#India – Chhattisgarh Diagnostics Privatisation Cancelled #goodnews #healthcare


The plan for privatisation of diagnostics services in Chhattisgarh has been cancelled. The RFP and tenders which had come in are no longer valid. This is a victory for  Jan Swasthya Abhiyan in Chattisgarh , The most heartening part of the struggle was the overwhelming support that this issue got from varied quarters.
indiahealth

Chhattisgarh diagnostic project on hold

SUVOJIT BAGCHI, The HINDU

State government says the policy requires a “fresh look”

The Chhattisgarh and Union governments have decided to halt the prestigious public-private partnership (PPP) project in diagnostic services in the State.

While Chhattisgarh’s Principal Health Secretary M.K. Raut said privatisation of diagnostic services was rolled back “for the time being,” the National Rural Health Mission (NRHM) refused to partially fund the outsourcing of diagnostic services. Last February, the State government invited private players to “set up shops” in the health facilities sector. Defending the programme on the government’s behalf, the Health Department’s technical assistance body, the State Health Resource Centre (SHRC), said that “outsourcing of health services” to private laboratories would enhance efficiency and facilitate delivery of services.

Mr. Raut, however, denounced the flagship privatisation project, which required a “fresh look.”

“In [the] near future we will take a fresh look at the project and decide a course of action,” he told The Hindu . A “revised PPP model” would be in place “in the coming months.”

Chhattisgarh has 154 community health centres (CHC) and 756 primary health centres (PHC). The government, Mr. Raut said, may consider implementing the PPP model in “a few” remote CHC and PHCs. “It would depend on whether it is possible for us to reach those areas or not. The PPP in diagnostic services will not be implemented in the district hospitals or 5,211 sub health centres.”

The government had issued request for proposals (RFP) from private health service providers to set up diagnostic services at public hospitals and health facilities, paid for by the taxpayer. The proposal was severely criticised by health activists and Mr. Raut said the “RFP and the floated tenders are closed chapters now.”

Explaining what compelled the government to retract a project floated only few months back, he said the “gaps need more scrutiny.” “We have to figure out a mechanism to monitor private players in remote areas.”

The Health Department is also not sure how the private players can be regulated. “A diagnostic chain may use government premises to market its services to the outpatients. We need to ask, why the government should provide incentive to a private player to do business using public facility,” said Mr Raut. He clarified that the government would not dismantle its “existing infrastructure and retrench staffs” to create space for the private players.

Owing to inadequate and chaotic public health care services in India, patients turn to private facilities, which are mostly unregulated and where quality is a concern. With the Union Health Ministry’s growing focus on more privatisation in health care, it was clear decades back that the health budget would not get the necessary boost. Rather, in view of the growing flow of private finance in health sector a National Health Policy was formulated in 2002 and the PPP model was suggested.

Chhattisgarh, known for abysmal health care in remote regions, has followed that model as it could not fill the post of 965 radiographers and laboratory technicians over the last several years. To fill those vacancies and provide necessary equipment to the health centres, the State health budget needed an additional funding of at least Rs. 30 crores, which was not available. Besides, trained technicians are generally reluctant to work in remote areas. In this context, the government opted for the PPP model.

However, in a span of four months the policy changed and Mr. Raut said the government had a “new PPP policy” in place and the “diagnostic sector policy has to fall in line with the new one.”

The NRHM has also refused to partially fund the present model and asked the State to “revise the proposal based on the Government of India recommendation” and submit a supplementary programme implementation plan.


  • Private players were invited to “set up shops” in the health facilities sector last February.
  • The Chhattisgarh Government has put the scheme on hold pending a “fresh look”.

 

NRHM -Removal of conditionalities for institutional deliveries underJanani Suraksha Yogana #Womenrights #Goodnews


Access the G.O. No. Z.14018/1/2012- JSY  relating to Removal of conditionalities associated with parity and minimum age of mother for institutional deliveries in High Performing States and for home deliveries in all the States/UTs under Janani Suraksha Yojana 

 

English: National Rural Health Mission of India

 

 

 

No. Z.14018/1/2012-JSY
Government of India
Ministry of Health & Family Welfare
(JSY Section)
Nirman Bhawan, New Delhi
Dated: 13.05.2013
To,
The Mission Director-NRHM,
All States/UTs
Subject: Removal of conditionalities associated with parity and minimum age of mother
for institutional deliveries in High Performing States and for home deliveries in
all the States/UTs under Janani Suraksha Yojana-Approval of Mission Steering
Group (MSG) –in continuation of letter dated 8.5.2013 regarding
Madam/Sir,
As you are aware, Janani Suraksha Yojana (JSY) is under implementation
throughout the country since 2005. The scheme encourages institutional delivery
among pregnant women by providing conditional cash assistance. In Low Performing
States, the financial assistance for institutional delivery is available to all pregnant
women regardless of age and parity who give birth in a government or private
accredited health facility. However, in High Performing States, financial assistance for
institutional delivery has only been available to women from BPL/SC/ST households,
aged 19 years or above and upto two live births for giving birth in a government or
private accredited health facility. Further, in all the States/UTs, the scheme provides Rs.
500/- to BPL women, aged 19 years or above and upto two live births, who prefer to
deliver at home.
Despite the fact that Janani Suraksha Yojana has contributed in increasing the
institutional deliveries in the public health facilities, recent evaluation conducted by
National Health Systems Resource Centre (NHSRC) and study report on Maternity
Protection in India by Ministry of Labour and Employment/International Labour
Organization noted with concern that JSY excludes a significant proportion of women by
virtue of exclusion criteria/ conditionalities of minimum age of mother and parity. These
women who are excluded include adolescents below the age of 19 years and
multiparous women who are at higher risk of maternal and perinatal outcomes.
Considering the above, a proposal to remove conditionalities associated with
minimum age of mother and parity was placed before Empowered Programme
Committee (EPC) which recommended the proposal for consideration of Mission
Steering Group (MSG) of National Rural Health Mission. The proposal has now been

approved by Hon’ble Health & Family Welfare Minister and Chairman of the Mission
Steering Group of NRHM as under:
 Removal of conditionalities associated with parity and minimum age of the
mother for institutional deliveries in the High Performing States.
 Removal of conditionalities associated with parity and minimum age of the
mother for home deliveries in all States/UTs.
In view of the recent decision approved by competent authority (mentioned
above) and the decisions of the competent authority taken at different times earlier,
comprehensive entitlements of beneficiaries covered and ASHA incentives, under
Janani Suraksha Yojana beyond 7th May 2013 are given below:

 

JSY

 

* Rs. 600/ per delivery in rural area includes Rs. 300 for antenatal component and Rs. 300 for
facilitating institutional delivery

 

** Rs. 400/ per delivery in urban area includes Rs. 200 for antenatal component and Rs. 200 for
facilitating institutional delivery

You are, therefore, €quesied to issue necessary instructions lo sll concem€d
field level officers lo ensu€ implementaiion of Janani Su€ksha Yojana in acmdance
with the abovo decision we.i 8.5,2013, the daie on which the decision has been
communicated (copy enclosed).
Yours sinceely,
Kr’t’(
(D.. Rak€sh Kumar)
Joint Secretary (RCH)

 

 

 

 

 

 

 

