The session initially focused on facilitating an understanding of the concept of mental health and mental illness. Causes, symptoms, disease burden and treatment related to the illness were elaborated with the aim of demystifying many misconceptions related to persons suffering with mental illness. The next half of the session concentrated on the National Mental Health Program, activities under it, available services and progress till now was discussed. Proactive role that BPM could take on under the program was then debated.

Permit me to outline how the first operates in translating great planning on paper to a non-functioning apparatus in the field. The experience of these visits will be used to illustrate why, even if we straighten out the “systems”; integrated, holistic, affordable care will never be available to our one billion people, while our “experts” in the field hold conferences on achieving Universal coverage in New Delhi and Geneva.

In every document that outlines how the public health systems in the rural and urban areas should function, the interface with the population of responsibility is seen as being important. Obviously, people should know who they should rely on for health care, but experience has shown that it is equally important that the health care services should be responsible to the population they serve. The balance of this translates as a spectrum of community participation- from the lowest level where people are passive recipients of care to the highest level where communities plan, monitor and evaluate the services.

We strive to the latter goal. Let me clarify who ‘we’ are. As a team of researchers, trying to bring both private and public providers onto a platform with local community leaders, we have been working for two years with the local doctors and community members in a single geographic ward of the city. Time and again we have been struck by the warm hearted welcome in the homes, particularly the poorest. The home of a patient in the community may consist of a single room, 6 feet by 10 feet, in which a family of 2 to 8 members might live. Even so, in this room, where walking is restricted by the tiny space, there is no awkwardness in rolling out a mat or putting out the single foldable chair to make one feel at home. And with this single human act of trying to make the visitor feel at home, a relationship is established which dictates the future partnership.

Contrast this with the reception our team met with in the various offices we visited last month. In an effort to meet the officers in charge of the health services in the city, we hired a taxi and went from office to office, hopeful that someone in the system might be interested in what we were attempting. And everywhere the response was the same. More often than not, a waiting of 15 -45 minutes outside the room, a cursory invitation to enter, not necessarily to sit…a brief look up from the files to hear what we had to say. And before we had launched two minutes into our story , an interruption with “ So tell me Madam, what is it you want me to do?” as we shuffled on our tired feet.

The interesting fact is, in both cases (the patient with us and then us with the officer) the only need was to be listened to. But in the first, the community member has taken the proactive step of setting the stage for listening to happen. (I remember a senior physician who taught us in Medical College saying that sometimes the most important input for an inpatient on rounds is the doctor sitting by the bedside in order to listen to him or her.) And in the latter, a power equation that invisibly translates from officialdom – top-down. The assumption on the part of these authorities is that they already know what needs to be done, so your presence in their office could only be for audience, permission or financial aid. And undoubtedly, the stroke of a pen on a file changes the response down the line. A three minute brief at the Commissioner’s office got us the desired result.

So we were honoured by the visit of the officer-in-charge to the ward, at the behest of the senior authority a day later. The visit and her interface with the community workers can be best described in their own words. “Madam, when they learn to be big doctors and officers like this, are they not taught manners?”

So I conclude that while community participation and corridors of power are identical, mutually exclusive acronyms, like all health system reforms, work must happen at both ends.

Consistent global advocacy from WHO, UNICEF and Rotary International were successful in bringing in the commitment of Government of India which has consistently announced the share in the yearly budget for polio eradication initiative., Two billion US dollar had been financed by the Indian Government. , In addition to the same amount spent by of USA, Rotary International and BMGF donated one billion each.

Though the initial efforts were aimed at reaching above status a decade earlier, mere implementation of strategies that proved successful elsewhere, did not work in a complex context like India. The complexity of context in India in areas of health delivery system, health governance, hurdles in community participation, supply chain management, poor sanitation, and interfering factors in vaccine uptake posed numerous challenges to the programme.

There was criticism from many in India saying that polio eradication initiative has been getting undue attention neglecting other health priorities. The criticism also voices the concern that India is in a situation of double burden of diseases. Many Communicable diseases like Tuberculosis Malaria and measles are still major concern while incidence of non communicable diseases which need chronic care are also on the rise and needs health system attention.

