Health Care Beyond Zero Ensuring a Basic Right for the Homeless
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Ensuring a Basic Right for the Homeless
by Health Initiative Group for the Homeless (HIGH)
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Aashray Adhikar Abhiyan
Institute of Human Behaviour & Allied Sciences
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Community Health
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Community Health Cell
85/2. 1st Main, Maruthi Nagar, Madiwala
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Tel (080) 25531518 email clic@sochara org
www.sochara.org
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Publication 2003
© HIGH — Aashray Adhikar Abhiyan,
(ActionAid India’s Programme) Delhi
!•
Price
(excluding postage)
:
Individuals
Rs. 60/Organisations Rs. 80/-
$ 10
$ 15
Copy of this publication can be collected from :
HIGH Secretariat at Aashray Adhikar Abhiyan,
S-442, Shakarpur, 2nd Floor
Delhi 110 092 • © 9868122997, 32368807, 22022440
E-mail: creatinghomes@yahoo.co.uk
Produced by:
Print-O-Graph
44 Subhash Khand, Giri Nagar
Kalkaji, New Delhi - 110 019
© 26443745, 9811647698
Any part of this book, including the photographs, may be copied or adapted to meet local needs, without
permission from the authors or publishers, provided the work incorporating the parts copied are distributed free or
at cost - not for profit, and with due acknowledgement. For any re-production done commercially, permission must
be obtained from AAA. We would appreciate being sent a copy of any materials in which text, photographs, maps
or graphs have been used.
Do send in your comments and suggestions on this publication.
Do enrich us by informing about your work with the homeless community in your city/country.
LET’S REACH OUT
ZXCPHE - SOCHAfXX
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edication
To all those homeless who
acknowledge our efforts to alleviate
their health conditions and provide
us an opportunity to touch their
lives meaningfully.
Acknowledgement
>
"V'XT'T’6 would, first and foremost, like to express our gratitude to all the homeless
\ X / people who by their involvement and participation made this report
V V possible.
The printing and publication of this report were only possible through the help and
support of many people. We are grateful to Harsh Mander, Country Director of
ActionAid India (AAI) for conceptualizing the process of documentation of the Outreach
Health Service right from its inception. We highly appreciate Cherian K. Mathew and
Aditya Nath Jha of AAI for their initiative and drive in this endeavour. We are extremely
thankful to Trudy BJ. from Aashray Adhikar Abhiyan (AAA) who made the outline draft
of this report. Our thanks to Puja Trisal from AAA for her competence in creating the
secondary draft on which this report has been balanced.
We are extremely thankful to the AAA team in launching and establishing the Outreach
Health Service, especially the HIGH clinic and fondly recollect the enthusiasm and the
spirit of the ‘Deepalaya’ team for their street play, on the occasion of the inauguration
of the clinic, through which we were able to disseminate information about the clinic
to the Homeless.
We have a special word of appreciation for Abdul Ahad for his untiring help and
support at the clinic, as also for Sharmaji of Daryaganj, who unfailingly has been donating
medicines every month.
Particularly helpful has been the questioning and examination of concepts and ideas
by colleagues and partner organizations, which have existentially both supported and
challenged our initiative, and for which we are grateful.
Colleagues who have shared in the writing are, of course, the major sources of
inspiration. Form them, we have learnt much in working through various drafts of this
report. We also thank our designer friend, who has designed all the covers (front, back
and inside) of this report. He prefers to remain anonymous.
We also commend the hard work put in by both Prakash Zaveri and Ipshita Mukherjee
from AAA, in taking this report to its completion.
We also thank J.S. Dubey of Print-O-graph, whose patience was tested during the
typesetting and printing of this report but was able to deliver this report in the shortest
possible time. We are also appreciative of and thankful to all our Partner and Supporting
Organizations, Volunteers, HIGH clinic team, and especially to Babloo for his zeal and
enthusiasm towards running of HIGH clinic.
iv
HEALTH
CARE
BEYOND
ZERO
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HI. -5.
Govt, of National Capital Territory of Delhi
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S.P. Aggarwal
DELHI SECRETARIAT, ROOM NO. 907/908 A-WING
I.R ESTATE, NEW DELHI-110002
TEL./FAX 23392017
D.O. NO.:
IAS.
Principal Secretary
RhR? / 25th September, 2003
Date:
,
MESSAGE
I am conveying this message of my congratulations to all the teams involved
in the Health Care Services for the Homeless, with regrets for not having been able
to join the Session today, at the India Habitat Centre. I have requested Mr. Anand
Prakash, Special Secretary (Health), Government of NCT of Delhi to sit in for me
for the Session today. As discussed in our meeting yesterday with the HIGH part
ners, I consider the effort that has been made a very laudable one..All the individu
als, and organizations involved in this effort deserve praise. The homeless popula
tions have usually been neglected in many aspects, and particularly in humanistic
services like health care. I quite support the position taken with follow up action by
the HIGH, of ensuring that the basic right of health care is made available to the
homeless.
I also wish to convey the support of the Department of Health & Family Wel
fare, Government of NCT of Delhi for the HIGH Clinic & Services at Jama Masjid
Clinic, in the coming years. Ivwill be highly desirable that the partner organizations
involved in the current effort viz. AAA, IHBAS & Sahara, consider preparing a
Plan of Action for reaching the health care services to all the homeless population
in Delhi, based on the model developed. I can assure you of full support in this
endeavour.
(S.P. AGGARWAL)
PRINCIPAL SECRETARY (H&FW)
GOVERNMENT OF NCT OF DELHI
HEALTH CARE
BEYOND
ZERO
y7
Contents
A Word from the Partners
vii
Introduction
1
CHAPTERS
1
2
3
4
5
vi
HEALTH
CARE
BEYOND
Health Care Scenario For the Homeless:
At Zero Level.............................................
3
Outreach Health Service For The Homeless:
An Initiative Beyond Zero Level....................
13
Profile of Health Problems At The Outreach Health Service:
Making A Difference....................................................................
23
Preliminary Evaluation:
Making The Initiative More Meaningful
32
Future Horizons: Carrying The Initiative To Completion
49
Epilogue
52
References
53
Appendices
55
ZERO
V
A Word from the Partners
AASHRAY ADHIKAR ABHIYAN (AAA)
I
Health Intervention amongst the Homeless emerged from the needs that were
I projected through the Rapid Assessment Survey carried out by Aashary Adhikar
-A. Abhiyan in June 2000. To effectively carry out the intervention a process was
undertaken in which a Health Needs Assessment Survey was undertaken and consequently
a coalition between organisations was formulated. This coalition came to be known as
Health Intervention Group and in course of time it was re-named as Health Intervention
Group for Homeless.
The coalition between the partners came to be termed as “collaborative measures” as
each partner was to service a specific component of the Health Intervention. It was a
unique and innovative experiment to carry out such a program. We may state here that
the diversified vision and objectives of the partner organisations was a difficult task to
try and converge, so as to formulate a plan of action keeping in mind the specific health
needs of the Homeless. The issue that proved to be a meeting ground for the partner
organisations was the target group of Homeless people which had never been addressed.
This coming together was also to address the misconceptions about the Homeless that
the members of partner organisations had within them.
In the course of two years of working with the Homeless the myths about them got
dispelled as did the fears that inhibited the partners in the initial stages. The close
communication and interaction with the Homeless enabled us to understand them better
and provided us the opportunity to touch their lives in a meaningful way.
The operational factors of Health Intervention which went through changes for better
achievement of our objectives was possible because of the understanding and commitment
towards the Homeless which emerged through the effective co-operation between the
partners.
This report seeks to provide the details about the nature of co-operation, and the
process adopted to achieve the vision and objectives. The title of the report “Health Care
Beyond Zero” reflects completely the journey covered from the beginning to the present
with a “rights based approach.”
Our endeavor is that through this report similar Health Interventions may be
established throughout the country, specifically for the Homeless.
Paramjeet Kaur
Director
Aashray Adhikar Abhiyan, Delhi
Jagdish Bharadwaje
Coordinator - Health
Aashary Adhikar Abhiyan, Delhi
HEALTH CARE
BEYOND
ZERO
vii
INSTITUTE OF HUMAN BEHAVIOUR AND ALLIED SCIENCES (IHBAS)
ur colleagues and we have been enriched by the opportunity of understanding
the health care scenario for the homeless populations, which is certainly in a
zero situation, and joining the effort to go beyond the zero situation, through
this innovative and collaborative endeavour. The opportunity occurred when the Aashray
Adhikar Abhiyan team contacted us at the Institute of Human Behaviour & Allied
Sciences (IHBAS), for assisting them with the problem of dealing with mentally ill and
drug dependent persons they had begun to come across in the initial part of their work
with these populations. The collective deliberations among the two teams led to the idea
of a systematic Health Care Needs Assessment Study which was carried out in September,
2000. The major health problems identified included Severe Mental Illnesses (SMIs),
Common Mental Disorders (CMDs), and Alcohol & Drug Abuse Problems, besides
Respiratory Infections and Skin Problems. The Needs Assessment Survey also included
eliciting the health service needs and identifying the strategies for meeting these service
needs. A careful evaluation of the possible strategies, following the community based
assessment study, led to the crystalization of the idea of a collaborative programme with
a mobile health clinic service for the homeless populations.
The IHBAS team has provided the specialist and general duty medical personnel, the
medicines and the training facilities for the specialist areas of mental health & drug abuse
problems, in addition to the overall medical & public health expertise, as well as the
scientific perspectives. The nature of this collaborative effort required facilitation by the
Director, IHBAS which was available readily and the participation of various categories
of the clinical & general duty staff, which has been possible with some effort. The
encouragement by the officials of the Department of Health, Govt, of Delhi has also been
helpful in sustaining these activities. The participation in the Health Initiative Group for
the Homeless (HIGH), has been seen as a learning experience at the community level
for the faculty, the staff and the students of IHBAS. This service programme has been
accepted as one of the community outreach programmes of IHBAS, and is considered
as one of the innovative programmes. The institute, specially in view of the tremendous
need for such programmes and the opportunity to work with the Non Governmental
Organisations (NGOs). This program has been recognised as one of the important
activities of the outreach Mental Health Programme of the Govt, of India, for the State
of Delhi.
The reach of the programme for the persons with alcohol & drug abuse problems has
been reasonably satisfactory, although the retention rate for this group of patients can
be further improved. On the other hand, the reach of the programme for the mentally
ill persons in the homeless populations has been limited in the initial years, and the legal
and ethical issues of enhancing this reach, as well as the operational and the programmatic
viii
HEALTH CARE BEYOND ZERO
V
1
needs for ensuring a more extensive reach of such an effort are being explored. There
is room for more work in these areas, and the responsibility of doing so is well recognized.
Nonetheless, the relative success of integration of the services for the mentally ill persons
and the alcohol & drug abuse persons, with the services for the general health problems
is striking as one more evidence of such an integration being feasible and meaningful.
The immense potential of the application of this innovative, collaborative experiment
which has been carried out in Delhi, needs to be realized by the concerned agencies,
organizations and academic institutions and departments. The replication of this
programme in the other cities and towns of India, and possibly also in the other
developing countries, needs to be taken up by interested voluntary agencies and the
NGOs, with the involvement of academic institutions and departments of community
health, with participation of mental health professionals and active support from the State.