#India – Maternal Health Whistle Blower Arrested #Vaw #Womenrights


madhuri1

Published: Thursday, May 30,2013, , http://www.ibtl.in/
ByDr. Rita Pal

Madhuri Ramakrishnasway, a maternal health activist was arrested on the 16th May 2013 outside the court in Barwani, Madhya Pradesh [MP], India. The police had received a complaint from those in charge of a hospital currently under scrutiny for the alleged mismanagement and neglect of maternal health. The background of this complaint is as follows:- On the night of 11th November 2008, a very poor tribal woman from the village of Sukhpuri came to the Menimata Public Health Centre [PHC] during labour. She was admitted by those in charge who allegedly left her unmonitored all night. The hospital then demanded Rs 100, an amount she could not afford. She was asked to leave and the staff refused to arrange transport. Finally, the patient delivered her baby on the street with the help of the local “Dai” (Traditional Birth Attendant), only covered by a cloth held by her father in law. Having witnessed the event, Madhuri took the patient to another hospital to receive treatment. A protest was launched against the unacceptable incident that appears to have been one of many. This case was also part of the writ petition filed in the High Court of MP, Indore Bench in which the substandard state of maternal health services was raised – e.g. the 26 maternal deaths recorded in Barwani District Hospital in 2010 over 8 months were mentioned. The compounder of the hospital was suspended after repeated demands for action but was soon reinstated. It is notable that no one was subsequently held accountable for the dozens of avoidable maternal deaths that have taken place in Barwani. The picture is similar across the rest of the state. The finer points of the case are discussed in more detailed by an excellent Indian blogger and can be read here . “An investigation of maternal deaths following public protests in a tribal district of Madhya Pradesh” [Reproductive Health Matters] states

“We found an absence of antenatal care despite high levels of anaemia, absence of skilled birth attendants, failure to carry out emergency obstetric care in obvious cases of need, and referrals that never resulted in treatment. We present two case histories as examples. We took our findings to district and state health officials and called for proven means of preventing maternal deaths to be implemented. We question the policy of giving cash to pregnant women to deliver in poor quality facilities without first ensuring quality of care and strengthening the facilities to cope with the increased patient loads. We documented lack of accountability, discrimination against and negligence of poor women, particularly tribal women, and a close link between poverty and maternal death”

This whistleblower’s concerns were not without merit. She was subsequently witch hunted as the hospital in question filed a complaint against her, the patient and the patient’s husband. They received a court notice to appear at Barwani Court regarding this case on the 16th May 2013. Apparently, the police filed a closure report but sadly the court remained unsatisfied with this and the report was refused. Madhuri was arrested from the court and imprisoned in Khargone Women’s Jail. The petition completed by her supporters states

“Although the police had filed a Closure Report, it was refused since “clear reasons for closure had not been stated” and Madhuri did not opt for bail since the charges were clearly false[i]; one Section 148 actually refers to “rioting armed with deadly weapons”! She was sent to judicial custody until May 30th 2013”

It goes onto say

“We find unacceptable that the government targets those who work to protect the rights of the poorest Dalits and Adivasis who are suffering due to poor quality of health services; and we demand accountability from the erring officials who are indirectly responsible for thousands of women dying due to preventable pregnancy related causes”

Madhuri Ramakrishnasway is popularly known amongst the tribals of Barwani as “ Madhuri Ben” .She is a leader of Jagrit Adivasi Dalit Sangathan (JADS), a tribal and Dalit Rights Collective. Various advocacy groups under them often hold peaceful protests with a view to raising awareness of the substandard healthcare during pregnancy and labour. She has been involved in developing a grassroots movement demanding good care for rural maternal and child health in some of the remotest parts of the district. In support of Madhuri Ben’s concerns, it is notable that last year :

“The study, conducted on 819 deaths of a total of 1,065 probably maternal deaths reported in Madhya Pradesh between April 2011 and January 2012, suggests 132 women died on their way home or to a health facility” [Source – The Hindu ].

While recent news reports ran headlines about the sudden miraculous “improvement” in mortality rate in the state [ Times of India ], these reports conflicts with a presentation in the previous year on maternal death reviews in MP. Apurva Chaturvedi, State Consultant, National Rural Health Mission, and Archana Mishra, Deputy Director (NRHM), explained that 32 per cent of the reviewed deaths had occurred in district hospitals, 25 per cent in maternity centres, 13 per cent in sub-centres and 6 per cent in private facilities.

“Only 17.7 per cent of the expected maternal deaths are being reported and analysed while the remaining go unreported. Worse, in 37 per cent of the cases the cause of maternal deaths is registered as ‘other’,” they said.

The questionable statistics and the reasons for this was argued well by Sachin Jain. The government’s position isn’t convincing given the reports on the ground. It is therefore time for a legitimate investigation into the serious risk posed to vulnerable mothers in this state. The first task for the government is to cease harassing its whistleblowers who point out their spectacular failings. Then they should apply their minds more constructively to improving healthcare for patients at risk of neglect and death. They may also wish to improve their ability to collect statistics to avoid being embarrassed further. Click here to Sign the Petition

Author : Dr Rita Pal, Follow her twitter.com/dr_rita39

 

Age limit relaxed for financial assistance to institutional deliveries #Goodnews


AARTI DHAR, The Hindu

Move expected to reduce neonatal, maternal mortality in young mothers

The Ministry of Health and Family Welfare has relaxed eligibility parameters for the Janani Suraksha Yojana (JSY), which provides financial assistance to mothers for institutional deliveries. Now, Below Party Line (BPL) women can access JSY benefits irrespective of their age and number of children.

All women from BPL category, Scheduled Castes and Scheduled Tribes in all States and Union Territories will be eligible for JSY benefits if they have given birth in a government or private accredited health facility. BPL women who prefer to deliver at home can also get JSY benefits.

Launched in 2005, the JSY is the government’s main scheme to enable women — especially those from vulnerable sections — to access institutional delivery. This was done to reduce maternal and neonatal mortality.

“The decision was taken after it was realised that a majority of women, who needed JSY benefits, remained out of the purview of the scheme because they had to prove they were 19 years of age and had no more than two children,” Anuradha Gupta, Additional Secretary and Mission Director, National Rural Health Mission (NRHM), told The Hindu on Tuesday.

The highest maternal mortality is reported among girls aged 14-15; the majority of these were out of the purview of the JSY as they were unable to produce proof of age or verify the number of children they had, Ms. Gupta explained.

Till now, the scheme provided assistance for institutional delivery to all pregnant women who give birth in a government or private accredited health facility in Low Performing States (those with bad health indicators, such as Uttar Pradesh, Bihar, Chhattisgarh, Madhya Pradesh, Uttarakhand, Jharkhand and Assam). A woman gets Rs.1,400 for delivery in a government facility or accredited private facility and Accredited Social Health Activist (ASHA) gets Rs. 600 in rural areas. In the urban areas, the amounts paid are Rs.1,000 and Rs. 400 respectively.

However, in High Performing States (those with good health indices, such as Kerala, Tamil Nadu and Karnataka), assistance for institutional delivery was available to women from BPL/SC/ST households, aged 19 or above and only up to two live births for delivery in a government or private accredited health facility. The financial entitlement was Rs. 700 to the mother and Rs. 600 for the ASHA in rural areas and Rs. 600 and Rs. 400 in urban settings.

Further, in all States/Union Territories, the scheme provided Rs. 500 to BPL women — aged 19 or above and who deliver up to two live births — who prefer to deliver at home. With the amendments, all women who deliver at home will be entitled to this amount, basically for nutrition.

The government claims that as a result of the scheme, there has been an increase in institutional deliveries — from 47 per cent in 2007-08 to 72.9 per cent in 2009 (Coverage Evaluation Survey) and, most recently, to approximately 79 per cent — as per Health Ministry data.

 


  • Henceforth, all BPL women will get JSY benefits
  • Many were excluded for being under 19

 

#Chattisgarh – Maoists do not “obstruct” government health programmes- Jairam Ramesh


Health services in Maoist areas a challenge and an opportunity: Ramesh

SUVOJIT BAGCHI, The Hindu

His letter to Azad acknowledges Maoists do not “obstruct” government health programmes

Union Rural Development Minister Jairam Ramesh, in a letter to Health Minister Ghulam Nabi Azad, has acknowledged that Maoists do not “obstruct” government health programmes.

Mr. Ramesh has defined delivery of health services to Maoist-controlled areas as an “opportunity” to reach millions of tribal people in the remotest areas of the country. However, government health workers and administrators cite Maoist intervention as a reason for non-delivery of health services.

