duties assigned to health wofkers. In a coufitry with widespread illiteracy, usirrgrvall writing, posterl'ng, campaigns ricularlyamong women, awafeness-generadng

leaflet distribution, etc. have their own limitations and the most effective way of creating awarenessabout health and health services is direct contact with the villagers. One male Health Assistant and one female Health Assistant at every sub-centre are supposed to spearhead the public health programmes in the rural areas.They are supposed to visit each famlly vrithin his/her geographical arca o{ operation duly fixed once in a morrth in a 16 days' cycle i.e. 4 days in a week'1o. A Health Assistant(Nlale)is supposedto perform different activitiesassociated with malaria and othet communicable diseases,immunisation, family welfare, nutrition, environmental sanitation, recording of vital events, first-aid and treatment of common ailments. The duties of a Health As.sistant (Female) are associatedwith prenatal and post-natal care of the women at home, care in the clinic (at the sub centre) care in the community (visiting the households in the villages), etc. However, ^ mere list of the many different tasks assigned to health workers does not guarantee the effective delivery of health services. In a situation where some of the health workers themselves (in both distticts) were found to be unaware of their assigned duties, the knowledge of the villagers concerning the services avallable from the pubJic health delivery system can well be imagined. The lack of access to information further exacerbatesthe lack of the availability of proper health services. In our study only 37 percent of the sampled households in Birhhum ard26 percent of the households in Dumka were reportedly visited by any health worker during the year preceding the survey. Again, the majority of the visits were made by Health Assistants (both male and female) and ICDS workers and not by doctors or senior health workers. In the househoids reportedly visited by health wotkers, a large number of resoondents said that the visits were made onlv once in a vear or so.

Table 8.3. Periodicity

of visits by health workers

Birbhum Dumka:: I
A

B;r*..n

one and *o

.on,h,

I4

Three months - l2 months

74
Ar peranlsge of lata! bmnbol.d: whirh rQorlut! reeiued any uis't

Village wise data sheets and observations further indicate that the delivery of health services is not only different in the respective districts but there are also considerable intra district variations. Nfe found a sharp dividing line between the villages with positive and negative respoflses. While the positive responses were found only in a few villages, the negative responses were distributed over a large number of villages. Our observatibns also support the above findings. The relatively better functioning of some sub cefltres was due primarily to the dedication of their workers, not because of any policy or structure. In most of the casesthe sub cenftes were left to

A4 i.,F.\'r'':f

'.

,,?:.r''

, I

the mercy of the individual health v/orkers, some of whom - out of humanitarian commitment - tried to keep the system running in spite of many difficulties.
QU/:,L|TYOF tf?,'.ll{iS A1 tiAfl,t

Similady, when asked about the quality of services extended by the health workers during their visits, most of the respondents expressed satisfaction. This again shows that a small section of health workers who visited the villages had tried to do iustice to their iobs. Eghty six percent of the respondents of Birbhum (visited by health workers) said that the health workers talked nicely with them. In Dumka, the figure was lower - 45 petcent. Seventy eight percent of such respondents in Birbhum responded that health workers spent sufficient time with them. The Dumka figure was much lower - 55 percent As to what type of serviceswere delivered at home, vaccination ranked first. (fhe list included supply of pills, condoms, follow-up after ster't\zation, counselling for family planning and othet related services,awareness-generation prevention of diseases, on treatment of general ailments, etc.). The other services provided were negligible (see Appendix table E 7.b for details). A female health worker in Dumka said that she felt helpless fot she was seldom provided u.ith the required pills and other medicines. Besides, she complained, she found very little time to visit the households as the area assigned to her was large and there was no communicatton available.Another female

health worker reported that het area was under thick forest cover and villages were scattered.To add to her probiems, the areais prone to elephant attacks.I I \[hi]e there wete practical difficulties faced by some health workers, some of them, as we have seen, neglected their duties simply because of the perceived difficulties. Many of them were found to live in urban or semi-urbart are \ from where it was vefy difficult for them to cornmute to their areas of operation. In addition, their difference from the villagers they are supposed to serv - both in terms of status and mentality - perhaps leads to the development of inhibitions towards villagers and rural life. Some of the health workers in both the districts, echoing the doctors, officials, and other middle class persons, held the villagers responsible for their ailments. "Villagers arc ft7tht'', "they are illiterate", "they dont care for their health," "th.y don't want to use modern medicins", were a few of the comments made by healrh workers. Crlln M PRLtrll\Trt/f hAlu'?h5 In both the districts, diarrhoeal diseases were