It has been a privilege and a learning opportunity for us at IHBAS, to have been a part
of this model experiment, not only as specialists in the fields of mental health &
behavioural sciences, but also as health professionals interested in community health and
public health.
Dr. Nimesh G. Desai
Professor & Head, Deptartment of Psychiatry And Medical Superintendent,
IHBAS, Delhi
Dr. Narendra Singh
Assistant Professor of Psychiatry
IHBAS, Delhi
HEALTH
CARE
BEYOND
ZERO
ix
Introduction
I
I
I
his report is a description of an
innovative and collaborative
initiative to ensure one of the basic
rights of the homeless population, viz.
health care services, over an initial period
of two years i.e. 2000-2002. The report has
been prepared with the larger purpose of
sharing experiences and stimulating further
action. The collaborative experience
amongst the three partners along with the
supporting organizations has been
meaningful and yet not always smooth
sailing or easily synchronous. The constant
endeavour on the part of the collaborative
group had been to maintain an ongoing
dialogue and synthesize or integrate
apparent and real differences in approaches.
The fact that this has been possible has
been rewarding in itself, in addition to the
primary satisfaction of being able to ensure
the basic right of access to health care for
this highly disadvantaged section of the
population.
This report is also reflective of the
by the partner organizations involved in
the process.
Chapter One titled Health Care
Scenario for the Homeless: At Zero Level,
describes the current situation in Delhi
and some other cities in India, which is
nearly non-existent, in the context of the
larger issues and emphasizes the
international legal provisions for health
care being a basic right.
Chapter Two titled Outreach Health
Service for the Homeless: An Initiative
Beyond Zero Level explains the process of
the collaborative effort for reaching the
health care services to the homeless, from
the abysmal extant situation to a minimal
level of health care services delivery.
Chapter Three titled Profile of Health
Problems at the Outreach Health Service
describes the profile of patients and their
health problems seen at the outreach
health services, while referring to some
important issues of access and utilization
of these services.
attempt at integrating the various
approaches and practices, which have
ranged from the academic and scientific
through to a community outreach
perspective and a rights based approach.
This could well be seen as a public health
approach to a problem like the health care
services for the homeless. The task of
documenting such a collaborative initiative
as this, is fraught with its own inherent
strengths and weaknesses. It is hoped that
this report will be seen as an earnest
attempt at documenting and sharing the
facts and the impressions as seen collectively
HEALTH CARE BEYOND ZERO
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Chapter Four titled Preliminary
Evaluation : Making the Initiative More
Meaningful describes the observations and
the findings of the preliminary evaluation
carried out in the period of first two years
of services, which include the ongoing
process evaluation and the endpoint
evaluation through PRA (Participatory
Reflection And Action) exercises carried
out at the end of each year. It also
highlights the other methods of evaluation
that are proposed to be carried out.
Chapter Five titled Future Horizons:
Carrying the Initiative to Completion
briefly outlines the future course of action
of this collaborative initiative, mainly in
terms of sustaining and expanding this
health outreach services, as well as potential
for its application country wide and in
other developing countries.
The appendices provide some of the
tools and inventories, which have been
developed as part of this collaborative
effort, which are likely to be of utility for
application of this model at other places.
It is fervently hoped that the readers of
this report will find it as meaningful and
satisfying, as the various teams from the •
partner organizations, which have played
an invaluable role in sustaining this outreach
health services, and the authors who have
documented it. The feeling of satisfaction
at having been able to carry this initiative
so far is juxtaposed with the reality of the
larger picture in two perspectives i.e. the
wide range of problems that the homeless
population has to deal with and the
deprivations thereof, and the whole gamut
of issues related to the availability of health
care services for various disadvantaged
populations. In the context of these two
grim realities it is recognized that the
experience documented here provides a
possible solution for a relatively small
problem area. Nonetheless it is reiterated
that health care services is one of the basic
rights of all populations including the
Homeless. The model described here makes
a small but critical and decisive contribution
towards ensuring this basic right and
ameliorating both the grim realities with
positive action.
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HEALTH
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Health Care Scenario
for the Homeless:
At Zero Level
1.1 Political and Legal Scenario
T ndia has made great strides in overall
JL development and progress in different
spheres of life. While we are exploring the
possibility of a mission to the moon, the
stark reality is that a basic concept, such as
‘Health For AH’, till date, remains a distant
dream. As a nation, health has never been
an area of priority. This is further
compounded by major constraints facing
the health sector viz. lack of resources,
inadequate medical staff, lack of an
integrated multi-sectoral approach, poor
involvement of voluntary organisations,
inadequate laboratory services, poor disease
surveillance and response systems (VHAI,
1993).
The issue of health care is also aggravated
by the inequity of coverage - a malaise
inflicted by the disparity of income
distribution on one end and lack of
awareness and socio-cultural prejudices
and practices on the other end. A large
section of society is not in a position to
meet the basic needs of food and shelter.
The Indian Government has not spent
more than 1.8 percent of the Gross
Domestic Product (GDP) on health
(Sainath, 1996) and this is constantly
falling. The government budget allocation
for hospitalisation of the poor has decreased
from Rs. Six crores in 2000-2001 to Rs.
Four crores in 2001-2002 (Times of India,
13 March, 2001). As state support for
health care services decreases, poor people
are increasingly forced to resort to private
services of variable quality. According to
the National Sample Survey (NSS)
conducted by the National Council for
Applied Economic Research (NCAER),
60 to 80 percent of primary health care is
sought in the private sector for which
households contribute four to six percent
of their total income. Recent studies show
that healthcare is the second most important
cause of indebtedness (The Telegraph, 31
January 2001).
State health care institutions/providers
are obliged to provide medical treatment to
all persons without discrimination. The
concept of non-discrimination is
incorporated in Article 14, 15 and 16 of the
Constitution ofIndia. Every citizen in India
is entitled to health care. Under Article 47
of the Constitution of India, “it is the duty
of the state to raise the level of nutrition and
the standard ofliving and to improve public
. health.” Under Article 21, the right to health
is inherent in the right to life. Therefore,
“attending to public health is ofhigh priority,
perhaps at the top” (Vincent Parikulangara
vs. Union of India 1987 (2) SCC 165, AIR '
1987 SC 990).
The right to health is also recognized by
various International Covenants/
Instruments to which India is a signatory
(see Box 1.1).
1.2 Health Status of the Urban Poor
The health status of the urban poor is
HEALTH CARE
BEYOND
ZERO
3
influenced by several factors, such as
urbanisation, urban economy and urban
environment.
As per census 2001, 285 million Indians
live in nearly 4378 towns and cities spread
across the length and breadth of the
country. This comprises 27.8 percent of
Box 1 .1___________________
The Right to Health under International Laws
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il* Everyone has the right to a standard of living adequate for the health
and well-being of himself and. of his family, including food, clothing;
housing and medical care and necessary social services, and the right
to security in the event of unemployment, sickness, disability,
■
widowhood, old age of other lack of livelihood in circumstances beyond
his/her control (Universal Declaration of Human Rights (UDHR) 25.1;
International Convention on Economic, Social and Cultural Rights
(ICESCR) 11; Convention on the Elimination of Discrimination Against
Women (CEDAW) I4.2h; International Convention on the Elimination
of all forms of Racial Discrimination (ICERD) 5e; Convention on the
Rights of the Child (CRC) 27.1)
• : Everyone has the right to the highest attainable level of physical and
mental health and the right to equal access to health services, including
family planning (ICESCR 12; CEDAW 12; CRC 24)
• Women have the right to special health services with respect to
pregnancy, childbirth and the postnatal period (ICESCR 12.2a; CEDAW
12.2; CRC 24.Idf)
• Every person has the right to have safe and adequate water and
sanitation and to live in a hygienic environment (ICESCR 12.2b; CEDAW
I4.2h; CRC 24.2e).
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Box 1.2
--------- - ——---------- Homelessness as a Crime
itself is perceived
in India tO;._be
to be a,.cr
a crime::
' i To
•'T begin with homelessness .'MV'iywjirai
vciycy ui
Wandering persons (vagrants), mentally ill homeless persons (MIHP), are
-ill 'niiilh?
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‘guilty’ of violating several penal, statutes
under which the entire.
■ i; enforcement is left to the police ancf
and the magistracy. In a moving study in
1991, leading Supreme Court lawyer and civil rights activist S. Murlidhar •
points out:
- Criminalising the homeless is a serious problem; wandering people of . I
a wide variety can be defined as beggars and powers are given ,to,the police.’’’
to deal with such persons. Squatting on the pavement is a nuisance under
the Municipal laws.'Creation of nuisance can be penalised. Same; is'the
s approach of the law of trespass. Given the non-availability of space in urban
J centres every unauthorised dwelling would amount to trespass and be ;
punishable as such. Housing, therefore, has law arid.order dimensions and |
there is a crying need for, a humanjrjg^ts approach to
|
population, in sharp contrast to only 60
million (15 percent) who lived in urban
areas in 1947 when the country became
Independent. During the last fifty years,
the population of India has grown two and
half times, but urban India has grown by
nearly five times
The scale and speed of urbanization in
Delhi is markedly different from other
metropolitan cities of India. Delhi has
witnessed one of the fastest growth rates
when compared to other metropolitan
cities. Since 1941, Delhi has grown 427
percent, Bombay 227 percent, Madras 49
percent and Calcutta 39 percent (VHAI
1993). The census of 2001 confirmed this
trend as among all the States and Union
territories, the National Capital Territory
of Delhi is most urbanised with 93percent
(of 127.9 million) urban population.
Almost two-thirds of the employment
in the manufacturing, trade, transportation
and commerce sectors is concentrated in
the urban areas. However, the benefits of
this urban growth is not shared by every
one living in urban areas. In the large cities
around 15 percent of the male workforce
and 25 percent of the female workforce
have no regular employment (Mathur,
1993). Such persons are considered a
burden from the economic point of view
and are vulnerable from the health point
of view.
Imperfections in the land and housing
markets and exorbitant increase in land
prices have virtually left the urban poor
with no alternative except seeking
settlement in small groups in slums and
unauthorised colonies. Today, about 35
percent of Delhi’s population resides in
slums. The health status of people living in
urban areas is generally better than that of
the rural population, but this is not true
of those living in urban slums. The major
problems that arise in context of slums are
unhygienic accommodation, inadequate
Source: AAA, 2001.
4
HEALTH CARE BEYOND ZERO
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water supply, sanitation and solid waste
disposal, rights over land tenure, inadequate
food supplies and the increasing demand
for employment and social services.
The link between urbanisation, a
degraded environment, inaccessibility to
health care ;and deteriorating quality of
life, is particularly significant. Large-scale
unplanned rural-urban migration and the
continuous growth of towns and cities
have resulted in overloaded public services,
scarcity of housing and inaccessible health
care facilities.