In underdeveloped areas of Chhattisgarh, especially in Maoist-controlled districts, government healthcare is virtually non-existent. In most cases, primary health centres (PHC) are miles away from villages and people could hardly make it to the PHCs due to non-availability of transport, hostile terrain and extreme climatic conditions.

In addition, health workers rarely visit the PHCs due to what is perceived as “Maoist threat.” Even in a place like Chintagufa in Sukma district, next to a Central Reserve Police Force camp on the main arterial road, the health centre is only occasionally visited by health workers, the villagers toldThe Hindu .

Moreover, according to data released by the Chhattisgarh Health Department, a huge percentage of health workers’ posts are vacant across the State. For example, in Dantewada, 60 per cent posts are vacant. The situation is more or less the same in all tribal districts.

Interestingly, the National Rural Health Mission (NRHM) has also failed to fill the vacant positions announced by them. The demand-supply gap of health workers has been met by quacks and barefoot Maoist doctors, who provide basic health care to villagers.

Mr. Ramesh has said in his letter, a copy of which is with The Hindu , delivery of health services in Maoist areas is “both a challenge and an opportunity.” “It is an opportunity since the health programmes are not obstructed by the Maoists, and if delivered effectively, [it] has the potential to soften the local tribals’ attitude towards the government,” wrote Mr. Ramesh.

Mr. Ramesh has suggested to Mr. Azad to introduce some “flexibility” in the NRHM to deal with “health challenges” in Maoist areas. He has strongly recommended government support for four non-profit health organisations, which have done substantial work in central India. These are Ramakrishna Mission (RKM) in Narayanpur and Jan Swasthya Sahyog (JSS) in Bilaspur district of Chhattisgarh and the organisations led by Dr. Abhay Bang and Dr. Prakash Amte in southern Maharashtra.

He feels the NRHM should not only be used “to support existing institutions,” but also to create “new [health] networks,” and, therefore, “such organisations” should be supported under the NRHM.

 


  • In underdeveloped areas of Chhattisgarh, government healthcare is non-existent
  • Health workers rarely visit PHCs in remote areas due to perceived ‘Maoist threat’

 

Maternal Health Activist Madhuri of JADS arrested #Vaw #Tribalrights


 

English: National Rural Health Mission of India

English: National Rural Health Mission of India (Photo credit: Wikipedia)

 

