OtherIndia.org

The programme envisaged the selection, training and deployment of a statewide system of community health workers. These workers were supposed to have certain special characteristic, as follows -

a. All the workers were to be women. They would be known as “mitanins”. The use of these terms, which denotes a culturally hallowed relationship generated considerable opposition; what was finally agreed upon was a compromise.

b. All the women would be selected from within the communities that they would be serving through a process of consensus.

c. The communities in question would be self-defined hamlets rather then villages. In other words any group of families regarding themselves as a community would define themselves as such and proceed to select a health worker for themselves. This provision was specifically design to tie in with the concept of “Gram Sabha” in the PESA.

d. Educational attainment would not be a constraint on selection.

e. None of the mitanins would receive any govt. salary or allowance in lieu of their services. This provision generated prolong debate, but was agreed to on the grounds that the mitanin should be a community representative rather then a government functionary. This provision did not preclude the payment of compensatory allowances during training or the provision of community based interventions at a later stage of the programme.

f. The mitanin would perform certain technical functions by way of first contact care within the community, for which she would be specifically trained over a period of time. However, her main function would be to articulate the demand for health care within the community in the form of the right to health care. A slogan was coined, “Swasthya Hamar Adhikar Hawe” (Health is Our Right).

A national level consultation in January 2002 identified a number of areas of the current health services provision which need structural changes in state policy and practice, in laws, in programmes and institutions. The focus was mainly on strengthening community health systems, primary and district level health delivery systems, health surveillance and epidemic control. The areas of reform, which would go along with the programme, were detailed as shown below.

Agreed reform agenda with role of civil society partners was specified:

• Assisting in the finalization of the communitybased health programme of the GOC (Mitanin Scheme).
• Assisting in designing a social mobilization campaign for popularizing the idea of “people’s health in people’s hands’ and creating effective demand for the programme.
• Assisting in designing the media and communications strategy and package for the programme.
• Assisting in developing operationalisation details and implementation schedules for the mitanin programme.
• Assisting in developing all training modules and pedagogy for the Mitanin Programme (see annexure).
• Assisting in monitoring and evaluation of the programme.
• Assisting in the co-ordination and logistics for the training programmes.

2. Delegation and Decentralization

• Assist GOC in developing an autonomy package for (a) integrated District Health & Family Welfare Agency (DHA), (b) Hospitals, (c) Programme managers at district and facility levels and (d) PRIs and ULBs.
• Planning of devolution of financial powers and other resources, specifically financial resources to PRIs and ULBs.
• Strengthening system of transparency and the right to information and social audits.

3. Strengthening Health Intelligence, Surveillance, Epidemiology and Planning

• Review of current systems of health intelligenc and surveillance, and proposing reforms in integrating the mitanin scheme.
• Developing systems of village and district health plans, with community participation.
• Improving the quality, reliability and analysis of statistics.

Improving community and primary health care systems for (a) prevention (b) early detection (c) early intervention (d) early prevention of morbidity and mortality because of epidemics.

• Participatory studies of major health problems of rural and urban poor people.
• Participatory plans at local, district and state levels to overcome these health problems of poor people.

• Assisting in identifying capacity building needs and training packages for the DHA officials and Hospitals managers to enable them to perform their new role effectively.
• Assisting identifying capacity building needs and designing training packages for the PRIs, starting from the Gram Sabha level as well ULBs to make devolution of powers to control government health institutions and services effective.
• Assisting in building capacities to utilize existing funds, draw budgets and plan interventions.
• Assisting in building capacities to develop accountable community mechanisms, like social audits to effectively manage and monitor the local health department.

• Develop a rational drug use policy for the state.
• Monitor the implementation of the rational drug use policy.
• Establish transparent systems for community monitoring of the implementation of this rational drug use policy.

• Identifying internal systems that need reform.
• Proposing changes for identified areas of reform.

  9. Workforce Management and Transfer Policy

• Assisting in the development of a workforce management policy that is clear and transparent.

• Assisting in identifying bottlenecks in the distribution and supply of drugs.
• Conduct a feasibility study to set up a parastatal organization for the distribution and logistics of drug supply across the state.
• Based on the recommendations of the study, suggest policy norms and guidelines to further extend the reach of the state drug distribution network.
• Monitor the implementation of the new drug distribution norms.

• Recommend standardized clinical protocols across the state at the primary, secondary and tertiary level.

• Assisting GOC in designing comprehensive computerized management information system for the health department from the mitanin up o the district level.
• Assisting GOC in the user need analysis as well define outputs expected from the MIS across all levels.
• Assisting GOC in the process flow analysis of the Department.
• Assisting GOC in feasibility of hardware platforms and software across all levels of users within the health department.
• Assisting GOC in the development of atleast two websites: one for the mitanin programme and one for the health department of the GOC.

• Assisting in developing low cost diagnostic tools and systems for decentralizing laboratory services to the primary care level.
• Assisting in developing training packages for “barefoot laboratory assistants” across the state.

• Studying feasibility of integrating some aspects of traditionally practiced tribal medicine in Chhattisgarh.

• Studying extent of drug resistance (to chloroquine) in selected areas of Chhattisgarh.
• Focussing on the incidence and prevalence of forest-fringe malaria in Chhattisgarh and recommend comprehensive treatment protocols for malaria.