The vertical disease control programs do have inbuilt negative externalities of affecting the health system functioning. It may put pressure and affect regular health service delivery while at the same time; they also come with positive externalities. As part of this, the polio eradication program in India drew the health system’s attention to maintain the good cold chain system, equipments and training throughout the country that contributed to improving quality vaccine delivery for other antigens of the universal immunization program. Large scale polio campaigns also brought community awareness to other vaccines resulting in community demand for vaccination.

I got an opportunity to witness the measles catch up campaign last week in Rajasthan where the campaigns were planned from the lessons learnt from polio campaigns and community mobilization was being encashed from the set mode of community participation from polio campaigns. Measles injections being administered to children between the age groups of 9 months to 10 years, The micro plans are in place with the details vaccination sites, Vaccinators, mobilizers, beneficiaries and logistics etc. This catch up campaign for such wide age range of children (20% population) will be conducted only once in the lifetime of the district, one time strategy later will be followed up by routine vaccination and follow up campaigns after 3 to 5 years. Unlike polio vaccine which is administered orally we need, vaccinators who can give injections for the children in measles campaign, In Sawai Madhopur in addition to ANM’s from the health sector, general nurses from private, who are already involved in routine immunization on contract basis under NRHM been taken for the campaigns. Campaigns are school based first followed by the community or Anganwadi centers and span upto three weeks.

Parents bringing their children for measles campaign at Sawai madhopur

In the era of National Rural Health Mission and thrust on health system strengthening, future vertical programs need to have components of health system strengthening which will contribute to the general health systems functioning and strategic integration of the programs.

The role of a robust and strengthened health system, high quality routine immunization and a good surveillance system are crucial in sustaining the success of last year of polio and reach the goal of eradication soon.

I followed Ms Leela to the door of the OBG outpatient department, where the lady gate keeper stood blocking the way. Normally (so Leela told us) only a ten rupee note is the key, but today took her blocked hands from the door to let us in. She asked only Leela to leave her slippers outside…”Why not me?” I wondered.. “Maybe I didn’t look like poor patient!!”  Next Leela went to the nurse who was deciding where the patient should go. Sister pointed towards long waiting line of pregnant women and said “Go there”. That is when I intervened and asked “Why not in the next room where doctors with hardly any patients?  She grinned at me and guided me forward.

Now it was Leela’s turn to follow me, I walked towards a doctor who was sitting with another senior, introduced myself as doctor and explained Leela’s problem. After a minute she looked at me..that look was like “Why are you standing here ?”….I continued to stand …after listening to Leela, the doctor said  (without looking at me): “ We will see her … The unsaid message was “Why  are you still standing here you can go” . I continued to stand…after few minutes looking away she said    “ you sit”…I was not sure whether she was addressing me or someone else…. but there were no one around …so I presumed she addressed it to me and decided to sit comfortably  on the chair!! She gave me a dirty look when I sat on the chair ..  “May be she did not mean her words, I said to myself  but this chair does not belong to her you don’t get up”. The senior doctor who was sitting opposite me gave a warm smile…wow that was such a nice feeling ……someone in that outpatient department smiled for the first time!! I decided to ignore that grumpy doctor (by then I had decided that doctor was an insensitive/inhuman lady!! ) and initiate conversation with the senior doctor.

Before I could initiate talk with the senior doctor, medical representatives started coming near her one after the other, and I got no time to talk. I was just observing all the activities around me…in that next 10-15 min..this grumpy doctor had told her students many times to.. “Go see my patient who was in the examination room”…may be she was not happy to see me next to her… but for some reason I stayed put …that gave me more time to observe!! Two incidents diverted my thought process from this grumpy doctor.