Five Years of NRHM-JSY and more than a decade of RCH: continuing maternal deaths in Barwani and MP
Background
Janani Suraksha Yojana (JSY) was launched under the National Rural Health Mission (NRHM) in
April 2005 as a safe motherhood intervention, with the specific objective of reducing maternal and
neo-natal mortality by relying on institutional delivery as the primary strategy for making available
medical care during pregnancy, delivery and post delivery period, and thus promoting safe
motherhood. All women are encouraged to avail institutional care during pregnancy and delivery,
and through ASHAs recruited specifically for this purpose institutional delivery is being promoted
among poor pregnant women. JSY is a 100 % centrally sponsored scheme, and it links cash
incentives to pregnant women with hospital delivery and post-delivery care. Reproductive and
Child Health (RCH-I) has been operational since 1997 as a project to provide a variety of
reproductive and child health services in rural areas to bring down maternal and infant mortality, in
order to reduce fertility rates and achieve population control. The second phase of the program
(RCH-II) also commenced in 2005. NRHM itself was launched with the promise to improve
availability and accessibility to health care services to the rural population, especially the
disadvantaged groups including women and children, by strengthening public health systems for
efficient service delivery, improving access, enabling community ownership and demand for
services, enhancing accountability and promoting decentralization.
It is against this context of programmes and interventions and associated fund flows from
the central government and several international agencies that one needs to view the status of
public health services, of maternal and child health in the country in general and specifically in the
high-focus states like MP, and the developments in Badwani that is the focus of this report.
Mass protest against maternal deaths in District Hospital, Barwani
On 28th December 2010 a rally was held in Barwani town, the headquarters of a predominantly
adivasi district in south-western MP. Nearly a thousand people gathered under the banner of
Jagrit Adivasi Dalit Sangathan (JADS), a mass organisation, to protest against extremely
negligent treatment of women in pregnancy and labour, particularly the death on 29th November
2010 of Vypari bai, an 8-months’ pregnant woman admitted in the District Hospital.
The people had come for this rally
from far-flung adivasi villages of the
district, and sought to draw attention to and
to protest against extreme callousness and
ill-treatment regularly meted out to women
in pregnancy and labour by the public
health system, particularly the District
Hospital (DH). A quick perusal of the DH
records indicated that between April-
November 2010 there had been 25 maternal
deaths, and 9 maternal deaths had been
recorded in this hospital in the month of
November 2010 alone. In addition, deaths
of 21 neonates (within 24 hours of birth) had been recorded, related to 511 deliveries conducted
in the hospital during November 2010. People complained that women with problems during
pregnancy and labour were frequently referred to Indore Medical College Hospital, located 150
kms away, despite the DH being supposed to deal with such cases.
The tragic story of Vypari bai – ‘institutional death’ instead of ‘institutional delivery’
Vypari bai, a 22 year old woman had travelled over 55 kms from her village Ban since the
morning of 27th November 2010 to reach the District Hospital, having been referred from the
PHC at Bokrata, and then from the CHC at Pati. She had been carried in a `jhuli’ (cloth sling)
over the first 10 kms from her village to Bokrata, from where the family managed to get the
Janani Express ambulance. She had experienced a convulsion that morning, and had high blood
pressure (BP) and eclampsia at the time of admission in the DH around 1.30 pm on 27th
November.
Following her examination by a gynaecologist at the time of admission in the DH on 27th
Nov., she was visited only once by another doctor during the entire day on 28th Nov. She had been
prescribed medicines after admission to control her BP, but her treatment sheets show only two
measurements of BP during the entire stay from 27th to 29th Nov. No attempt seems to have been
made to deliver the baby, by either induction or cesarean, as is the standard procedure in such
cases. An ultrasound scan on 28th November (for which the woman was taken by auto-rickshaw to
a private centre even though the hospital has this facility) showed the presence of live foetus.
Both the mother and mother-in-law of Vyparibai are trained health workers, presently
working as ASHAs in the NRHM. The mother-in-law Dunabai in desperation attempted to contact
the gynaecologist, who never turned up to see the patient in spite of repeated pleas from the
patient’s family. Moreover the doctor on duty, after checking the patient only once on 28th, was
also absent from the hospital premises. After repeated efforts to contact her, at late night at around
11 pm on 28th November, she instructed the nurse on duty that the relatives could take the patient to
Indore, but did not bother to examine the patient or modify the treatment. When the family went to
the doctor’s residence (which is within the hospital premise at a stone’s throw from the ward) on
28th night to ask her to attend to the woman as she was in great pain, the doctor refused to go,
saying she would phone the instructions to the nurse. The young woman finally breathed her last at
5 am on 29th November 2010, without medical attention despite being admitted in the District
Hospital.
Both the block CHC and Barwani DH are CEMONC (Comprehensive Emergency Obstetric
Neonatal Care) centres, and the DH is equipped with a Blood Bank. Such centres are supposed
to provide emergency services related to pregnancy/ delivery round the clock and 365 days a year.
In any case, a hospital at the level of district hospital is supposed to provide emergency services at
all times, whether or not it is a CEMONC. Further, there is provision that in case of complications,
CEMONC centers can contract-in services of private medical practitioners. So she could have been
referred under the ‘Janani Sahayogi Yojana’ to one of the two local private hospitals. The DH has
four gynaecologists and two anaesthetists, who could have ensured Vypari bai’s delivery. However,
the case paper shows that nearly 35 hours after admission, the patient had been referred to the
medical college hospital in Indore at around 11 PM on 28th. Further, the family was asked to sign
an undertaking, stating that they were refusing to take her to Indore and they took responsibility for
the consequences. It has been repeatedly experienced that, rather than using the institutional
provisions, patients are generally referred to Indore. And are also made to sign such undertakings.
Several other cases of denial of services leading to complications and ill-treatment at all
levels of health services have been documented by JADS. Few illustrative ones are described
below.
District Hospital, Barwani – Baltabai, 20 years, Village- Ubadagad, Pati Block,
On 6th June 2010, 9-months’ pregnant Baltabai was taken to Pati CHC with labour pains, by bus at around 12
o’clock in the afternoon. There was no doctor in the CHC. When the family contacted the BMO and
requested him to see Baltabai, the BMO did not do so, but simply arranged for the Janani Express
Ambulance and referred the patient to the District Hospital. Around 3 PM Baltabai was admitted in the
female ward of the DH. Not a single doctor was present in the female ward, ostensibly because `it was
Sunday’. The nurse on duty informed the doctor who was supposed to be on duty, but was not physically
present in the hospital premises, about the serious condition of Baltabai. She was advised some blood test,
and after the blood report was available, referred by the doctor to M.Y. Hospital, Indore. During this period
the relatives were not adequately informed about the condition of the patient and need for referral. What is
more serious is that the family was not informed about intrauterine foetal death. Following the nurse’s
advice to go to the local hospital instead of Indore, the family took Baltabai to the private trust hospital in
the Barwani town, where the doctor examined Baltabai and informed them that the foetus was dead. She
recommended an emergency operation to remove the dead foetus and save the mother. The family had no
option but to go ahead with this surgery. They incurred a cost of around Rs 10,000/- and an additional Rs.
7000/- were spent on medicine. The family, dependent on daily-wages, had to borrow money from local
money lenders at very high interest rate.
On 14th June Baltabai was discharged from the trust hospital. However, her agony was not
over yet. On reaching home that evening she complained of abdominal distension and pain. On 15th
June, at 4 am she was taken to a private practitioner, where she was cathetarised, and again referred
to the DH, where she was treated till 21st June. On 21st June Baltabai was referred to M. Y. Hospital
Indore for treatment of paraplegia. What exactly happened to Baltabai from15th – 21st June is not
very clear, largely because there are no trustworthy clinical records. Why and how Baltabai
developed paraplegia was never explained to the family members and other concerned people.
Fortunately Baltabai’s condition improved in the M.Y. Hospital and she was subsequently
discharged on 1st July. The ordeal of Baltabai lasted for 24 days (6th June to 30th June), and has left
the family severely indebted.
In September 2008 a woman in labour at the District Hospital was referred by the attending
doctor to Indore as a case of obstructed labour. The family took her to the local Trust hospital,
where a caesarean operation was performed and the child delivered safely. However, due to the
delay the child developed complications and had to be admitted in the neo-natal intensive care unit
(NICU) in the DH.
CHC-Pati block – Meera, Patel phaliya , Pati
Meera had symptoms of threatened abortion since the second month of pregnancy; and was treated
at CHC, Pati. However, the doctor advised her that she should not rely on the medicines available
in the hospital, and made the family purchase injections and medicines from outside the hospital,
worth about Rs 1000-1200. Meera followed all the instructions given by the doctor, as she was told
that she would have a difficult labour. Despite this treatment Meera had intrauterine bleeding one
morning. When she called up the CHC for the Janani Express ambulance she was told that since
she was from Pati itself, she should go to the hospital by herself, and would not be provided the
ambulance. The lady walked over 5-8 km, for almost 2 hours, bleeding and in terrible pain, to reach
the CHC. At the CHC, she was informed that the baby had died in the womb. The family was
forced to purchase few special medicines from outside for the operation to remove the dead foetus.