Delhi is the only urbanised territory
having 93 percent urban population. It
also has a large network of medical and
health services but there are many
organisational, managerial and technical
problems with the health care services in
Delhi as there are multiple authorities
responsible for delivering different services
relevant to health and they are without any
co-ordination (VHAI, 1993). Despite the
multiplicity of the health care services, a
strong private sector has emerged in the
field. But even with this addition there is
no visible improvement in the fair
distribution of services for the rich and the
poor (VHAI, 1993).
they have no or little land holding/
recurrent droughts and floods have made
agriculture impossible/some are also socially
persecuted, divested of property by their
relations or dominant castes and a host of
other personal and economic reasons.
Despite over five decades since
Independence, our villages remain starved
of any tangible development. To address
their grim situation they are left with no
options but to seek better opportunities in
urban areas. As per a head count survey
conducted by AAA, in the year 2000, there
were 52,765 homeless on the streets of
Delhi. They are migrants, mainly from UP,
Bihar, West Bengal, Rajasthan, MP, etc.,
who have left their homes in the village due
to extreme distress situations. They have
their unique problems and in order to
solve some of those, they are compelled to
lead varied existences, be they children,
women, men, elderly, disabled or destitute
(AAA, 2001).
The most visible manifestation of urban
poverty is in crowding of large masses of
the urban poor people under the open sky,
__ _
Box : 1.3
•Box:l.3
_
Homeless Defined or Ill-defined
1.3 Urban Poverty and Homeless
Urban poverty remains, for the most part,
an area of significant and persistent neglect
in public policy, despite evidence of
burgeoning urban populations, fuelled by
distress migration from impoverished
villages, with stubbornly high levels of
both absolute and relative poverty.
The general belief is that glamour and
privileges of metropolitan cities like Delhi
attract people from the hinterlands. On
the other hand, it can also be argued that
the homeless are pushed out of the rural
economy, as there is no work for them /
they are redundant as their skills of
weaving, crafts etc. do not fetch a living/
<1999), "People sleeping rough, which means in the street, in public |
(on railway platforms, under flyovers, in parks or in any other plac
meant for human habitation), are those forming the core population <
‘homeless’. Those sleeping in shelters provided by welfare orinstitutions will be considered as a part of this population. PerSo
households living under these circumstances will furthermore be d«
as houseless”.
The “poorest of the urban poor” (Jagannathan and’Halder, 199?
homeless people, also commonly referred to as "pavement dwel
“beghar log” (people without houses) or “kangla” (destitute).
The census of India defines the notion of'houseless population’ as pe
census houses^Jhe latter refers td d ‘kructtirewith
HEALTH CARE BEYOND ZERO
I
5
completely vulnerable to the extremes of
nature.
Moreover, by definition the homeless
have no stable address, no ration card and
do not appear on any voting list. Among
those living on the streets, some of the most
defenceless groups are women, children,
aged, destitutes, mentally ill and the
handicapped. There are no reliable surveys
available to estimate the actual proportion
of these groups in the total population. But
case studies portray sub-human conditions
of stigma, exclusion and survival.
1.4 Health Status of the Homeless
1.4.1
General Health Status of the
Homeless
There is very little existing data on the
health status of homeless people in India
and more so for Delhi, as most studies on
urban poor and health have concentrated
' ta?bhr^
eauecomam
ino poor prot
•
han'lOdegree
-Mo.
Times of India, January 14, 2003, Delhi
6
HEALTH
CARE
BEYOND
on slum dwellers. It is known that the
health status is determined by three basic
factors - healthy environment, adequate
nutrition and lifestyle (VHAI, 2001) and
by exploring these factors in the context of
homelessness an assessment of the health
status of homeless people can be
undertaken.
Healthy environment: Homeless people
have no access to safe drinking water or
sanitation facilities. They sleep in the open
exposed to high levels of pollution, extreme
weather conditions and mosquitoes. Their
working hours are long and much of the
work done by homeless people is physically
demanding and sometimes hazardous with
little or no safety precautions (see box
1.4B).
Adequate nutrition: The food habits of the
homeless in their living conditions make
them prone to health hazards. Some of the x
homeless in Delhi collect food at religious
places and there is no dearth of it. The
concern arises from the fact that their
intake of food is not balanced either they
over-eat or eat stale food (purchased/
collected for later consumption), and it is
believed that therefore, homeless people
fall sick more often.
The homeless haye no place to cook food,
which exposes them to odd food habits;
including buying food regularly from
‘Khomchas (pavement food vendors), which
are not always hygienic. To sum up, instead
of nutritional value, price and filling
capacity determine the choice of food.
Lifestyle: The rural people, when they come
to a city like Delhi, are at loss of cultural
identity, lack of community bonds and
even communication due to the problem
of language. This situation drives the
homeless to pursue a life in isolation.
Usually homeless are employed in unskilled
or casual jobs which are insecure and
poorly paid. The realities of urban life
ZERO
O’
he
become overwhelming. In such a situation,
the stress level mounts up; the homeless
become more susceptible to communicable
diseases or take refuge in drugs.
isic
te
nd
>£
1th
>e
It is obvious, even without specific data
that in the face of such poverty the health
of homeless people is likely to be neglected.
In a study of 60 homeless people in 2002,
over half (55 percent) reported falling ill
frequently (Chaudhry, 2002).
□le
>r
en
e
eir
1.4.2 Health Status of Homeless
Women
_ie
•'y
A study on reproductive health and fertility
of homeless women in Calcutta found they
suffered from conditions like leucorrhoea
(28.5percent), menstrual irregularities (12.3
percent), infertility (2.5 percent) and STIs
(1.3 percent). The reproductive behaviour
of street dwelling women was characterised
by early marriage, teenage pregnancies,
and scarce use of contraceptives (32 percent)
as well as frequent abortions (2.8 percent)
(Ray et. al, 2001).
ih
X
Ue
mC
s
ic
r
-y
1.4.3 Health Status of Street Children
is
1,
■i
n
d
e
d
p
In a survey of 300 street children in
Thiruvananthpuram 1998, it was found
that skin disease was the most common
problem followed by diarrhoea and fever.
Besides, unhygienic living conditions, many
illnesses are caused by poor diet. Nearly
one-fourth of children feed themselves
from the dustbins (Don Bosco, 1998).
Sexual activity amongst street children
starts very young and is undertaken with
numerous partners (with the younger
boys, girls living at the railway station, sex
workers in the red light area and also with
eunuchs). Condom use is negligible as
children do not know how to use them or
where to get them. Many boys are also
under the false impression that condoms
are only required if they have sex with sex
workers. A study of 100 street adolescents
v*
I
-
Box L4B
, , ~
(
Factors Contributing to Health Problems of
the Urban Poor
■c-
Health problems amongst the urban poor, many of which are homeless are'
determined by three main groups of factors, which act in consonance
• Direct, problems of poverty: unemployment, low income, limited
education, inadequate diet, malnutrition, etc.;
• Environmental Problems leading to communicable and infectious
diseases (air-borne and water-borne), accidents, etc;
• Psychosocial problems: stress, alienation, instability and insecurity,
leading to depression, smoking, drug addiction, alcoholism, etc.
_
'___ --T-'.
.
~l
Source: Harpham et al, 1988
at New Delhi Railway Station found that
30 percent of the boys had sex related
complaints (Raj Kumar, 2000).
1.4.4 Mental Health of the Homeless
“Discarded by families or wanderingfurther
andfurther awayfrom home, their real selves
are lost or submerged under layers ofdirt and
idiosyncrasies - handicaps both primary and
secondary. They become non-persons,
consciously ignored or worse, paid unhealthy
attention. Women areparticularlyprone being
easy targets ofsexual abuse. The mentally ill
destitutes comprise a largely forgotten and
unthought ofsection ofthe homeless. Lacking
protection by law, there are no Government
plans!programmesfor thesepeople who by law,
simply do not exist’1 (Out of sight, Out of
Mind, 2002).
There are not many studies on the
mental health of homeless. However, Patels
study, (Patel, 1996) reveals that poverty is
strongly associated with common mental
illnesses, such as depression and anxiety,
because they are triggered by adverse life
events such as physical illness, housing
problems and unemployment, events more
likely to affect the poor. This suggests that
homeless people, who are the urban poor,
houseless, exploited and socially excluded,
are more vulnerable to mental health
problems which do not get adequate
HEALTH CARE BEYOND ZERO
7
attention. The social neglect of the mentally
ill homeless persons (MIHP) coupled with
the difficulties involved in the
implementation of the provisions of the
Mental Health Act, 1987, often lead to
these persons continuing to be living in the
street, with virtually no social support or
sense of self care or protection, and so they
deteriorate further into vegetative existence.
This is certainly true for persons with
Severe Mental Illness (SMIs). The plight of
these persons has been one of the factors
contributing to the collaborative initiative
described here. The psychosocial needs of
the homeless persons with Common Mental
Disorders (CMDs) like Depression,
Anxiety, Phobia and other such disorders,
are of course hardly even recognised, leave
alone being met with.
The mental health service needs of the
homeless population have been highlighted
in the initiatives on urban mental health
services (Desai and Shah, 2002).
1.4.5 Substance Dependence and
the Homeless
In 2002, a ‘Rapid Assessment Survey of
Drug Abuse in India’ was commissioned
by the United Nations Drug Control
Programme and the Ministry of Social
Justice and Empowerment. Interviews were
undertaken with 4648 substance
dependents in 14 states. The majority of
respondents (36 percent) reported heroin
as the primary drug of abuse. Other
opiates (buprenorphine, propoxyphene and
opium) accounted for 29 percent and
cannabis 22 percent. Most persons
interviewed had been using drugs for five
years or more. Overall, 43 percent x
confirmed injecting drug use (ever). Sharing
injecting devices with three persons or
more was common in Amritsar, Delhi,
Thriuvananthapuram and Hyderabad. The
study revealed that about one-fourth of
respondents were homeless and this was
much higher in urban centres such as
Ahmedabad (83 percent of 314),
Hyderabad (65 percent of 300), Mumbai
(54 percent of 356) and Delhi (39 percent
of 465).
Substance Dependence and Mental Health Problems
■ a significant number of neoolp with Xip nr al
b P| h
disorders are amokp th& comriionl^diagnosed co morbid
Source: UNDCP South Asia: 1998
8
hl
h “
’
In a study Sharan, an NGO working
with substance dependents in Delhi,
estimates there are 1.40 lakh substance
dependents in the city and that 10,000 to
15,000 are injecting. It is estimated that
approximately 1 percent of substance
dependents in Delhi are females (Sharan,
2001).
It is clear that chronic substance use
impairs health and shortens life span
(UNDCP, 1998). Adverse health
consequences of drug abuse depend on the
drug taken and its route of administration.
In a substance dependence treatment centre
HEALTH CARE BEYOND ZERO
V
d
1
I
at All India Institute of Medical Sciences
(ARMS) 20 percent of heroin users had
symptoms suggesting pulmonary disease
and 55 percent of them had pulmonary
tuberculosis. Various other ailments such
as cardiovascular problems, skin problems
and poor dental hygiene were also found
(UNDCP, 1998)
Infections commonly seen amongst
injecting users include cellulitus (infection
of subcutaneous tissue), infection and
blocking of veins, bacterial infection
of the heart (endocarditis) and serious
generalised infection (septicaemia)
(UNDCP, 1998). A study of 200
injecting users in Delhi in 1998 showed
the rate of 44.8 percent sero prevalence
(Sharan, 1998) and in the northeastern
states between 1989 and 1990, 54.2
percent of injecting users screened (out of
a sample of 1412) were found to be
infected with HIV.