A lady with fifth pregnancy requesting help was told   “We do not do abortion unless you want to go for permanent sterilization, either Tubectomy or current operation (Laparoscopic sterilization).  If you do not agree then you continue with pregnancy”. When she said even her fourth child was not planned, the question rose in my mind whether she  had been given information about contraception methods or were the doctors forcing women to go for sterilization because it is the easy option? I know with my experience of working with the Muslim community for some, it is against their cultural belief to undergo sterilization. Only educating about contraceptive methods works for many of them..but are the doctors aware of this and do they have time and patience to explain?

Another incident was more shocking and uncomfortable to witness. The grumpy doctor shouted at a young girl who looked not more than 14-15 yrs sitting quietly in the corner, “Why are you here ? Go out.” This young girl with a dazed look started walking towards this doctor…in the mean while the post graduate student said,  “ Madam, her pregnancy test is negative”. But her tummy was saying something…and she was pregnant..5 months confirmed the grumpy doctor!

The next thing was in a loud voice doctor screamed “Who has come with you..you are pregnant, what you want to do?” She turned towards the senior doctor and said “UM” (unmarried) that was the code word!! The very next moment more than 15 pair of eyes…were staring at that young girl…I was trying to read that girls mind..but I failed…may be because her expression was so cold …I felt she did not know what had happened to her. Her sister in law came inside..grumpy doctor had two “VALUABLE” suggestions to make , very matter of fact and devoid of sensitivity.

(1) Carry on with the pregnancy and then give away the baby later….as if it was as simple as giving away book or pen to someone. I asked myself ‘Does she even know what she is suggesting?’.

(2) We can abort if the girl’s guardian, preferably male can come and sign for minor girl.

The sister in law who appeared to be in her later 30’s had no right to do so. ‘Who made this rule?’ I wondered ….I guess doctors decide on case to case basis. It was sad to witness the sister in law pleading with this grumpy doctor “Madam nobody in the house knows, if they come to know it will create lot of problem in the house, I will take responsibility and you please abort.” Her words fell on deaf ears, statues who sat with white coat and stethoscope around their necks with knowledge gained from medical books but lacking common sense or humanity.

A very interesting conversation followed after the  young girl and sister in law was shouted at to leave and come with someone elder while  I thought ‘30+ is not minor to consider as guardian for that doctor’. The senior doctor said “We didn’t have UM cases for some time, how come suddenly we are getting many cases?” Reply from grumpy doctor was… “May be this is the season”.  Then they said “We should also do like private doctors…..…I was finding it hard not to ask what private doctors do? but I said to myself ‘the grumpy doctor who was giving dirty looks now and then will show you the way out, sit quietly’.

But the conversation continued and they revealed that in the private sector if an UM ‘case’ goes, they will not even say she is pregnant…. they will continue treating for anaemia till full term and then say she needs to be operated for some stomach tumor and give away the baby without anyone in the family knowing. By now I was in semi shock! When I heard this, I thought…does this really happen?’ I heard this story for the first time and could not believe my ears. And another thought came ‘Where the medical ethics has gone…Forget about ethics, where  has the humanity  of the individual  gone…may be it is lost in the process of becoming so called white collared DOCTORS!’

Dr. Prashant NS, faculty and PhD scholar at Institute of Public Health, facilitated a session on District Health Action Plan (DHAP) and NRHM Program Implementation Plan (PIP) on 9th of January 2012 for the District and Block Program Managers, Tumkur

The session focused on understanding the PIP guidelines with greater attention to chapters that would help the participants in formulating an effective PIP for the year 2012 – 13. The session started with a brief interactive discussion on definition of planning, planning process, planning cycle and its importance. This was followed by a group activity, in which the participants were given a scenario (from their work) and asked to apply the planning cycle and understand the difference between each step involved.  This was followed by a debriefing and discussion session. The session ended with an assignment on making a situational analysis at individual block level.

Dr. PK Srinivas, Lead Consultant NHRM, was invited to facilitate a session on ‘Administrative procedures’ on 4/1/2012 for the district and block program managers of Tumkur.

The session was an open discussion on the concerns and problems related to administration. While primarily focusing on challenges in administration, the session also dealt with issues such as enhancing interpersonal communication, creating visibility and value for one’s role and improving working relation between all health staff in respective health care facilities.