PHC Menimata – Baniya Bai
On the night of 11th November 2008 Baniya bai went to the PHC Menimata for delivery. The
compounder and nurse asked her family for Rs 100, which the family did not give. The next
morning she was forced to leave the hospital on grounds of being anaemic. Baniya Bai, in
labour pain, managed to crawl out to the road outside the PHC, where she delivered with the help
on the local dai. She was then sent by members of JADS to CHC Silawad by the Janani
ambulance.
These are not isolated cases; there are reports of similar incidents of maternal deaths and
denial of treatment at the health centres, including the DH in Barwani.
Demanding Accountability for Negligence
We were visiting Barwani to get a firsthand
account of the situation there
concerning health services, particularly
in the District hospital. On the morning
of 28th December when we tried to meet
the CMHO and the concerned lady duty
doctor (who happens to be the CMHO’s
daughter) we were told that they were
out of town. The gynaecologist who had
admitted Vypari bai on 27th November
said she had anemia and eclampsia and
was not in a condition to be operated
upon; and that they did not have a
ventilator in the hospital. This
gynaecologist was not around the day
after admission (28th November) to monitor the progress; she is usually out of the hospital four
days of the week performing sterilization operations in family planning camps.
We observed the rally taking place outside the DH on 28th December. About 500 people
(nearly half of them women) had gathered at the entrance of the DH at around 12 noon, by which
time the OPD was almost over. The 2-3 doctors present there left when they heard the rally
approaching. The police tried to snatch away from the rallyists their microphone and the cart on
which it was placed; however the rallyists managed to convince them that they would leave very
soon. About fifteen minutes later the people moved away from the hospital premises and
continued their dharna on the road in front of the Collectorate office, well away from the DH.
Several activists and ordinary village women, including the mother-in-law of the deceased
Vyaparibai spoke of their travails at the DH. A set of 22 issues concerning the District hospital,
which were mentioned in the memorandum of demands, were read out to the assembled people.
The Civil Surgeon was asked for, but he refused to come out to receive the petition; finally the
ADM came and just gave a brief assurance that the issues would be responded to in writing in 15
days time. By around 4 PM the rally had dispersed.
Response by the administration – ‘the message is secondary, crack down on the messenger’
We met the Collector on 28th December evening after the rally and apprised him of the state of
affairs in the DH. It emerged that the process of carrying out maternal death reviews had not
been carried out in case of any of the 25 maternal deaths. During our meeting with the Collector,
the CMHO and CS came when they were summoned. According to the CMHO such maternal
deaths keep occurring, that women here were very anaemic, and it was ‘not possible to bring
them down to zero’. When pointed out that the DH was a CEMONC centre, that there were 4
serving gynaecologists and 2 anaesthetists, and it was enquired why such institutional deaths
were still taking place, there was no satisfactory response. The Collector appreciated our
bringing things to his notice, and said he would initiate
the task of Maternal Death Reviews. At the same time,
he also hinted at linkages of the mass organisation with
‘Bastar’ and ‘Andhra Pradesh’, thereby seeking to
discredit the people’s organisation as being associated
with the ‘Naxalites’, who have been outlawed by the
central government.
We are now extremely shocked and dismayed
that two days after this rally (on 30th Dec.) as per local
press reports, the police has foisted several charges on
the leaders of JADS and 200 people who participated
in the protest. They have been charged with Sec 146 of
IPC (unlawful assembly, rioting, armed with deadly weapon which when used is likely to cause
death), Sec 186 IPC (obstructing public servant in discharge of public functions), and Sec 16(3)
of MP Kolahal Rules. On 31st December one of the activists of the organisation, Bachhiya bhai,
was arrested and sent to jail on charges that were slapped on him and others in 2008, when they
had protested against the denial of services in PHC Menimata (described above).
It needs to be mentioned that the pilot phase of community-based monitoring of rural
health services in MP under NRHM had been implemented in Barwani during 2007-08. Even
prior to this the mass organisation JADS had been actively addressing the health problems in the
area in several ways. In May 2008 a three-day programme of monitoring of services at the CHC
Pati and dialogue with health officials (with the intention to improve them), was followed up
with a rally at Barwani town on the dismal state of health services in the DH. So the area has a
history of peaceful rallying for improvement of rural health services. However, there seems to
have been hardly any concerted response from the administration to address the genuine
problems faced by and raised by the people.
Is the situation restricted to Badwani?
The situation regarding maternal deaths seems to be similar in many other districts of MP. The
audit report of NRHM in MP by the CAG gives an idea of the serious situation in the state.
According to the CAG audit report for the period 2005-06 to 2008-09 incidences of maternal and
infant deaths in MP remained high. In the 12 districts surveyed for the audit there had been 1377
maternal deaths in all in the four-year period – Betul recorded 152, Bhopal 269, Indore 162,
Shahdol recorded 393, Dhar recorded 125, Ujjain 124, and so on. Shahdol district reported 55
maternal deaths in 2008-09. The audit report also points out that despite increase in number of
institutional deliveries, post-delivery mortality remained alarmingly high. The Maternal Mortality
Rate remained high at 379 per lakh live births. Interestingly, the state government has fixed a
lower target than that of the central government for reduction of MMR and IMR. While NRHM
envisages MMR of less than 100 per lakh live births and IMR of 30 per 1000 live births by 2012,
the MP government has set these at less than 220 and 60 respectively. It has said that due to
shortage of manpower it was not possible to achieve the NRHM targets! The audit also found that
Maternal Death Review Committees were to be constituted at each district, but had not been done.
A large number of neo-natal deaths also seem to be occuring: according to figures (collected by
RCH – NRHM for monitoring and evaluation) between April-November 2010, there were 154 neonatal
deaths in the entire district of Badwani, of which 133 have been recorded at the District
Hospital (3879 deliveries recorded at the DH in the same period).
Some other findings of the CAG audit indicate that even after four years of NRHM the
state government was not taking adequate measures to address the long-standing problems of
lack of basic medical facilities, lack of physical infrastructure, and of doctors and other staff.
For instance: the number of health centres fell short of the prescribed norms; several centres,
particularly sub-centres were functioning without buildings; none of the institutions had been
upgraded to Indian Public Health Standards (IPHS); of the 82 CHCs designated as first referral
units (FRUs) 80 percent were non-functional and the rest were only partially functional. The
state government itself acknowledged that the health centres are non-functional due to shortage
of man-power. 101 out of 297 PHCs in the 12 districts studied were running without doctors,
despite the provision for hiring contractual staff under NRHM. Monitoring Committees too at
state and at lower levels to review the activities under NRHM had not been formed till 2009.
One also finds that several hundreds of crores of rupees have been spent over the past few
years under RCH-JSY. Government reports show that the allocations for RCH-JSY had increased
since 2005, and expenditure too had increased from Rs 26.29 crores in 2005-06 to Rs 344.87
crores in 2008-09. By 2009-10 Rs 797.65 crores from NRHM funds had been spent on activities
to improve maternal and child health.
Issues and Concerns
We wish to draw attention to the grave situation that seems to be building up in places like
Barwani. It is now more than a decade of RCH and five years since NRHM, RCH-II, JSY etc,
were launched as flagship programmes. On one hand, the government is spending several
hundreds of crores of rupees annually, is vigorously promoting institutional deliveries as a
panacea for high maternal and infant mortality, and talks of safe and guaranteed health services;
through processes such as community monitoring it is promoting the idea of demanding
accountability from the public health machinery. On the other hand, the ground reality in places
like Barwani shows little change. And when people get organized to demand accountability
through peaceful actions, attempts are made to discredit and ‘brand’ their leaders, to intimidate
and repress them, and to shield the responsible officials who seem to be to completely indifferent
to the plight of the patients.
One finds that in spite of several interventions and expenses of crores of rupees, women
continue to die in large numbers. Majority of these deaths are avoidable and completely
unacceptable. It is precisely these preventable deaths that JSY claims to address, right from
ante-natal care (ANC) to post-delivery care of mother and new-born, by getting the pregnant
women to register soon after pregnancy and `motivating’ them to go to a hospital for delivery.
However, the ground reality indicates that the government is not improving the `health’ of the
health facilities in order that they treat satisfactorily women in labour, especially those with
complications. This is corroborated by the findings of the audit of the performance of NRHM in
MP. The experiences of ill-treatment narrated by the rural women also point to the apathy of the
doctors and the poor quality of care they receive when they come in pain and suffering.
How many more such `institutional deaths’, complications and denial of services, are to
occur before the hospital doctors become responsible and accountable; before the state health
department, the health ministry, the rogi kalyan samitis, the district health societies, the
numerous managers, planners, consultants, and international agencies look beyond their
ritualistic exercises of working on technical assistance, planning, evaluating, re-evaluating, replanning,
merely recording numbers of pregnant women registered, of institutional deliveries and
of beneficiaries etc., in the name of safe motherhood and child health, and seriously take note of
the reality of the deaths of women and infants?
Dr Abhay Shukla – National Joint Convenor, Jan Swasthya Abhiyan
Dr Indira Chakravarthi – Public Health Researcher, Delhi
Rinchin – Bhopal
8.1.2011

