It was about 3 pm when we left the Highway 33 and turned further north east. We crossed a small town with a number of facilities connected with the coal industry. The scenery would have been very pretty had the trees of the fairly well preserved forests not been so much covered with black soot or coal dust and had the air been freer of dust.
We crossed a couple of streams and then reached a village. Let us christen the village Birsapur. We asked for directions and after winding through – quite unnecessary it retrospectively seemed since it was easier when we exited – some lanes, stopped in front of the health sub-center. It was a nice building, freshly painted. A solitary stray dog guarded it this Friday evening.
As we stared at the shut gate and locked door, someone came and told us it was closed as the sister didi had gone away to her hometown the previous day. Our persistence made the urchin fetch an elderly bespectacled woman in a saree. She looked very kind and was voluble. Her husband followed and opened first the gate and then the locked door for us.
We were being shown the improvements in the sub-center using the District Mineral Fund. The lady told us that she was the retired midwife of the village. She told us though the sister didi was posted, she was very young and inexperienced and everyone came to her to deliver the babies. Having been a resident of the village for decades, she could not turn them away.
Poorly maintained sub-centers
The delivery room of the sub-center was equipped with a bed that looked awfully rusted. The retired midwife told us that the family that was bringing in the expectant mother brought their own bed on which the mother lay during labor. There was no budget with the sub-center it appeared, either to put rubber sheets on beds or to clean the blood-stained sheets, so families had to bring their own.
There was a forlorn sort of oxygen cylinder in a corner along with some trays and assorted things. She took us to the new room to show us the baby warmer / incubator telling us that in winter the temperatures dropped and babies had to be warmed, else they contracted pneumonia.
While the equipment was as described to us earlier on our way, there was a heap of cardboard boxes with polythene bags. A family of cockroaches looked up enquiringly, resenting our presence. The lady was embarrassed by their audacity and whisked us away.
Some registers were produced to show the record of births. She had no clue if anyone ever came to the sub-center for anything other than “institutional delivery” which got the family Rs 1,400.
This was Jharkhand. Please do not exclaim “Oh! what else can you expect in these states!” since the picture does not change too much as you travel across different parts of the country. National Rural Health Mission (NRHM) gave states a lot of money with which buildings were done and equipment procured and delivered. Some of that equipment remains unopened.
NRHM could not change the basic ground situation: inadequate or missing medical and para-medical staff (who do not want to stay in villages) and the stronghold of the traditional birth attendants. Most telling is the story that everyone assumes that these rural health outreach centers are only for maternity and child health (MCH) issues, with no attention whatever to ailments of the rest of the population.
Primary Health Centers (PHCs) are overcrowded with patients waiting for the doctor to come, which for many places is a sort of a chance event. The compounder and auxiliary nurse midwife (ANM) are both harassed but usually in station and help people to the extent they can.
COVID-19 jerked a lot of administers out of their stupor and perhaps sub-centers and PHCs have become far more functional now than before. Some friends told me how the health staff in these locations had acquired martyr-like sanctimony since they were the only people who were required to work during these lockdown periods.
Neglected rural health system
As Amartya Sen writes in his Uncertain Glory, there has been glorious neglect of rural health and education systems in post-independence era. The reach of health systems was really low and focused mainly on child inoculations and control on epidemics of cholera and small pox those days.
All enlightened middle class or elite persons abandoned the public systems making only the voiceless poor their sole clientele. This reduced their accountability. The degree of neglect has not significantly changed over years despite changes in ruling regimes and the rhetoric, except possibly in states like Tamil Nadu which did exemplary work in this field.
By the time bigger funds were made available, the politicians and administrators had mastered the fine art of siphoning off public resources. This bred entrenched vested interests and those in turn brought criminal elements. It is moot which of the rather audacious scams: UP’s NRHM or (in a wholly different field) MP’s VYAPAM led to more murders which were not investigated.
As the government health delivery systems faltered and failed, people resorted to private health service providers, which in huge swaths of rural areas meant the “jholawala” “doctor” who formally had learnt as much medicine as I have learnt Chinese.
Digital health policy
And with this at the foundation level we have been offered this marvelous Digital Health Policy. You can not fault it for the intent: it says that patient records will be digitized and stored electronically. Through a Health Identity number and Aadhaar number, these can be fetched wherever the patient goes so it will save the patient the tedium of having to carry her case files elsewhere.
Since the typical patient of public health systems in rural areas will be from poorer sections of the society, they also will go to public facilities wherever they go. This digitization will help reduce diagnostic and treatment load on the pubic tertiary systems located far off. In theory, wonderful.
Let us face it. Rural health delivery system is in complete shambles in a large swath of land. It suffers from apathy, staff paucity and staff absenteeism among medical and para-medical staff, over-emphasis on MCH, neglect of attention to most other health conditions, and loads of complicated form filling loaded on the staff by a series of “system strengthening” efforts. To spruce up the system now the new policy wants health records to be digitized and shared via Health ID number.
An adage goes that when you aim to reach the moon, you will at least hit tree tops. True. But if you are wallowing in slush, aiming for the moon will make you slip and possibly get deeper. You need to hit hard ground where basic things are in place and function. Will rural India receive these basic services?
Sanjiv Phansalkar is the director of VikasAnvesh Foundation, Pune. He was earlier a faculty member at the Institute of Rural Management Anand (IRMA). Phansalkar is a fellow of the Indian Institute of Management (IIM) Ahmedabad. Views are personal.