As per the study by Association For
Development (AFD) on the ‘Problems of
Street and Working Children Living at
Railway Stations in Delhi’, about 78
percent of the children disclosed that they
use different substances such as correctional
fluid, cannabis, smack, alcohol, etc. Out of
these children, a majority (48 percent) did
so daily, while 10 percent had it often and
20 percent occasionally. Over 67 percent
of these children smoked cigarettes too.
(AFD, 2002). The effects of sniffing glue,
correctional fluid and kerosene are
potentially fatal and include irreversible
damage to internal organs and mental
development (England, 2002).
1.4.6 Disabilities and the Homeless
As per the World Health Organisations
estimate 10 percent of the Indian
population is disabled (VHAI, 1992).
However, there are no statistics; on how
many homeless people are idisabled,
____ r
although disabled destitutes or distressed
Ii
.1
I
’ 'la
.-i’l
- -<•
e 1991 Gulf War There he was earning'fc. 13,000 per month. That
money he was sending home.
Once back
back ,n
in India,
Indiana
started working
working in
in aa factory.
factory As
As fate
fate would
would have
have
Once
he started
It.
severe burns
hnme during an accident
a. in the
. rfactory.
.
■.
It, he
he received
received severe
This accident
made him unfit for work. Once he lost his job, he became a burden on
burden on :
the family and finally one day his children threw him out of house
I KA NowMrtXAZ. ConTaug^te
an Mandir,
Observations by M.S.W student. Feb. 2003
people, many of whom are homeless, can
be seen on most roads in Delhi suggesting
that the proportion of disabled amongst
the homeless may be higher than the
housed population. This hypothesis is
backed up by the fact that the poor are
more likely to suffer from disabilities (see
box 1.4D). Over 70 percent of disabilities
are preventable but only 2 percent of the
rural and 5 percent of the urban physically
challenged population have access to
rehabilitative services and so easily curable
medical problems such as cataract and
glaucoma go untreated and then result in
a permanent disability such as blindness
(VHAI, 1992). Poor hygiene and diet
can also cause disabilities such as hearing
loss (blockage of ear canal by wax),
HEALTH
CARE
BEYOND
ZERO
9
.A’
J.’.- '
k
■
ospltals
A,'
os'V-.'} kUVA
Source: Choudhary, 2002
nutritional blindness (lack of vitamin A in
diet) and mental retardation (lack of
iodine).
Accidents are also a major cause of
disabilities in India. Nearly a quarter of all
amputations (24.3 percent) in urban areas
are due to accidents (VHAI, 1992). These
accidents often happen at the workplace
and on the road. Homeless people pulling
rickshaws or pulling handcarts are
particularly vulnerable to accidents as the
modes of transportation that they haul,
built as they are, expose them to serious
injuries even when the crash is of a low
velocity.
1.5 Barriers to Accessing Hospital
Services
Most of the homeless people do not seek
medical help when they are ill. In a study
of female pavement dwellers in Calcutta,
three-fourths of women did not get their
gynaecological illnesses treated. Very few
pregnant women received adequate
10
HEALTH
CARE
BEYOND
ZERO
antenatal care (3.8 percent); delivery on
the street was a common practice (51.8
percent) and conducted mostly by
untrained birth attendants (Ray et. al,
2001). Studies of street children show that
they are also unlikely to seek medical
treatment but depend on their friends to
care for them (Don Bosco, 1998; Rajkumar,
2000).
A study of homeless people in Delhi
revealed that those who do seek medical
treatment rarely go to government hospitals
(Chaudhry, 2002). They are more likely to
go to private clinics and medical stores or
depend on NGOs and religious
organisations (Fig. 1).
1.5.1 Why Homeless people do not
go to Government Hospitals
The main reason for homeless people
not seeking medical treatment is the cost.
Even visits to the government hospitals,
involves direct costs (cost of clinical
investigations, implants, medicines, etc) as
well as indirect cost (loss of a days wage,
etc).
There is a National Illness Assistance
Fund (NIAF), which allows each
government hospital to sanction up to Rs.
50,000 for the treatment of poor patients.
However, to access the money in this Rind,
patients are required to provide a certificate
to show they are below the poverty line and
also give proof of residence. The
complexities of the process are brought to
fore in Box 1.5. Homeless people who do
go to government hospitals are many times
turned away. Since over 80 percent of
homeless people do not have any form of
identification (AAA, 2001), this means
they are unable to access this fund. In
1999-2000 the All India Institute of
Medical Sciences, the largest hospital in
Delhi, only assisted the hospitalisation and
treatment of 12 poor patients (Times of
India, 2001).
I
on
1.8
oy
al,
iat
:cal
to
ir.
hi
cal
Is
to
or
•is
■le
al
e,
:e
)
f
|
This is highlighted by the recent
case where a 25-year-old migrant
worker with TB was told he was “ineligible”
for treatment at a government hospital
because he did not have any evidence
to prove he lived in Delhi. Doctors at
the hospital involved said it was not an
isolated case and that “a large number of
patients are turned away on the ground
that they can not provide any proof of
residence in the Capital” (Hindustan Times,
2000b).
In another incident during the survey of
homeless in Delhi, AAA found a homeless
man with a serious infected wound on his
head infested with maggots (AAA, 2001).
The man said he had been to the hospital
but medical staff had refused to dress the
wound. AAA then accompanied the man to
the hospital and again the medical staff
refused to treat him because the man was
too “dirty”. Says one homeless man of his
experience, “When I fall sick, I go to the
nearby Government hospital The doctors there
are always reluctant to treat people like me.
They are right, in a sense because lam shabbily
dressed and never look neat. How can Igo well
dressed when I don t even get enough money to
fill my stomach?” (Menon, 2001). This
attitude by hospitals has also been observed
by Delhi House, an NGO that works with
sick and dying destitutes. In their experience,
hospitals will treat homeless patients if they
have been cleaned up first. However, they
say it is difficult to admit a homeless patient
to hospital because family support has a
large role to play in the care of patients in
government hospitals and homeless people
do not have this support. The difficulty of
admitting patients is highlighted in Box
1.5.
Street children cited “lack of knowledge
about the location and procedure in
government hospitals” and “time shortage”
as the most common reasons for not going
to hospitals (Institute of Manpower
■ V/■'S
V
lilu
Jilt;
’ ZLZZ
J A.i. 3 .. 3• JsBSBftg.
t0 iSAdhiltar Abhiyan (AAA) a NGO f'
dP
N„
^Po°na-.outs,dethc
d ' b
Hospital
'A dog
dog bite
bite patient
patient needs
need’s immediate
’ndon'and
we .
Hospital (RMLH).'
(RMLH). "A
immediate atte
attention
and we
do not have the Anti Rabies Serum (ARS)”, said SKH Medical Superintendent.
Maheshwari Sharma.
H... j After giving her an ARS shot. RMLH directed her back to SKH for the
| want of round the clock psychiatric care. SKH further directed Poonam
1
to Institute of Human Behaviour and Allied Sciences (IHBAS) for psychiatric
treatment.
At IHBAS. she was administered sedatives to relieve her pain. .After^
waiting for two hours, she was sent back to SKH by’the doctor on duty
_ saying “sh$ needs to be treated for the physical ailments first”.
•*
But Poonam’s ordeal did not end there, AAA had to win an argument
with a doctor at the Psychiatry OPD .who insisted that Poonam could not
be admitted to the hospital. Finally, after an hour’s wait, a consultant;
I
examined her. She was sent to Psychiatric.Department where she was
? admitted after a gynaecological examination.'
---
“Despite the proclamation of the ‘Citizen’s Charter’ of giving priority
to treatment over paperwork. Poonam’s gynaecological examination was
held up; for the want of a letter from police”, said AAA Director Indu
Prakash Singh.
:
■
/
-
Il
Source: The Indian Express: "20 hour ordeal to get into hospital" - 7Ih August, 2002
N.B: The above description highlights the difficulties involved in obtaining hospital based care for the
homeless. It also highlights the issues of interdependent functioning of various health core systems which
require to be effectively coordinated.
After successful psychiatric treatment and an operation on her fractured arm at SKH. Poonam recovered
at the Delhi House Sewa Ashram. AAA by then located her family in Asansol, West Bengal. Seven months
after finding her at the Railway Station, AAA staff accompanied her back to Asansol and she was reunited
with her husband and five daughters, the youngest being I '/i year old
Research, 1999). These two reasons are
related because not knowing the hospital
procedure, where to go and whom to see,
makes a trip to the hospital much longer
and tedious.
Most homeless are paid below the
minimum wage (AAA, 2001) and are not
given benefits such as sick leave, therefore,
they can not afford to forgo a days’ wages
to visit the hospital, which is often a full
day affair. Says one paper bag producer in
Nizamuddin; “Doctors do not bother
about us in government hospitals, we are
HEALTH
CARE
BEYOND
ZERO
11
r—
.'W
ss
ite of Heal
A:-
■
in-Rii
ill
’aEes'^^
I had
band'
‘dical-
V..
L_
i. . naa io see my nustx
IL- '
7- ■Observation by M.S.W
Final Year Student, Feb 2003
4
kept sitting- there all day at the risk of
losing a days’ wage. And during an
emergency, we merely get pushed around”
(VHAI, 1992).
1.6 Homelessness Caused by Lack
of Medical Care
The total government per capita
expenditure on health for cities is Rs. 161
per person per year, while in the rural areas
it is Rs. 16 (VHAI, 1992). The inadequate
health services in rural areas results in
many poor people coming to major urban
centres for treatment. Leaving their families
behind in the village, they come to places
like Delhi with very little money and when
they reach the hospital they find that a)
whatever treatment they need will cost
money and b) during the operation and
recovery period they are required to provide
an attendant in the "hospital. The AAA
team has encountered many homeless
people in the street contact programme
who had come to Delhi for medical
treatment and after spending all their
money had been unable to get treatment -.s
or return home and thus forced to beg, all ' in order to survive, and walk that extra
mile for life before calling it quits (see box
1.6). The backdrop reinforces Health Care
scenario at Zero level for the Homeless.
u
ai
c<
v>
1
tl
c:
li
d
12
HEALTH
CARE
BEYOND
ZERO
F
:k
ta
61
is
ate
n
an
Outreach Health Sen/ices
for the Homeless:
An Initiative Beyond Zero Level
2
2S
'es
cn
2.1 Prelude to the Initiative
A)
)St
d
de
V
!SS
-’J
ii
x
A comprehensive and integrated
Z-A response to the city’s health issues
-Z. JLrequires an assessment of both local
needs and the level of provision citywide.
This assessment must include strategies for
identifying those most in need and hardest
to reach. As explained in the previous
chapter the health problems of urban poor
are closely tied to their living conditions
and must be tackled in the relevant
context. The needs of the homeless
population have been largely overlooked
and neglected.