Dr. PK Srinivas, a motivational speaker, encouraged participants to raise questions and clarify issues that hindered their routine work processes. He predominantly spoke drawing examples from his own diverse multi faceted experience in the field of health.

]]> http://www.iphindia.org/bpm-dpm-training-on-admin-procedures/feed/ 0 http://www.iphindia.org/how-quality-health-care-services-is-possible-for-all/ http://www.iphindia.org/how-quality-health-care-services-is-possible-for-all/#comments Wed, 28 Dec 2011 11:14:26 +0000 arupa http://www.iphindia.org/?p=10882 Just want to share some of my feelings/observations during my two weeks visits to these hospitals for my parent’s treatment:

Now I have some questions:

1. Poor village people also have the right to avail at least these basic health services in their villages. Why cannot they?
2. It requires some additional manpower, orientation & finance? Does not govt. has this much resources?
3. How universal health care is possible, with these vast differences in private & public hospital?
4. Can’t private and public institution work together for to strengthen the health facilities in rural areas?

The session while primarily focused on the basics of vector borne disease, it also stressed on understanding interpreting health data, identifying gaps in the current data and ways to improve vector borne disease surveillance and intervention. To improve the effectiveness of the session, he had invited and had involved the District Malaria officer and Malaria Inspectors as well. It helped the participants procure a better understanding of their role in disease control. The session ended with a photo display of the vector and malaria control strategies.

The urban health team organized the grievance redressal meeting on 28th 0ctober 2011 in Bharathmatha slum at Grace Centre, with the help of Mr.Chottu Qureshi (husband of councilor Mrs Shaheena Taj).

The meeting started at 12.45pm inviting the guests Mr. Chottu Qureshi, Ms.Bhargavi (Asst Engineer PWD) and Mr.Rayappa (senior health inspector, BBMP), and around 70 community representatives. Urban health team staffs were also present. Similarly Mr. Rayappa and other guests were welcomed. The purpose of this meeting was reiterated to the community. Then we requested participants to share their problems one after the other. Women were encouraged to talk in any language, which they are comfortable with.

Community members raised issues with regard to:

1. Drinking water
2. Sanitation
3. Cement  road
4. Drainage
5. Ration card
6. Widow pensions
7. Unemployment
8. Anganawadi
9. Community Hall
10. Garbage collection.

Chottu Qureshi listened to all the problems and responded positively. He answered all the problems… He shared the programmes what all he has done, Community also agreed. And taken some time to solve the problems.

Overall our observation about the grievance redressal meeting in BM Slum.

The meeting was supposed to start by 11.30 am. Our team members went to the BM slum to invite the community for the meeting. But community said “we will not wait for the councilor, let him come first, and wait for us, only then we will come”. At last councilor came at 12.45 pm saying sorry for the delay. After hearing councilor’s presence community started coming one by one.

Once the meeting had begun participants started asking questions, which they are facing in their day to day life.  Both team and councilor felt difficult to maintain silence among participants.  Once after they were convinced, the questions poured from them to the councilor. Councilor listened to them patiently.  Even though everyone were asked to raise their voice only a lady called  ‘Banu’ was asking questions continuously , when we interrupted her saying that she must give chance to others to talk, she replied  “ sir  I am talking on behalf of our community;  it is our problems, let me ask all the questions”. Finally she shared all the problems related to the community, and also let others to talk.

I am very happy for this meeting to happen because on one hand majority of them actively participated and they were able to ask questions as well challenge the councilor, on the other hand councilor also able to convince the community by giving a list of services (electricity, water connection, installing taps etc) what he had done so far to the community. Along with sharing service that he has done, he also took some time to provide solution for the other problems.

One of the objectives of the urban health project is to facilitate a process of bringing the community and government officials and elected members together on a platform. So that this type of activity will motivate the community to discuss their problems and grievances directly to the officials and elected members, which will lead to workable solutions jointly. We hope that the councilor will keep up his promise and fulfill the needs of the community at the earliest.

Blog posted by: Munegowda C.M

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