 

 

Madhuri of JADS has been arrested for fighting against contnuing Maternal Deaths In Barwani #Vaw #Tribalrights


 

 

English: National Rural Health Mission of India

 

Five Years of NRHM-JSY and more than a decade of RCH: continuing maternal deaths in Barwani and MP

 
Background
Janani Suraksha Yojana (JSY) was launched under the National Rural Health Mission (NRHM) in
April 2005 as a safe motherhood intervention, with the specific objective of reducing maternal and
neo-natal mortality by relying on institutional delivery as the primary strategy for making available
medical care during pregnancy, delivery and post delivery period, and thus promoting safe
motherhood. All women are encouraged to avail institutional care during pregnancy and delivery,
and through ASHAs recruited specifically for this purpose institutional delivery is being promoted
among poor pregnant women. JSY is a 100 % centrally sponsored scheme, and it links cash
incentives to pregnant women with hospital delivery and post-delivery care. Reproductive and
Child Health (RCH-I) has been operational since 1997 as a project to provide a variety of
reproductive and child health services in rural areas to bring down maternal and infant mortality, in
order to reduce fertility rates and achieve population control. The second phase of the program
(RCH-II) also commenced in 2005. NRHM itself was launched with the promise to improve
availability and accessibility to health care services to the rural population, especially the
disadvantaged groups including women and children, by strengthening public health systems for
efficient service delivery, improving access, enabling community ownership and demand for
services, enhancing accountability and promoting decentralization.
It is against this context of programmes and interventions and associated fund flows from
the central government and several international agencies that one needs to view the status of
public health services, of maternal and child health in the country in general and specifically in the
high-focus states like MP, and the developments in Badwani that is the focus of this report.
Mass protest against maternal deaths in District Hospital, Barwani
On 28th December 2010 a rally was held in Barwani town, the headquarters of a predominantly
adivasi district in south-western MP. Nearly a thousand people gathered under the banner of
Jagrit Adivasi Dalit Sangathan (JADS), a mass organisation, to protest against extremely
negligent treatment of women in pregnancy and labour, particularly the death on 29th November
2010 of Vypari bai, an 8-months’ pregnant woman admitted in the District Hospital.
The people had come for this rally
from far-flung adivasi villages of the
district, and sought to draw attention to and
to protest against extreme callousness and
ill-treatment regularly meted out to women
in pregnancy and labour by the public
health system, particularly the District
Hospital (DH). A quick perusal of the DH
records indicated that between April-
November 2010 there had been 25 maternal
deaths, and 9 maternal deaths had been
recorded in this hospital in the month of
November 2010 alone. In addition, deaths
of 21 neonates (within 24 hours of birth) had been recorded, related to 511 deliveries conducted
in the hospital during November 2010. People complained that women with problems during
pregnancy and labour were frequently referred to Indore Medical College Hospital, located 150
kms away, despite the DH being supposed to deal with such cases.
The tragic story of Vypari bai – ‘institutional death’ instead of ‘institutional delivery’
Vypari bai, a 22 year old woman had travelled over 55 kms from her village Ban since the
morning of 27th November 2010 to reach the District Hospital, having been referred from the
PHC at Bokrata, and then from the CHC at Pati. She had been carried in a `jhuli’ (cloth sling)
over the first 10 kms from her village to Bokrata, from where the family managed to get the
Janani Express ambulance. She had experienced a convulsion that morning, and had high blood
pressure (BP) and eclampsia at the time of admission in the DH around 1.30 pm on 27th
November.
Following her examination by a gynaecologist at the time of admission in the DH on 27th
Nov., she was visited only once by another doctor during the entire day on 28th Nov. She had been
prescribed medicines after admission to control her BP, but her treatment sheets show only two
measurements of BP during the entire stay from 27th to 29th Nov. No attempt seems to have been
made to deliver the baby, by either induction or cesarean, as is the standard procedure in such
cases. An ultrasound scan on 28th November (for which the woman was taken by auto-rickshaw to
a private centre even though the hospital has this facility) showed the presence of live foetus.
Both the mother and mother-in-law of Vyparibai are trained health workers, presently
working as ASHAs in the NRHM. The mother-in-law Dunabai in desperation attempted to contact
the gynaecologist, who never turned up to see the patient in spite of repeated pleas from the
patient’s family. Moreover the doctor on duty, after checking the patient only once on 28th, was
also absent from the hospital premises. After repeated efforts to contact her, at late night at around
11 pm on 28th November, she instructed the nurse on duty that the relatives could take the patient to
Indore, but did not bother to examine the patient or modify the treatment. When the family went to
the doctor’s residence (which is within the hospital premise at a stone’s throw from the ward) on
28th night to ask her to attend to the woman as she was in great pain, the doctor refused to go,
saying she would phone the instructions to the nurse. The young woman finally breathed her last at
5 am on 29th November 2010, without medical attention despite being admitted in the District
Hospital.
Both the block CHC and Barwani DH are CEMONC (Comprehensive Emergency Obstetric
& Neonatal Care) centres, and the DH is equipped with a Blood Bank. Such centres are supposed
to provide emergency services related to pregnancy/ delivery round the clock and 365 days a year.
In any case, a hospital at the level of district hospital is supposed to provide emergency services at
all times, whether or not it is a CEMONC. Further, there is provision that in case of complications,
CEMONC centers can contract-in services of private medical practitioners. So she could have been
referred under the ‘Janani Sahayogi Yojana’ to one of the two local private hospitals. The DH has
four gynaecologists and two anaesthetists, who could have ensured Vypari bai’s delivery. However,
the case paper shows that nearly 35 hours after admission, the patient had been referred to the
medical college hospital in Indore at around 11 PM on 28th. Further, the family was asked to sign
an undertaking, stating that they were refusing to take her to Indore and they took responsibility for
the consequences. It has been repeatedly experienced that, rather than using the institutional
provisions, patients are generally referred to Indore. And are also made to sign such undertakings.
Several other cases of denial of services leading to complications and ill-treatment at all
levels of health services have been documented by JADS. Few illustrative ones are described
below.
District Hospital, Barwani – Baltabai, 20 years, Village- Ubadagad, Pati Block,
On 6th June 2010, 9-months’ pregnant Baltabai was taken to Pati CHC with labour pains, by bus at around 12
o’clock in the afternoon. There was no doctor in the CHC. When the family contacted the BMO and
requested him to see Baltabai, the BMO did not do so, but simply arranged for the Janani Express
Ambulance and referred the patient to the District Hospital. Around 3 PM Baltabai was admitted in the
female ward of the DH. Not a single doctor was present in the female ward, ostensibly because `it was
Sunday’. The nurse on duty informed the doctor who was supposed to be on duty, but was not physically
present in the hospital premises, about the serious condition of Baltabai. She was advised some blood test,
and after the blood report was available, referred by the doctor to M.Y. Hospital, Indore. During this period
the relatives were not adequately informed about the condition of the patient and need for referral. What is
more serious is that the family was not informed about intrauterine foetal death. Following the nurse’s
advice to go to the local hospital instead of Indore, the family took Baltabai to the private trust hospital in
the Barwani town, where the doctor examined Baltabai and informed them that the foetus was dead. She
recommended an emergency operation to remove the dead foetus and save the mother. The family had no
option but to go ahead with this surgery. They incurred a cost of around Rs 10,000/- and an additional Rs.
7000/- were spent on medicine. The family, dependent on daily-wages, had to borrow money from local
money lenders at very high interest rate.
On 14th June Baltabai was discharged from the trust hospital. However, her agony was not
over yet. On reaching home that evening she complained of abdominal distension and pain. On 15th
June, at 4 am she was taken to a private practitioner, where she was cathetarised, and again referred
to the DH, where she was treated till 21st June. On 21st June Baltabai was referred to M. Y. Hospital
Indore for treatment of paraplegia. What exactly happened to Baltabai from15th – 21st June is not
very clear, largely because there are no trustworthy clinical records. Why and how Baltabai
developed paraplegia was never explained to the family members and other concerned people.
Fortunately Baltabai’s condition improved in the M.Y. Hospital and she was subsequently
discharged on 1st July. The ordeal of Baltabai lasted for 24 days (6th June to 30th June), and has left
the family severely indebted.
In September 2008 a woman in labour at the District Hospital was referred by the attending
doctor to Indore as a case of obstructed labour. The family took her to the local Trust hospital,
where a caesarean operation was performed and the child delivered safely. However, due to the
delay the child developed complications and had to be admitted in the neo-natal intensive care unit
(NICU) in the DH.
CHC-Pati block – Meera, Patel phaliya , Pati
Meera had symptoms of threatened abortion since the second month of pregnancy; and was treated
at CHC, Pati. However, the doctor advised her that she should not rely on the medicines available
in the hospital, and made the family purchase injections and medicines from outside the hospital,
worth about Rs 1000-1200. Meera followed all the instructions given by the doctor, as she was told
that she would have a difficult labour. Despite this treatment Meera had intrauterine bleeding one
morning. When she called up the CHC for the Janani Express ambulance she was told that since
she was from Pati itself, she should go to the hospital by herself, and would not be provided the
ambulance. The lady walked over 5-8 km, for almost 2 hours, bleeding and in terrible pain, to reach
the CHC. At the CHC, she was informed that the baby had died in the womb. The family was
forced to purchase few special medicines from outside for the operation to remove the dead foetus.
PHC Menimata – Baniya Bai
On the night of 11th November 2008 Baniya bai went to the PHC Menimata for delivery. The
compounder and nurse asked her family for Rs 100, which the family did not give. The next
morning she was forced to leave the hospital on grounds of being anaemic. Baniya Bai, in
labour pain, managed to crawl out to the road outside the PHC, where she delivered with the help
on the local dai. She was then sent by members of JADS to CHC Silawad by the Janani
ambulance.
These are not isolated cases; there are reports of similar incidents of maternal deaths and
denial of treatment at the health centres, including the DH in Barwani.