The magnitude of the homeless situation
has never been addressed, and to fill this
void Aashray Adhikar Abhiyan came into
existence adopting a rights based approach.
This campaign was brought about by the
efforts of concerned individuals both from
the Government (including the Planning
Commission) and civil society, who came
together to address the ever-increasing
issues of Homelessness in Delhi.
In order to address this issue, at the very
outset, a Rapid Assessment Survey (RAS)
was undertaken by the AAA team as it was
essential to know the scale of the problem
so as to obtain a basic understanding of the
lives of the Homeless and the ways and
means adopted by them to deal with their
different problems. This survey was carried
out in June 2000.
Delhi is no exception to the
phenomenon of neglect of the urban poor,
specifically the homeless, when compared
to other cities of India. Indeed, Delhi fares
possibly the worst, in terms of the way the
poor are treated. Amongst the poor, the
homeless i.e., the people who sleep on the
pavements, rickshaws, handcarts, rehris,
railway platforms, flyovers, in parks, under
bridges etc., are really the vulnerable ones.
These also include sizeable proportions of
the physically and mentally challenged and.
persons with significant health problems
which are not attended to.
In the light of the understanding gained
through the rapid assessment survey, the
need for some kind of health intervention
in collaboration with some civil society
organisations (CSOs) was felt. To further
this, AAA held a voluntary organisations
meet on 10th August 2000 at the Indian
Social Institute in which the attending
organisations were asked to come forward
and extend their cooperation for dealing
with the health problems of the homeless.
The organisations that came forth on the
health issue were Sahara House and World
Vision. IHBAS had already committed
itself for treating the mentally ill individuals
amongst the homeless.
2.2 Health Needs Assessment
Survey (HNAS)
In response to the concerns raised about
the health of the homeless in the survey
(RAS), on 12th August 2000, a
brainstorming session was held with the
Aashray Adhikar Abhiyan (AAA) and the
HEALTH CARE BEYOND ZERO
13
Institute of Human Behaviour and Allied
Sciences (IHBAS) teams so as to determine
the approach to be followed. Through this
session, the need for carrying out a small
scale but intensive survey to determine the
health need of the homeless was felt. This
Health Needs Assessment Survey (HNAS)
was undertaken by AAA, IHBAS and
members of Narcotics Anonymous and
World Vision. The objectives, geographical
area, methodology and expected outcomes
were discussed and identified. The survey
was conducted between August 21st to 31”,
2000, between 7 p.m. till midnight for 10
days. The team for the survey consisted of
doctors, psychiatrists, psychologists, social
activists from the different organisations
cited above, (see appendix 16)
2.2.1 Objectives of HNAS
between Turkman Gate and Ambedkar
Stadium were identified as being the
peripheral area of the Walled City. This
area, due to the high concentration of
homeless, provided a comprehensive
understanding of the various health
problems being faced by those living on
the streets. After surveying the specified
area from 21st to 27th August, the group
moved towards the interiors of the Walled
City (Jama Masjid and adjacent areas) and
came to understand the severity of the
health problems in the inner concentration
area of the Walled City, as compared to the
peripheral area.
if '
]
2.2.3 Tools used for data collection
«’ Free listing of the illnesses prevalent
among them
In-depth Interviews
The objectives of the HNAS were :
To identify the major health problems
prevalent among the homeless
To assess the priority health service
needs of the homeless
To study barriers in accessing health
services
To identify suitable strategies to meet
the health needs of the homeless
2.2.2 Area of coverage
For the purpose of the HNAS, the stretch
Focus Group Discussions - a) inside the
night shelters; b) outside the shelters i.e.
on the street
Direct Observation - a) inside the night
shelters; b) outside the shelters i.e. on
the street
2.2.4 Findings of the Survey (HNAS)
The analysis of the survey revealed the
following findings:
A high proportion of homeless people
h
I
LEGEND
Arrows indicate route
taken during HNAS
Adapted from : Eicher Rood Mop of Delhi
14
HEALTH
CARE
BEYOND
ZERO
kar
*e
his
:„e
itn
i
ed
>
ed
1
he
were suffering from serious respiratory
ailments including tuberculosis, acute
and chronic infections, skin diseases
and diarrhoeal diseases.
Substance dependence was a major
problem, especially in Yamuna Bazaar,
Ajmeri Gate, Delhi Gate, Turkman
Gate and ISBT
Severe mental illnesses were an important
component of the mental health needs
of the homeless in Delhi. The team was
able to identify nineteen persons with
severe mental illness during the short
assessment period of ten days.
Common mental disorders were usually
unrecognised and so were likely to
remain untreated.
Many terminally ill or chronically
physically/mentally ill patients were
surviving in the open without any kind
of medical help
n
The majority of the homeless people are
unable to access government hospitals:
a) they are turned away as they are
unkempt and have no identity card /
proof of residential address b) they
cannot arrange for any attendant which
is a requirement for being admitted in
government hospitals.
V A few good private health facilities are
available but are expensive and hence
virtually out of reach of the homeless.
I
I
I
I
I
Slr^or^n'identity .intent and '
throng
many feared past ,
hostile experiences of discrimination and
neglect.- ! Thus, health care has been
.S.
.......... i - ///
____________ '
•
•
________ .
\ '________
As expected, HNAS provided an
understanding and an insight into the health
situation of the homeless which served as a
basis for setting up some initial services to
address immediate health needs.
2.2.5 Reflections
The collaborative participants met several
times to discuss the kind of health
intervention appropriate for the homeless
community. During strategic brainstorming
by the group, it emerged that any health
service for this population would be
incomplete without general and mental
health aspects being catered to. This
necessitated a team of physicians,
neurologists and psychiatrists as a basic
requirement for the health facility. The
homeless peoples perceptions of fear,
rejection and distance from current health
services led to the considerations that the
facility would be better utilized if it is
made available at an appropriate place and
time and being exclusive to their needs it
would be accessible to the homeless
population all the time for emergencies
and would have the flexibility of catering
to the most vulnerable of urban poor viz.
the homeless.
Initially, advocacy for opening a specific
facility for the homeless within the existing
nearby government hospitals was
considered as one strategy, with the HIGH
partners providing medical and non
medical logistical support. Later discussions
revealed that in such a scenario the
interested and motivated group loses its
energies, at least initially, to an uninvolved,
already ignorant professional setup. The
limitation of service provisions in a
government setting would still be persisting
and all the more, will not be cost effective.
2.3 Health Intervention Group for
the Homeless (HIGH)
Based on the striking findings of the
HEALTH CARE BEYOND ZERO
15
outreach service, Mentally Ill Homeless
Persons (MIHP), specially persons with
Severe Mental Illnesses (SMIs)
To provide street based counselling and
treatment for homeless substance
dependents and persons with common
mental disorders.
To create awareness amongst homeless
people regarding their health rights as
provided by the Indian Constitution
and equip them to access health facilities.
To sensitise government hospital staff to
recognise and respond to the rights of
the homeless for medical treatment.
HNAS mentioned above, AAA, IHBAS,
Narcotics Anonymous, Sahara, Youthreach
and World Vision decided to form a
Health Intervention Group for the homeless
(HIGH)1. In view of the multi-faceted
health problem of the focus population,
demanding varied resource inputs, it was
decided that a collaborative health initiative
would best manage the health issues of this
homeless population. In due course of
time, Dr. Shroff’s Charity Eye Hospital,
Youthreach and Delhi House Seva Ashram
joined in as supporting organisations, (see
appendix 3).
2.3.1 Objectives of the HIGH’s
Outreach Health Services
The constituent partners of HIGH
identified the following objectives for their
health outreach services,
To provide street based free medical
services, suiting the needs and priorities,
for the general health problems of the
homeless.
To attempt to engage in treatment at the
1 After HNAS, the collaboration of health partners was
called HIG. It was only in February 2003, that HIG
partners decided to suffix the word 'Homeless’ to their
name. Hence Health Intervention Group for the Homeless
came to be referred to as HIGH.
16
HEALTH
CARE
BEYOND
ZERO
To develop a referral system between the
outreach health service and government
hospitals.
■« To formulate a database for further
intervention and research.
2.3.2 The HIGH Outreach Health
Services
Thus, through a series of consultations
among the potential partners, a consensus
for the appropriate service facility for the
concerned population rested upon starting
a Outreach Health Service for Homeless.
It was envisaged to be an out patient
outreach health service with resources to
cater to the health needs of the homeless
at their sleeping places. It was also decided
that this outreach service would have to be
held in the evenings because the majority
of homeless work during the day. Just
adjacent to Jama Masjid is Meena Bazaar
which came to be chosen for the location
of the clinic, not only because of the many
people sleeping in the nearby Urdu Park
but also due to the fact that the Meena
Bazaar* Night Shelter was near by and the
* The Meena Bazaar Shelter was closed in Sept. 2001 by
the Municipal Corporation of Delhi for. beautifying the
area, going by Zafar Saifullah Committee report, and
subsequently demolished.
I
■F
Figure 1: HIGH Network (2000-2002)
i
AASHRAY‘
ADHIKAR
ABHIYAN
I
SAHARA
I
Recovering Substance Users
as Volunteers & General
Physician
General Physician, Medicines,
Counsellors, Clinic Management
& Secretariat
I
IHBAS
Psychiatrists, Psychiatric nurse, Special
& General Medicines, Training CWs,
Transportation for Team & Technical
Inputs in Data Management
. -............
I----------------------------------------------------“I
I
Day Care, Residential
I
|
Detoxification,
l<
| Crisis Intervention Centre
i
' HIGH N
Outreach
Health
Service at
Jama
< Masjidy
,
r
n
I
>1
Govt.Hospitals
& Free Beds in
Pvt.Hospitals
|
i____ __
__________
I
j
Dr. Shroff’s Charity
Eye Hospital
Delhi House
Seva Ashram
(For Eye Surgery and Spectacles)
(For In-House Health Care Support
and as a Half Way Home)
Youth Reach
St. Stephens
Hospital
(To Provide Volunteers from
Civil Society & Cultural
Event Support)
(For Critical Illness and
Eye Camps)
Partner Organization
Supporting Organization
Referrals
L
HEALTH
J
CARE
BEYOND
ZERO
17
mH
ml
findings of the RAS had revealed at the
high concentration areas of the homeless
people, such as Asaf Ali Road and Yamuna
Bazaar were in close proximity.
Initial service limits were decided so as
to set at practical level, a minimum
reliance on referral for admission to other
health agencies, in view of the limited
human resources at the beginning.
At a more finer level, apart from
location, timing and frequency of the
clinic, these issues were considered: free
medicines; avoidance of stronger
substitution agent than Proxyvon,
(Dextropropoxyphene) for substance abuse
treatment, for fear of misuse; immediate
referral, without local intervention, to
manage patients with a clear history of
18
HEALTH
CARE
BEYOND
open tuberculosis, for fear of making them
reluctant or resistant to more specific
treatment and taking local /legal authorities
in confidence, for managing severe mentally
ill persons.
For better utilisation of the available
resources, HIGH partners distributed their
work and functions among themselves.