Measures to prevent Diarrhoea:

reported to be among the most common. Difficulty in accessingpotable water is one of the major causes behind the increase in diarrhoeal diseases.In almost all the villages studied in Dumka there is scarcity of drinking wateq which becomes acute p^rticularly during the summer. In addition, despite the installation of many handpumps in the villages most of them were out of order during the survey. Villagers reported having lodged many complaints but to no avail. Some villagers alleged that the block office asked for money to repair the hand-pumps, which villagers could not afford. Thus, many of the villages, particularly those located in the hilly areas, depend upon streams or open dug wells for drinking water. In none of the study villages was the distribution of purifying agents @leaching powder, etc.) recollected by the respondents. In some of the villages, the quality of water was found to be extremely dirty and unhygienic - paticles of diffetent kinds of organic and inorganic matter were quite visible, in the water. The situatiotr in Bitbhowas relatively better, but the district is not completely free from problems regarding potable water. At least in two of the 12 villages surveyed, the situation was very similar to that of Dumka. The other villages were also not completely free of drinking water pollution. As reported by some of the PHC authorities in Birbhum, programmes related to water purification were carried out only in specific areas rvhere diarrhoe:atook an epidemic turn. It worth a mention here that the Panchayat ^nd Rural Development department of the Government of West Bengal has launched a programme of sanitation, "Gramin Swastha Vidhan" in 1991, which has been very successful in some districts (for example, Medinipur East and Hoog$. The progtamme became operational in 1993-4.Tbe number of low cost toilets built in the state has increased more than a hundred-fold (froin 19,565 in 1993-94 to 2,079,493 in 2002-3).12 In an interview, an official of the department sard that Nandigram II of East Medinipur district has become the first fullv sanitized Community Development Block in the country and

they were expecting orre or two districts to be fulty sanitized very soon. The achievement of the sanitation pfogfamme, as mentioned by the official, has had a direct particulady diarrhoea. impact in reducing the occurrences of water borne diseases, However, the programme has yet to achieve significant successin Birbhum district' Though the importance of sanitation has been acknowledged in pubhc policyll in Dumka district no tface of such a pfogfamme was found. Neady 100 percent of the people were reportedly using open grounds as toilets, r.vhich increases the possibilit-v of the occurrence of diarrhoea. Measures to pfevent rnalaia: Although we found very few malaria cases in our study areas in Birbhum, it has remained a menacing killet disease in the district, as u,e have mentioned earlier. In 2001-2, the reported cases of malarta in Birbhumla were 4L2 of which 35 percent were of Plasmodiam falciparatn. is known to be a malaria-prone disttict. In our study area malaria Dumka parients formed 24 percent of the population that suffered from any ailment during the year preceding the study. As mentioned eariiet, malaita is afl acute problem for many parts of the country, and takes a healry annual toll. The Cenffal Govetnment has launched the National Anti-Malaria Ptogramme, which compfises pteventive, Sprayingof pesticidesis one of curative and other measuresto eradicatethe disease. the important pfeventive measufes. However, none of our respondents in Dumka (including the residents of the malaria-prone villages of Gopikandar block) confirmed any such spraying. The National Anti-Malaria Programme 2002 tn the district claimed to have distributed mosquito nets. It also claimed that distribution of mosquito nets was done among 100 percent of the households in Gopikandar block, 40 percent of the households in Jatmundi block and 20 percent of the households in Sikaripara biock. Gopikandar is a highly malaria-prone block - the incidence of malaria was so enormous that it took 35 lives from a single village in our study area in the year prior to our visit. However, contrary to the claim of the health officials, noneof therespondents anlt wasfound to hauereceiued mosquitonetsin the block. As part of the preventive programmes, mass communication (mainly wall writing) has been carried out both in Bubhum and Dumka. But the effectiveness of such programmes cannot extend beyond the boundaries of the literate population. The most direct contact, was found to be largely absent. essentialmode of generating awareness,

Part II
d v n 1 : ' i, Y ; 1 : l ) , ! I L I : 1 f

When the much-focussed and heralded pubhc health services for prevention of diseasessuffer from such gross deformities, the state of the curative services can well be imagrned. We har,'eseen in section 5 that only a smali fraction of the patients visited the public health centres for healthcare. An absolute majority of the suffering