 
Demanding Accountability for Negligence
We were visiting Barwani to get a firsthand
account of the situation there
concerning health services, particularly
in the District hospital. On the morning
of 28th December when we tried to meet
the CMHO and the concerned lady duty
doctor (who happens to be the CMHO’s
daughter) we were told that they were
out of town. The gynaecologist who had
admitted Vypari bai on 27th November
said she had anemia and eclampsia and
was not in a condition to be operated
upon; and that they did not have a
ventilator in the hospital. This
gynaecologist was not around the day
after admission (28th November) to monitor the progress; she is usually out of the hospital four
days of the week performing sterilization operations in family planning camps.
We observed the rally taking place outside the DH on 28th December. About 500 people
(nearly half of them women) had gathered at the entrance of the DH at around 12 noon, by which
time the OPD was almost over. The 2-3 doctors present there left when they heard the rally
approaching. The police tried to snatch away from the rallyists their microphone and the cart on
which it was placed; however the rallyists managed to convince them that they would leave very
soon. About fifteen minutes later the people moved away from the hospital premises and
continued their dharna on the road in front of the Collectorate office, well away from the DH.
Several activists and ordinary village women, including the mother-in-law of the deceased
Vyaparibai spoke of their travails at the DH. A set of 22 issues concerning the District hospital,
which were mentioned in the memorandum of demands, were read out to the assembled people.
The Civil Surgeon was asked for, but he refused to come out to receive the petition; finally the
ADM came and just gave a brief assurance that the issues would be responded to in writing in 15
days time. By around 4 PM the rally had dispersed.
Response by the administration – ‘the message is secondary, crack down on the messenger’
We met the Collector on 28th December evening after the rally and apprised him of the state of
affairs in the DH. It emerged that the process of carrying out maternal death reviews had not
been carried out in case of any of the 25 maternal deaths. During our meeting with the Collector,
the CMHO and CS came when they were summoned. According to the CMHO such maternal
deaths keep occurring, that women here were very anaemic, and it was ‘not possible to bring
them down to zero’. When pointed out that the DH was a CEMONC centre, that there were 4
serving gynaecologists and 2 anaesthetists, and it was enquired why such institutional deaths
were still taking place, there was no satisfactory response. The Collector appreciated our
bringing things to his notice, and said he would initiate
the task of Maternal Death Reviews. At the same time,
he also hinted at linkages of the mass organisation with
‘Bastar’ and ‘Andhra Pradesh’, thereby seeking to
discredit the people’s organisation as being associated
with the ‘Naxalites’, who have been outlawed by the
central government.

 
We are now extremely shocked and dismayed
that two days after this rally (on 30th Dec.) as per local
press reports, the police has foisted several charges on
the leaders of JADS and 200 people who participated
in the protest. They have been charged with Sec 146 of
IPC (unlawful assembly, rioting, armed with deadly weapon which when used is likely to cause
death), Sec 186 IPC (obstructing public servant in discharge of public functions), and Sec 16(3)
of MP Kolahal Rules. On 31st December one of the activists of the organisation, Bachhiya bhai,
was arrested and sent to jail on charges that were slapped on him and others in 2008, when they
had protested against the denial of services in PHC Menimata (described above).
It needs to be mentioned that the pilot phase of community-based monitoring of rural
health services in MP under NRHM had been implemented in Barwani during 2007-08. Even
prior to this the mass organisation JADS had been actively addressing the health problems in the
area in several ways. In May 2008 a three-day programme of monitoring of services at the CHC
Pati and dialogue with health officials (with the intention to improve them), was followed up
with a rally at Barwani town on the dismal state of health services in the DH. So the area has a
history of peaceful rallying for improvement of rural health services. However, there seems to
have been hardly any concerted response from the administration to address the genuine
problems faced by and raised by the people.
Is the situation restricted to Badwani?
The situation regarding maternal deaths seems to be similar in many other districts of MP. The
audit report of NRHM in MP by the CAG gives an idea of the serious situation in the state.
According to the CAG audit report for the period 2005-06 to 2008-09 incidences of maternal and
infant deaths in MP remained high. In the 12 districts surveyed for the audit there had been 1377
maternal deaths in all in the four-year period – Betul recorded 152, Bhopal 269, Indore 162,
Shahdol recorded 393, Dhar recorded 125, Ujjain 124, and so on. Shahdol district reported 55
maternal deaths in 2008-09. The audit report also points out that despite increase in number of
institutional deliveries, post-delivery mortality remained alarmingly high. The Maternal Mortality
Rate remained high at 379 per lakh live births. Interestingly, the state government has fixed a
lower target than that of the central government for reduction of MMR and IMR. While NRHM
envisages MMR of less than 100 per lakh live births and IMR of 30 per 1000 live births by 2012,
the MP government has set these at less than 220 and 60 respectively. It has said that due to
shortage of manpower it was not possible to achieve the NRHM targets! The audit also found that
Maternal Death Review Committees were to be constituted at each district, but had not been done.
A large number of neo-natal deaths also seem to be occuring: according to figures (collected by
RCH – NRHM for monitoring and evaluation) between April-November 2010, there were 154 neonatal
deaths in the entire district of Badwani, of which 133 have been recorded at the District
Hospital (3879 deliveries recorded at the DH in the same period).
Some other findings of the CAG audit indicate that even after four years of NRHM the
state government was not taking adequate measures to address the long-standing problems of
lack of basic medical facilities, lack of physical infrastructure, and of doctors and other staff.
For instance: the number of health centres fell short of the prescribed norms; several centres,
particularly sub-centres were functioning without buildings; none of the institutions had been
upgraded to Indian Public Health Standards (IPHS); of the 82 CHCs designated as first referral
units (FRUs) 80 percent were non-functional and the rest were only partially functional. The
state government itself acknowledged that the health centres are non-functional due to shortage
of man-power. 101 out of 297 PHCs in the 12 districts studied were running without doctors,
despite the provision for hiring contractual staff under NRHM. Monitoring Committees too at
state and at lower levels to review the activities under NRHM had not been formed till 2009.
One also finds that several hundreds of crores of rupees have been spent over the past few
years under RCH-JSY. Government reports show that the allocations for RCH-JSY had increased
since 2005, and expenditure too had increased from Rs 26.29 crores in 2005-06 to Rs 344.87
crores in 2008-09. By 2009-10 Rs 797.65 crores from NRHM funds had been spent on activities
to improve maternal and child health.
Issues and Concerns
We wish to draw attention to the grave situation that seems to be building up in places like
Barwani. It is now more than a decade of RCH and five years since NRHM, RCH-II, JSY etc,
were launched as flagship programmes. On one hand, the government is spending several
hundreds of crores of rupees annually, is vigorously promoting institutional deliveries as a
panacea for high maternal and infant mortality, and talks of safe and guaranteed health services;
through processes such as community monitoring it is promoting the idea of demanding
accountability from the public health machinery. On the other hand, the ground reality in places
like Barwani shows little change. And when people get organized to demand accountability
through peaceful actions, attempts are made to discredit and ‘brand’ their leaders, to intimidate
and repress them, and to shield the responsible officials who seem to be to completely indifferent
to the plight of the patients.
One finds that in spite of several interventions and expenses of crores of rupees, women
continue to die in large numbers. Majority of these deaths are avoidable and completely
unacceptable. It is precisely these preventable deaths that JSY claims to address, right from
ante-natal care (ANC) to post-delivery care of mother and new-born, by getting the pregnant
women to register soon after pregnancy and `motivating’ them to go to a hospital for delivery.
However, the ground reality indicates that the government is not improving the `health’ of the
health facilities in order that they treat satisfactorily women in labour, especially those with
complications. This is corroborated by the findings of the audit of the performance of NRHM in
MP. The experiences of ill-treatment narrated by the rural women also point to the apathy of the
doctors and the poor quality of care they receive when they come in pain and suffering.
How many more such `institutional deaths’, complications and denial of services, are to
occur before the hospital doctors become responsible and accountable; before the state health
department, the health ministry, the rogi kalyan samitis, the district health societies, the
numerous managers, planners, consultants, and international agencies look beyond their
ritualistic exercises of working on technical assistance, planning, evaluating, re-evaluating, replanning,
merely recording numbers of pregnant women registered, of institutional deliveries and
of beneficiaries etc., in the name of safe motherhood and child health, and seriously take note of
the reality of the deaths of women and infants?
Dr Abhay Shukla – National Joint Convenor, Jan Swasthya Abhiyan
Dr Indira Chakravarthi – Public Health Researcher, Delhi
Rinchin – Bhopal
8.1.2011

 

 

 

 

 

National Urban Health Mission (NUHM) as a sub-mission under the National Health Mission (NHM)


PIB PRESS RELEASE

The Union Cabinet gave its approval to launch a National Urban Health Mission (NUHM) as a new sub-mission under the over-arching National Health Mission (NHM). Under the Scheme the following proposals have been approved :

1.        One Urban Primary Health Centre (U-PHC) for every fifty to sixty thousand population.

2.        One Urban Community Health Centre (U-CHC) for five to six U-PHCs in big cities.

3.        One Auxiliary Nursing Midwives (ANM) for 10,000 population.

4.        One Accredited Social Health Activist ASHA (community link worker) for 200 to 500 households.

The estimated cost of NUHM for 5 years period is Rs.22,507 crore with the Central Government share of Rs.16,955 crore. Centre-State funding pattern will be 75:25 except for North Eastern states and other special category states of Jammu and  Kashmir, Himachal Pradesh and Uttarakhand for whom the funding pattern will be 90:10.