AAA agreed to take care of the .
organizational coordination, publicity, IEC,
record keeping aspects of the clinic and in
recruiting community workers for capacity
building. IHBAS agreed to provide input
in terms of medical professionals
(psychiatrists and neurologists), medicines
for general as well as mental health,
training of volunteers on mental health
issues and providing the scientific and
technical inputs on public health issues.
Sahara agreed to provide a general physician
and volunteers for day-to-day functioning
of the clinic and so did Youthreach with
the addition that they would provide
volunteers for other activities related to
health service provisions for the homeless.
Unfortunately, World Vision and members
of Narcotics Anonymous were unable to
continue their support because of lack of
resources and withdrew from the group in
January 2001, after completing their
commitment of three months.
XT',
11'
bsc
d
f.
2.3.3 Pre-launch preparation
5
It had been decided to launch the Outreach
Health Service on 26th September 2000.
Publicity and information activities
included distribution of about 1500
handbills, one to two days prior to the
launch date. The leaflets contained
information about the clinic, its timings
and purpose (see appendix 4). As many
homeless are non-literate, it was decided to
spread information about the services and
purpose of the clinic through a street play.
Volunteers of an NGO “Deepalaya”,
presented a street play on 26th and 27th
t
I
c
ZERO
,L
September, 2000 at Meena Bazaar, depicting
various health problems and information
on the clinic. An initial batch of volunteers
were also identified through preparatory
fieldwork for help at the clinic and were
trained by the AAA team members.
Sensitisation of key local residents,
shopkeepers and police personnel had
been also started before the clinic actually
started functioning. Informing and
sensitising the public and opinion leaders
in the local area and local government
agencies were identified before hand, as
part of a constant and ongoing exercise.
On September 27, 2000, an Outreach
Health Clinic for homeless people, was
started in the Walled City of Delhi,
through a clinic based at Meena Bazar, (see
appendix 2).
In the two years from September 2000
to September 2002, 220 outreach clinics
have been conducted and 4139 patients
have been treated.
tic
iy
le
ii
it
s
2.3.4 Services
II
The priority ofproviding treatment services
for the health problems and the constraints
of the service provider teams necessitated
an approach of the Outreach Health
Service to be one of conducting a “clinic”
for providing a minimum package for the
homeless populations in the initial years.
It is expected that the Outreach Health
Services will take on a more comprehensive
perspective, including the preventive and
promotive elements. The service limits
envisaged for this outreach service were
out patient treatment of general physical
ailments, substance use disorders and other
mental illnesses with the underlying guiding
principle of providing care on the spot.
This means minimum reliance on tertiary
care institutions for help. Also, patients
needing specialised care including patients
with Tuberculosis are encouraged to seek
medical help at the specified centres and a
minimal or reluctant intervention is
provided so as not to enhance avoidance of
care at specified facilities.
All emergencies are referred with
community volunteers / workers for further
specialized treatment at appropriate
facilities. If admitted, such patients are
always being provided support in terms of
medicines and day-to-day help till the
patient is medically fit to take his or her
own care.
All patients with substance dependence
syndrome are treated towards acute
detoxification by substitution or supportive
treatment technique as the case may be. All
patients requiring detoxification for opioid
dependence are being treated with
substitution therapy in form of Cap.
Proxyvon instead of tablet Buprenorphine
(Tidigesic). Buprenorphine substitution
was considered less appropriate as the
conditions were less controllable like OPD
setting, and already prevalent abuse of
Buprenorphine. It is considered that harm
reduction value of Proxyvon is greater in
such a scenario.
It also became clear to the medical
service providers that for patients with
substance abuse disorders, it would be
appropriate to extend the length of acute
detoxification treatment (from the usual 710 days) due to the mobility of the patients
in relation to the clinic, OPD nature of the
service, harm reduction strategy and
motivational factors.
2.3.5 Human resources
The HIGH medical team consists of one
general physician, two consultant
psychiatrists, psychiatry trainees and one
nurse. The specialist psychiatrists and the
trainees often function as general physicians
in addition to their own role. The orientation
and training of the general physician and
other health workers, on the issues ofmental
health and substance dependence, has helped
HEALTH
CARE
BEYOND
ZERO
19
*
in their being able to provide these services,
if required. The medical team is supported
by Community Workers and Volunteers
who man a registration counter and dispense
the prescribed medicines. They also look
after the arrangements for setting up and
winding up the clinic, maintaining adequate
communication among team members,
maintaining discipline, guiding and
informing the general public about purpose,
scope, services and aims of the clinic.
2.3.6 Timings
The outreach health clinic is held twice a
week on every Monday and Thursday at
Meena Bazar, Jama Masjid.
The timings are:
5:30 PM to 8:00 PM - 1st October to 31st
March (winter)
6:30 PM to 9:00 PM - 1st April to 30th
September (summer)
This timing was kept to cater to the
specific needs of the homeless people as
during the day most of them are busy
earning/arranging their livelihood. This
health outreach runs twice a week in order
to enhance the contact of the homeless
with the medical professionals so as to keep
the motivation for abstinence high in
persons seeking substance abuse treatment
and to minimise misuse and the large loss
of medicines that may occur if prescribed
for a longer period of time. This helps in
ensconcing the faith in the minds of the
homeless that help was available very closeby and frequently and there was no need
to pass through an agonizing wait in case
of any need or emergency.
2.3.7 Registration
Registration is done at a registration
counter positioned at a distance from the
consultation area in order to avoid
disturbance. All registered patients are
given a registration number, a patient
record is made and s/he is handed over a
registration card bearing the date and
number of registration. All patients are
provided with a card bearing the registration
number in a plastic ID card holder and
asked bring the registration card at each
follow-up. No patient of substance use
disorders is entertained without a valid
registration card as the same is made at the
counselling sessions held each Wednesday.
Any patient reporting after registration
timing is requested to attend the clinic, the
next OPD day. Emergency, if any is looked
into and if needed, help is provided
immediately as also further medical care.
During the later part of 2002 and early
2003, all patients with substance use
disorders were requested to bring four
photographs before being registered at the
clinic. One photo is attached to the
centralized record register, another on the
daily registration book, third photo is
pasted on the patient file and the last on
the registration card given to the patient.
The patient is also required to ensure
regular attendance at the weekly experience
sharing meeting held on each Wednesday
between 7 to 9 pm in summer and 6 to 8
pm in winter at Urdu Park, Jama Masjid.
The above mentioned measures were
added as a precondition for registration
and follow-up ofall patients with substance
dependence in order to minimize misuse
of medicines, duplication of records
through re-registration, inculcating
discipline and increasing chances of treating
patients with high motivation and
preventing or minimizing functional and
financial load on the system.
To ensure only homeless people access
the health clinic, all patients at the time of
registration are asked about their place of
sleep. Homeless community workers are
also asked to identify people who are not
from the homeless community.
2.-
L
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d«;
d -
an<
r
pre
f
me
a
do
qu
2
VO
ex
1
co
c
ba
se-
P1
of
P:
F.
H
a
20
HEALTH
CARE
BEYOND
ZERO
F "
nt
jd
Te
*
:e
e
i
1
I
2.3.8 Medicines and Dispensing
All the medicines to the patients are
provided free of cost for a period of three
days following Monday OPD and for four
days following Thursday OPD. IHBAS
and AAA provide resources.for procuring
monthly medicines for the patients. IHBAS
provides specialised psychiatric medicines
for mental health and also essential
medicines for patients with general
ailments. Any medicine prescribed by the
doctor, if not available at the clinic
dispensary, is purchased and made available
to the patient by AAA. At present, a
qualified nurse is supervising dispensing
activity of trained supporters/workers/
volunteers at the clinic dispensing counter.
Each dose of the medicine prescribed is
explained to the patient at two levels. First,
by the clinician, while providing
consultation and then, at the dispensing
counter by the supporters/workers, while
handing over the sealed medicine pouches.
The pouches are made up of transparent
vinyl plastic for easy identification and
secure storing of medicines at patients end.
The pouch carries a sticker on which the
prescribed dosage is noted for the patient.
The dosage is depicted in symbols instead
of numbers (00-0-000) for the convenience
of non-literate patients. All medicines
given to the patients are dispensed without
their original packaging in order to
minimise chances of the medicine being
sold off and prevent misuse by not
divulging the identity of the medicine,
particularly for patients of substance abuse.
The prescriptions are kept with the
HIGH staff because homeless people have
no place to keep them. The prescription is
recorded in the patient profile card. A list
of medicines used by the HIGH clinic is
appended as appendix 8. Most of these are
commonly used medicines for general
health problems such as those mentioned
above. However, a few specialised medicines
are included for patients suffering from
mental illness.
2.3.9 Infrastructure
Following infrastructural resources have
been made available by HIGH Partners for
the Outreach Health Clinic:
A van for storing and dispensing
medicines.
Banner with the name and purpose of
the clinic
Seating and lighting arrangements for
the doctors, patients, registration and
dispensing counters.
Basic medical equipment like stethoscope,
BP apparatus and Otoscope etc
Water proof tent in order to run the
services on rainy days, (see appendix 9).
2.3.10 Public awareness exercises
During each clinic a banner depicting
name, purpose, scope and services of the
clinic is displayed. This seeks to inform the
general public about an unusual activity
taking place on the street. Apart from this,
the clinic organisers and supporters/workers
are always available for the more curious
bystanders to answer their queries. This is
a constant and on-going activity at the
clinic and helps avoid interference in the
functioning of the doctors and facilitates
disciplined OPD functioning.
The other aspect of awareness involves
making local residents, shopkeepers,
policemen, politicians, government
representatives, local agency officials aware
of the activities of the Outreach Health
Service. This helps in avoiding day-to-day
inconvenience caused by festivals, rallies,
processions and other stray instances which
may hinder the clinics functioning. It may
be noted that appropriate relocation of the
clinic under such circumstances has been
possible due to these awareness activities.
HEALTH CARE BEYOND ZERO
21
.. as
•
■
■
•■■■
Box 4.3
r-ry..
Functional difficulties
,
7
■
•
T
.
■
■
■
■’
‘
■■
■
From time to' time, HIGH team has experienced some harassment from
the police. In one incident, a police officer tried to expel the drug de
addiction sharing session from the Park.
SBtSSSIWBB Tr
mc"dT?
clinic was allowed to be operational in the area. Even thenF during Id, the
B.
Weaknesses
(i)
Logistics
The non-availability of a laboratory facility,
ambulance services, drinking water for the
patients.
(ii)
Community Participation
Participation ofpatients in the management
of the clinic, was felt to be low although this
was not blamed on the clinic team, but on
the patients as one patient observed litue
come only when we require medicines. Another
patient said, “theproblem is with its and after
getting treated we dont come back”.
problems come to the clinic, therefore, the
services of specialist doctors e.g., a dentist,
etc, are very much required (also see
suggestions).
(vi)
Effective Referrals
The second lowest score was given to hospital
referrals, though participants stressed the
need for having some provision which can
help in admissions to hospitals. Patients are
referred to various hospitals in Delhi, if they
are very ill or doctors think they need further
tests to diagnose a problem. In discussions
with patients, it was revealed that while
hospital referrals for OPD treatment such as
x-rays, sputum tests, etc. were successful,
hospital admissions was a difficult task (also
see suggestions).