Taking on board these suggestions, the Department of Health & family Welfare, Government of Chhattisgarh decided to formally formulate collaboration with the leading NGOs of the state who were involved in health action and who had been part of this process. These partners included Rupantar, Jan Swasthya Sahayog, Zilla Saksharta Samiti (Durg) and Bharat Gyan Vigyan Samithi, Raigarh and Ambikapur Health Society and Ramakrishna Mission. A high-powered State Advisory Committee (SAC) was formed by a government order. This state advisory committee was constituted with representatives of these NGOs, of senior state health officials and of representatives of funding agencies contributing to health sector development to monitor the progress of the reform process as well as provide inputs for the community health worker programme.

To provide on-going support to the health sector reform and development process and to facilitate this massive community health worker programme Action-Aid was requested to set up a State Health Resource Centre (SHRC), fully supported by the Government of Chhattisgarh in order to make available high quality human resource support for health services in Chhattisgarh. The terms of reference for this state health resource centre was agreed upon the crystallized in the form of a memorandum of Understanding signed between the country director Action Aid and the secretary health.

The memorandum of understanding defines the State Health Resource Centre as “an additional technical capacity to the Department of Health & Family Welfare in designing the reform agenda for the transition from existing health services to community based health services, developing operational guidelines for implementation of reform programme, and arranging/ providing on-going technical supporting to the District Health Administration and other programme managers in implementing this reform programme.

Almost 50,000 mitanins have now been selected and brought into the training process. They have been attending the training programmes held across the state. Many of them have been participating in village level n family health surveys. Their help and participation is also being sought in monitoring some of the functions of the ANM and other paramedical staff. Large numbers of them have been issued with dawa petis (medicine kits). We do not at the moment have any feedback about their ability to use the kits.

The Government of Chhattisgarh has begun by strengthening health services in 32 blocks so that then over the next 3 to 5 years the process could be repeated till all 146 blocks are covered.

After discussions, a participatory goal setting was abandoned in favour of a focus on reducing maternal mortality by:

• a. Ensuring 24 hour Emergency Obstetric Care capability in the CHC,
• b. Ensuring 24-hour institutional delivery capability in every sector PHC.
• c. Ensuring good quality sub-centre services at the sub-center.

It is reasoned that if the gaps are closed in infrastructure, equipment, manpower, skills sufficient to provide the above as well as in parallel organizational and motivational processes are addressed then not only care at delivery but service delivery in the public system as a whole-in that block-would be strengthened. In parallel many other bottlenecks identified like better location of facilities, a working referral system, and the integration with the mitanin system, the multi-skilling of workers etc would be addressed.

Many of these achievements have been obtained in the face of determined opposition from the many vested interests threatened by these measures. However, as we shall show, despite these changes, the possibilities created thereby for and equitable, accessible, effective, and humane health care systems remain unaltered in the main. While, a detailed analysis would yield many factors responsible for this outcome, the three major factors that we have been identified are -

• a. The total destruction of the political characters of the community health programme.
• b. The already highly privatized nature of the health service infrastructure in Chhattisgarh.
• c. The failure to make any attempt at administrative and financial devolution within this programme.

The critical assessment that follows discusses these issues in greater detail and elaborates on some examples of fundamental confusion that have bedeviled the programme.

Moreover, once the power elite in the government and outside it realized that the mitanin was a handy new source of patronage within the village, they quickly took over and occupied all the vacant spaces in the implementation of the programme. Within a year of the establishment of the new state, a very large number of new NGOs crawled out of the wall to serve as vehicles for the hegemonic aspirations of the existing elites. This nexus exerted great pressure to rapidly expand the programme. As a result of this expansion, the focus shifted away from the rights based approach to one that concentrated on technical milestones. This destroyed whatever possibilities were left in the development of an approach based on a realization of the right to health care. The para-statal Body, which quickly became a “quasi-statal body” implemented this total perversion of the original concept of the mitanin.

The current government health care infrastructure in Chhattisgarh is already heavily privatized. All salaried doctors are allowed private practice, and, with rare exceptions, devote a large part of the working day to this activity. Moreover with the widespread application of user fee for service, government hospitals and health centres are almost universally places where effective treatment only becomes available after money changes hands. BPL cardholders are eligible for free treatment, but in a state were 40 % of the people are calorie deficient, only 25 % of the people have BPL cards by World Bank fiat. Moreover, in a situation where most people pay, free often means inferior. Such norms worked themselves down the line. ANMs charge Rs. 500/- for a normal delivery, MPWs charge Rs. 100/- for a glucose drip in malaria and so on.

Public investments in such a structure can only increase the lack of equity and accessibility. This is not a plea for less public investment, but only a realization of the fact that unless the back of this corrupt system is broken, piecemeal approches will not work. No such attempt has been made within the parameters of the present programme. On the other hand while the total budget of the entire health sector reform programme over three years is Rs. 16 crores, of which up till now only Rs. 8 crores have been spent. In contrast, in the overall health budget of the state, Rs. 12 crores, out of an annual budget of Rs. 400 crores have already been invested in a public private partnership with Escorts Heart Hospital. The latter facility is housed in one wing of the Raipur Medical College, an institution built totally our of public funds

The two key concepts of public-private partnership and state-civil society partnership that form a large part of the sector reform discourse are called into question through the experience of health sector structural reforms in Chhattisgarh. In many circles the programme in Chhattisgarh has been hailed as a success story, particularly for its operationalization of these two aspects. Yet, our discussion above has  shown that important political prerequisites for the creation of a just, equitable, accessible, and effective health care system have not been met in this process. A widespread articulation of the right to health care is not a mere utopian dream. It is a necessary part of any process of genuine structural reforms in the health care system. In its current formulation, a liberatory role for the community health worker remains a myth-the myth of the mitanin.