The scheme will focus on primary health care needs of the urban poor. This Mission will be implemented in 779 cities and towns with more than 50,000 population and cover about 7.75 crore people.

The interventions under the sub-mission will result in

·         Reduction in Infant Mortality Rate (IMR)

·         Reduction in Maternal Mortality Ratio (MMR)

·          Universal access to reproductive health care

·         Convergence of all health related interventions.

The existing institutional mechanism and management systems created and functioning under NRHM will be strengthened to meet the needs of NUHM. Citywise implementation plans will be prepared based on baseline survey and felt need. Urban local bodies will be fully involved in implementation of the scheme.

NUHM aims to improve the health status of the urban population in general, particularly the poor and other disadvantaged sections by facilitating equitable access to quality health care, through a revamped primary public health care system, targeted outreach services and involvement of the community and urban local bodies.

Background

The Union Cabinet in its meeting held in April 2012 has already approved the continuation of the National Rural Health Mission (NRHM) and the other sub-mission under NHM till 31.3.2017.

 

#Chhattisgarh #Andhra – Setback to health insurance


Published on Down To Earth (http://www.downtoearth.org.in)

Setback to health insurance

Author(s):

Kundan Pandey

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Author(s): Kundan Pandey
Issue Date: Apr 30, 2013

Private hospitals in Chhattisgarh, Andhra refuse to treat under government insurance scheme

Strengthening primary healthcare facilities would cost one-third of what governments spend on health insuranceStrengthening primary healthcare facilities would cost one-third of what governments spend on health insurance (Courtesy: swasthindia.in)

LAST year when the Chhattisgarh government announced health insurance scheme for people above the poverty line (APL), it was touted as an initiative to improve healthcare delivery in the state. But within a few months of introducing it, Mukhyamantri Swasthya Bima Yojana (MSBY) has turned out to be a political gimmick to capure the vote bank as the government faces elections in October-November.

The state launched MSBY on the lines of the Centre’s Rastriya Swasthya Bima Yojana (RSBY), which caters to people below the poverty line (BPL). It provides cover for hospitalisation cost up to Rs 30,000 for a family of five on floater basis. The state has roped in the 350 private hospitals under RSBY for its MSBY scheme. But the hospitals are not willing to admit APL patients under the scheme, saying the insurance amount is too less.

Like RSBY, MSBY sets down the amount a hospital can charge for the treatment of a particular disease. For example, hospitals under the scheme can charge Rs 3,500 for treating pneumonia or malaria and Rs 9,500 for jaundice. The private hospital authorities say they treat BPL patients at such low rates as a welfare scheme. It would be difficult to provide the care to all at such low fees.

Ajay Sahay, president of the Chhattisgarh chapter of Indian Medical Association (IMA), says, “We have informed the government about our demands to increase the insurance amount to somewhere between Rs 1.5 lakh and Rs 2 lakh.” On April 4, a group of private hospital authorities held a meeting with the state’s health minister, principal secretary and other government officials to discuss their grievance. “Instead of proper solution, they proposed increasing the cost of one treatment and reduce that of the other. They also said that we would have to treat MSBY beneficiaries, if we want to treat people under RSBY,” says Sahay. “We are now left with no option except refusing BPL patients as well.” Sahay alleges that the government did not consult the private health sector while planning MSBY, but now it wants the sector to implement the scheme before the elections.

Can private players help?

In December last year, the Chhattisgarh government had tried to outsource diagnostic facilities for government hospitals to strengthen its public healthcare system. But no private party showed interest to provide diagnostic facilities in remote areas of the state.

“It is not strange or unexpected,” says T Sundararaman, executive director of National Health Systems Resource Centre, a technical support institution with the National Rural Health Mission. Private sector works for the maximum margin and is demanding just that, he adds. But increasing the insurance amount is not the solution, Sundararaman says, citing the example of Andhra Pradesh, where the private health sector is demanding an increase in the insurance amount from the existing Rs 1.5 lakh.

Private hospitals in Andhra Pradesh have threatened to discontinue providing treatment under Rajiv Arogyasri scheme for BPL category from May 3 if their demands are not met. Every year about 200,000 patients undergo surgery under the scheme for 938 listed diseases.

B Bhaskar Rao, president of Andhra Pradesh Specialty Hospitals Association (ASHA) says the government launched the scheme six years ago. But there has been no hike in the amount despite requests by the private doctors’ association. “We demand that the government raise the insurance amount by 30 per cent and thereafter increase it by 5 per cent every year,” says Rao.

To achieve universal healthcare, senior public health specialist Sakthivel Selvaraj, says governments should focus on strengthening primary healthcare facilities. After all, this would cost one-third of what they spend on insurance, he says, adding, “We have never invested sufficiently in public health system which can solve the problem.”

 

Uttar Pradesh IAS officer faces arrest in NRHM scam


, TNN | Mar 30, 2013, 01.23 AM IST

LUCKNOW: Senior IAS officer Pradeep Shukla faces arrest as a CBI court in Ghaziabad on Thursday dismissed his appeal against a non-bailable arrest warrant issued against him in connection with his alleged role in the Rs 5,700-crore National Rural Health Mission (NHRM) scam.

The politically influential bureaucrat, who would have to appear before the court on April 5, had moved an application before the court through his counsel seeking to quash the warrant issued on March 22 on medical grounds.

Special CBI additional district judge Shyam Lal had issued the warrant after Shukla failed to appear before the court till March 19. The Allahabad high court had set the deadline for him to appear before the CBI court a month earlier.

The high court directives came after it dismissed Shukla’s petition challenging a chargesheet filed against him before the special CBI court in Ghaziabad, saying it was filed on the basis of the statements of his co-accused. He had pleaded for the quashing of the chargesheet as statements of the co-accused were not admissible under the Evidence Act.

The CBI opposed the petition, insisting the statements of the co-accused could not be ignored as they were involved as agents. It sought the petition’s rejection, saying the statements of the agents “cannot be overlooked”, as they are admissible evidence.

The agency had arrested Shukla in May 2012 for his alleged role in the scam after the Allahabad high court admonished the agency “for not touching the big guns” named in the scam.

He was granted bail three months later after the CBI failed to submit a chargesheet against him.

A 1981 batch officer, Shukla was principal secretary, health and family welfare, and NRHM director between 2009 and 2011 when the scam took place. He is accused of bungling upgradation of 89 district hospitals, causing a loss of over Rs 18 crore to the exchequer.

Shukla was a powerful bureaucrat during previous CM Mayawati’s government.

Senior minister in CM Akhilesh Yadav‘s cabinet Shiv Pal Yadav had met Shukla in Jail in July 2012. Shukla’s wife, also an IAS officer, comes from a politically influential family.

The scam came to light after the murder of two chief medical officers in Lucknow.

The CBI had arrested former family welfare minister Babu Singh Kushwaha in the same case. He had accused Shukla of signing forged documents to make fictitious payments.