“Still when we are referredfrom here then
weget better treatment in the hospitals and we
are given medicines which were not available^
before”. A patient at the HIGH Clinic.
Even with facilitation by AAA, hospital
admission without family support,
especially for mentally ill homeless people,
is almost impossible in-spite of Health
Outreach providing attendants. (As shown
in Box 4.5).
C. Suggestions for Improvement
(iii)
Reaching out to the poor
Limited extent of out reach to the needy
ones (as explained in chapter 3) were
reported to be one of the weaknesses.
“The clinic should be advertised more by
distributing pamphlets, posters and keeping
a banner or board fixed at this place”. A
patients observation at HIGH Clinic.
(iv)
i)
In the second round of PRA, the
participants stressed that an ambulance
should be made available so that the
needs of emergency patients are met.
Though HIGH acknowledges the
need for an ambulance, no headway
till now is possible due to resource
constraints.
ii)
Duration of health outreach needs to
be extended by half an hour.
Follow-up
Almost a third of patients come back to the
outreach for a follow-up session with the
doctor although this figure reduces by half
for each further follow up. In chapter 3
follow-up rate is reported to be poor which
needs to be worked upon.
(v)
Specialist Doctors
The participants said that too many people
with dental, gastroenteritis and eye
36
HEALTH CARE BEYOND ZERO
iii) A small laboratory / testing facility for
<•
doing routine examinations like blood,
stool, urine etc. at the health outreach
should be provided. If it is not
possible to have a testing facility, at
least an arrangement with a laboratory
or government hospital be looked
into whereby samples could be
collected from the outreach clinic and
subsequently the report be given to
doctors at the clinic.
iv) Some monetary incentive to be given
to the homeless people especially
elderly to encourage their involvement
in the management of the clinic.
v)
In order to enhance user participation,
fortnightly/monthly meeting with
patients preferably on Sunday should
be organised. The participants assured
that if HIGH partners take the lead,
they were willing to provide their full
support especially in terms of logistical
support as they have benefited from
it immensely.
vi) A ‘Grievance Redressal Committee’ of
the patients should be set up to look
into the complaints of the patients.
vii) Traditional / basic knowledge to
prevent health problems should be
provided to the homeless community
through volunteers.
viii) The services of specialist doctors e.g.,
a dentist, etc. need to be arranged.
ix) Ambulance should be made available
to meet the needs of emergency
patients.
x)
xi)
Small group of attendants/volunteers
should be formed to attend to the
needs of hospitalised cases.
One patient suggested that the clinic
should be advertised more by
distributing handbills, posters and
keeping the banners or boards fixed at
the place of clinic.
Box 4.4
4.4_______?___
• ’ .
■
Accessibility to Health Care Services
'
According to the patients, HIGH health outreach is the most accessible to
homeless people, followed by Sheeshganj Gurdwara because
it treats,
because't
trMty
people from' the footpath, the service is free, it sends an ambulance if
needed and even provides food and tea. They further said that the-
added that^the drugs distributed were limited and ineffective
- The patierits seeking treatment at Guru Nanak Gurdwara’s (Charitable
Hospital) dispensary liked the doctor’s attitude. But complained that one /
has to wait for 2-3 hours before getting treatment, whereas it just takes
■7,-I hour at HIG heakb ourreKh clink.
the treatment by doctors was considered to be good but it was too far
yaway. Patients said that MCD clinic costs money and that the medicines
given by the MCD clinic in Kashmiri Gate were not effective. Quality of
medicines given by charitable clinics were also deemed to be poor.
,•
.
________
.
...
xii) Drinking water should be provided at
the outreach for weak and acutely sick
patients.
4.3.2
Evaluation by Patients with
b
Substance Dependence
Substance dependent patients were
separately asked to score the effectiveness
of the drug outreach including the sharing/
counselling sessions and the drug de
addiction programme, against the indicators
they had identified during the group
discussion (refer to Appendix 14, Table 2).
A.
Strengths
Motivation for Treatment
Score
Free Medicines
10
Good Medicines
Meetings/ Sharing sessions
10
Information/ Knowledge
7
10
De-Motivation for Treatment
Score
Smack Use
Engagement in Work
Other interests/ entertainment
10
Greed
9
2
2
HEALTH CARE
BEYOND
ZERO
37
exists, e.g. Sahara Day Care Centre. They
further remarked that it is ideal to have a 24
hours care facility for homeless drug patients.
However, Counsellors pointed out that
during sharing sessions they do talk about
other residential options for detoxification
such as Sahara House, Navjyoti and Asha
Bhavan (also see suggestions).
C. Suggestions for Improvement
i)
Sharing Sessions
Overall suggestion for making the outreach
service more effective, the group suggested
that the sharing sessions should be on daily
basis. The time of sharing session should
be increased, which would divert their
Box 4.5: AAA’s Stressed Night Out!
Sffl
in the dead of the night, 230pm,
i AAA
AAAvnn
van enters Chandni Chowk
.1. area and comes
_______ across
'
one young man standing in the middle .
T?
Ranlan.-(21 years of age) stands with a handkerchief tied on his face (covering his eyes), exhibiting martial art poses?:The AAA team succeeds in getting Ranjan to, the side of the road in spite of his (obvious) mental instability. Thereafter, the AAA
team approaches the nearby police station so that Ranjan could be admitted to a hospital. We tried hard to convince the Police ‘
to accompany us. They refused, we then asked them to give a written statement about Ranjan., After initial , resistance, the police#
finally agree to give a written statement on Ranjan being found in an unsound state. By 4am the ’drama’ in the police chowki ends
and AAA team along with Ranjan heads for LNJP hospital. - -,
At LNJP the doctor asks the AAA team to take Ranjan to LHMC/ S.K. Hospital as LNJP has no psychiatric ward. Hence Ranjan
is taken to LHMC where a doctor examines him and refers him to IHBAS. Meanwhile, Ranjan is administered sedatives to calm
him (as he becomes a little violent).
' i:
By 5.30 am AAA team brings Ranjan to IHBAS. The doctor in-charge refuses to admit Ranjan without the Metropolitan Magistrate’s ■
(MM) order. He asks the AAA team to call Police Control Room (PCR)/ No. 100 so.that the police would arrive and handle, thecase. So AAA members call 100 and wait for the police van. In spite of repeated calls and assurances given by the PCR, ho. police '
van arrives till 9 am. When the wait turns futile, at 9.20am AAA team takes Ranjan to the Dilshad Garden police station. The '
Investigating Officer (IO) tells the AAA team to take Ranjan to Chandni Chowk police station as he was found there. This time
AAA team calls up Mr. Amod Kanth, Jt. Commissioner of Police, seeking his help. Mr. Kanth asks the IO to help the AAA team
in admitting Ranjan in a hospital while doing the needful. Therefore, the IO and the AAA team along With Ranjan leave for Karkardoorha
Court for the MM order.
By 10 O’clock they reach the court. The IO already enters the concerned MM chamber while AAA team struggles to bring
Ranjan to MM’s court. On returning the IO tells the AAA team that the MM had directed them to take Ranjan to the Chandni
Chowk police station. Feeling that justice had not been done, AAA team decides to challenge the ‘unheard’ decision and represent
Ranjan in the court immediately. Hence, they take Ranjan to MM court room and Mr. Indu places the case, giving details of Ranjan’s
precarious conditions and the ‘torture’ he had to undergo all through the night. The MM decides in favour of Ranjan, instructing
the IO to get Ranjan admitted in IHBAS after writing an application to him for the same. By the time the IO completes his application,
the MM moves to the BSES (Bombay Suburban Electricity Supply) office nearby. So, 2 members of the AAA team and the IO go
to the BSES office and get the application signed from the MM. In the event, the MM asks the AAA team to first visit GTB hospital
to get the opinion of 2 psychiatrists before admitting Ranjan in IHBAS.
At around 12 noon, Ranjan is brought to GTB hospital. By the time the papers are readied, the psychiatric ward closes at 12.30pm.
The case is therefore referred to Medicine ward, room no. 259 on 2nd floor. Ranjan finally finds a bed and AAAiteam assigns John
as his attendant. At 3.15pm the AAA team, except John, leave for home. But, the story does not end here. At 4pm: John makes
a call to Mr. Indu, informing him that Ranjan has been discharged from GTB hospital. Mr. Indu calls up Dr. Nimesh Desai and tells
him about Ranjan. Dr. Nimesh suggests that the Chief Medical Officer (CMO) of the Medicine ward, GTB hospital should make.
a referral in order to facilitate Ranjan’s admission in IHBAS. By 6pm, the formalities are completed and Ranjan is taken to IHBAS.
At 730pm Ranjan is finally admitted in the Emergency ward of IHBAS. And he is again administered sedatives to calm him and
that he may get some rest.
But, will Ranjan’s soul ever rest, although he may get a physical calm? He may be quiet, not speaking of the ‘ordeal’ he underwent
through the hands of his fellow men and systems of his motherland. But, his soul will cry out in pain! and it will pain the hearts
of all who are human. And how long will it cry...only time will tell.
RS. - Ranjan remained in IHBAS for one and half month, for about a fortnight in our office, and then in Delhi House for a month.After that he came back to us in November 2002 and told us that he wanted to leave and work. Ranjan came back again in January
2003. He is working for marriage parties nowadays. We have told him that in case of any problem he can come back to U5> anytime,
he wanted to come. He visits the HIGH clinic to tell us that he is fine.
-
■ ,
40
HEALTH
CARE
BEYOND
ZERO
-- Zaved Nafis Rahman, Project Officer with AAA
T
n
mind from their addiction and help in
attaining greater self control. Another
suggestion to divert attention was to have
sessions on meditation.
Y
ii)
r
II
Prescription of Medicines
Some patients, suggested that a person
who had been taking drugs for a long
period of time should be given a higher
dosage of medicine for a longer period but
currently doctors are providing medication
at the same dosage as those newly addicted
to drugs.
iii)
Hospitalisation
The participants recommended that
hospitalisation should be for a period of 15
days as a person cannot leave drugs while
living on the pavement.
•v)
Day Care Facility
There should be some programme for the
whole day. A camp in the daytime should
be organised where people are asked to
work so that they don’t have time to take
drugs. There should also be provision for
food and if the person can be paid some
amount for his work, it will be an added
advantage and act as an incentive to come
to such a facility.
v)
Sitting Arrangements
Some of them suggested that plastic/
tarpaulin sheets could be used during the
rains.
4.3.3
Evaluation by the HIGH team
Simultaneously, when PRA was being held
with General health patients and substance
dependents, the HIGH team (Doctors and
Community Workers) as well as other
stakeholders (heads/ coordinators of partner
organisations) also sat down separately to
assess the effectiveness of the clinic using
Participatory Reflection and Action (PRA)
methods.
The exercise proved helpful in
finding how the service providers rate their
work. Also how close or different is
their rating / perception vis-^-vis the
Homeless i.e., general ailment patients,
substance dependent patients and
psychiatric patients.
A.
Strengths of Outreach for
Patients with Substance
Dependence
Like the patients, HIGH team, too was
satisfied with the punctuality and regularity
of the team, frequency* and accessibility
(except in cases of female patients) of the
clinic, quality of medicines being provided
at the clinic, punctuality of the HIGH
team
and
relationship
between
HIGH team including doctors and the
patients. But in the year 2002, doctors felt
that the HIGH team inclusive of
community workers became less cordial
with the patients as compared to the
previous year.
'CWs emphasised that • services of
specialist doctors are not required, if the
referral system is improved.
ii) Location of the Clinic
Doctors remarked that the place of health
outreach is fine but for community workers
the place is not suitable as there is a lot of
disturbance from various on lookers.
iii) Awareness of Existence
Some of the doctors had given 10 points
saying that there is considerable awareness
of the HIGH amongst the homeless in
Jama Masjid area and patients are also
coming from other areas like Nizamuddin
and Yamuna Bazaar but still awareness
about this facility needs to be created
among the homeless.
HEALTH CARE BEYOND ZERO
41
Basic Medical Equipment
iv)
The medical equipment already present in
the clinic is adequate.
Appropriate Timings of
Registration and Clinic
V)
The patients are registered for an hour
from the start of the clinic. The timings of
the clinic (6pm-9pm) are appropriate in
the sense that it suits a majority of the
homeless. But the participants also felt that
the clinic could cater to more patients.
able to handle patients well and establish
rapport easily. However, improvement is
possible in the registration of patients/
filling in complete data/ distribution of
drugs/ taking patients to hospitals/ bringing
patients to the clinic.
As per doctors and CWs, the facilities
were satisfactory. Few of the infrastructural
deficiencies at the HIGH were listed as
follows:
No drinking water facility for patients
Inadequate Lighting
No protection from the cold for patients
in winter
Adequate Composition of Staff
vi)
The present composition of clinic team
was appreciated well. Still there could be
more doctors involved and the management
staff could also improve in terms of quality.
Also, other medical professionals could be
approached to contribute voluntary
services.
Voluntary Participation of
Locals
vii)
The doctors remarked that participation of
locals is present in the form of support
from the local market association. However,
the participation could improve through
increased awareness, creating volunteers,
and having friendly staff at the clinic.
No benches for patients who cannot sit
on floor.
Disturbance during the festivals and
due to government orders
A bigger mobile van is required
ii)
V Time spent by doctors is less
The exercise of running the clinic has
become mechanical and monotonous.
Motivation is falling and insensitivity
seems to be creeping in.
One to one relation between the doctors
and patients is missing.
“For the last 19 years, I used to see people
sleeping here on the pavements, taking
injections, being beaten up by the police and
by other people. I thought ifI would be able
to contibute even a little bit to their
betterment, I would be very happy”.
Lack of knowledge amongst the patients
I the homeless about the possibilities of
their participation.
The HIGH team is not really focusing
on involving the patients.
Abdul, a Volunteer at HIGH clinic living at
Jama Masjid area
B.
Weaknesses of the Outreach
for Patients with Substance
Dependence
i)
Logistics
The doctors felt that the team is motivated,
42
Shortcomings involving the
team
iii)
Audio Visual Aids for I.E.C
(Information Education
Communication)
The participants felt that no audio-visual
medium is being used for generating
health awareness amongst the homeless.
HEALTH CARE BEYOND ZERO
I
The group felt that whatever awareness the
HIGH has been able to generate is through
its own goodwill.
Box 4.6
s«
SILVER.LININl
of 'age;afei;>a^’Keenta
(iv)
Need for Expansion
di
The participants felt that HIGH has
not expanded according to its potential.
They listed the following as areas of
expansion:
first i
»ori:she Was
ahf wi'u6
I
<e In amhe Hi treat,
i.Her husbanc1
Life was difficult - unable to make ends meet with g pKK.ng, sne
started workin? as a domestic heli
inJamaMasiiJ.
=„.
her children with her as she is required to go to work and she fears fot
for
their safety.
safety. She
She wants
wants to
to send
send her
her daughter
daughter to
to aa hostel
hostel because
because she
she fears
fears
their
Number of staff.
Availability of doctors, i.e. doctors with
different specialisations.
...
Expansion of the clinic to other places.
Participation of local community
Regular Monitoring by
|
Community
There is no real monitoring by the homeless
community of the HIGH. There are only
few instances when people have come up
to give their feedback about the clinic.
According to the participants, monitoring
will happen when homeless become a part
of the clinic operations.
(vi)
Referrals
The participants felt that referrals have
worked only sometimes and no mechanism
has been created to facilitate the referral of
patients to hospitals on a regular basis.
Some participants gave the example of Dr.
Shroffs Eye Hospital and Sahara, which
have responded positively to the HIGH
referrals while the referrals to LNJP have
not always been entertained.
Reasons for Not
Visiting Hospital
Patients belief system
Long and cumbersome procedure
Long queues
Due to distance
Fear of being insulted
Score
9
8
2
2
1
...; i
.
,
‘‘j
t
that if her daughter stays in that area she may get sexually exploited.
About the Drug De-addiction Outreach Shanti says, “ I came to know
from the people living here that doctors are good I did not believe them
but I thought there was no harm going there once. I am taking the medicine
'if Composition and quality of staff.
(V)
i
• l.teei
tney^can leave drugs,
,...........................................
J
Interview with Rimmy, ActionAid, Delhi on 25°’ March. 2002
The drug counsellors stressed the point
that no referral facilities exist for patients
with substance dependence.
HIGH staff also pointed out that
referrals for TB patients were not
successful1. DOTS centres do not accept
homeless people. This has serious
implications for homeless people with TB
as they could die without treatment (see
Box 8).
The TB centre does not accept peoplefrom
here. Ifwe go there they ask for a ration card
or some Netajis (political leader's) signatures.
Many people come here coughing, we know
who all are suffering from TB., but they are
not admitted to the centre. They don't even
1 TB medicine must be taken on a regular basis for an
extended period of time. If a person fails to take TB
medicine s/he can become resistant to the medicine and
if a relapse occurs, treatment becomes very difficult. The
World Health Organisation has developed a system called
the Direct Observation Treatment System (DOTS),
whereby a TB patient is required to attend a TB clinic
three times a week and take the medicine in front of health
workers. If the patient does not come to the clinic, health
workers are required to visit their homes. This system
ensures that patients take their medicines and do not
become resistant to the disease.
HEALTH
CARE
BEYOND
ZERO
43
SH—
?hSof
start the process of sensitising them. This
should also be in the agenda of policy level
meeting of the partner agencies comprising
the HIGH.
viii)
Need Oriented Services
■.ran’tthey,
-the disease and its implications. What makes our task more difficult is
Going Down Memory Lane
The doctors said that 70 percent of the
time the needs of the patients are known,
hence the clinic is very much needoriented. But it can improve. Also, it is
important that the services provided at the
HIGH clinic are updated/ enhanced
according to the feedback from the patients
particularly regarding the referrals.
On May 5, 2001 weekly sharing session with drug users was started in Urdu
Park near Jama Masjid. Initially, the number of substance dependents
ix)
attending the Wednesday session was less but slowly and steadily it started
ttelps them in improving their, life,; Through this sharing process, the
substance dependent individuals’ realised hoy/ they abstain from drugs
forever and why they should refrain from same.
My experience says that sessions.also proved fruitful in improving the
strained relations of substance dependents with their family; members, .
children, relatives, friends and society. Many drug addicts who had lost jobs
At present there are no surgical items and
arrangement for a testing facility at HIGH
clinic is lacking.
C. Suggestions for Improvement
i)
started getting jobs-and thereby were again gainfully employed. Some of
the substance dependents, who were from other states than Delhi, went
back to their homes. And those who belonged to Delhi continued taking
benefits of the sessions . while having integrated with their families. Also,
they were an invaluable-support in explaining to the new substance
dependents the benefits of sharing session.
There have been some bitter memories as well. Some substance
dependents quit drugs after having’ gone through sharing sessions but
relapsed. Most of them have come back to the sessions: and seemed to
acknowledge that they have been unable to imbibe or assimilate the insights
gained through sharing sessions in their life. Inspite of the malaise they find
themselves in it is heartening to see them come back to the sharing sessions
with' renewed vigour to overcome their substance dependence.
It is also noteworthy that occasionally, due to some event at Urdu park
we had to do the session in some other location. But it was not ever
. cancelled/ probably; because substance dependents don’t want to be
.deprived of the benefit.
■■
■
Coordination Among HIGH
Team Members
To have better coordination, the CWs
expressed the need to have regular meetings
at least twice a month.
ii)
Free of Cost Treatment
The doctors as well as CWs stressed that
nothing should be charged from the
homeless. A suggestion was made that
there can be a donation box at the HIGH
clinic. Volunteers/Supporters / CWs should
talk about the donations2 to various on
lookers.
Babla • Drug De-addiction Counsellor in October 2002 ||
Jii)
give them the forms”. — Amir Khan, a
Supporter at HIGH clinic
vii) Sensitising Key Persons
The doctors were of the opinion that there
is a need to identify opinion leaders and
44
Laboratory Testing Facilities/
Minor Surgical Items
HEALTH CARE BEYOND ZERO
Criteria for Registration
There should be criteria for registration
and treatment and people in distress
should be encouraged to attend the
clinic.
2 During the PRA with homeless patients, some of them
had said they would be willing to pay for the medicines.
V
't
■
iv)
Referrals
»«<»...... - -
.
J
V Identifying medical professionals in
government and private hospitals/ clinics
and motivating them to take up cases
Recovery from addiction
Slowty I got addicted to alcohol and b
al
mean^me;
on who
it Talking to the concerned professional
and seeking his/her commitment in
advance.
■ J**" he
o . ....
, f-. ——T?
.
me
-.y
'6
2===-==- ■ ■
BsSfe
1 B
List of referrals of nearest places and tieup with them
■
one aay
thenyl to
Make sure the patient reaches the right
place
v)
sa
nss-ssiS:
HIGH Staff emphasised the need for
more volunteers (ready group of
attendants) especially for taking patients
to hospitals for referrals or follow-up
treatment.
regularly, I got rid of my addiction to smack.
A strong fear lingered that as long as I stay in.
in this environment; I could
Sharing Session
Chowk, and sleep on the footpath near the Gurdwara or in Yamuna Bazar
There should be education on common
illnesses in the meeting
or somewhere in between. But I voWed to stay away fror, dr.igs. After
one week of participation at the Day Care, attending the N.A meeting
and returning to Chandni Chowk, I was sent to Sahara House. I stayed
there for about five months. Then I got work as a volunteer in the HIGH
project. I help people staying on the footpath and what I like most is where
Feedback should be shared with doctors
The frequency of the meetings needs to
be increased.
before I had to stand in line to get medicines, now I sit there on a chair
and distribute medicines, make the cards for the people, etc. I like doing
this a lot.
Continuous sessions should be held for
six days with different groups
- Attending the N.A meetings and the Wednesday .sharing session ■
In addition to discussion, there is a need
for some kind of action
'V Sports and more creative engagements
should be introduced
,
Manoj is now full time community health worker with
Aashray Adhikar Abhiyan
been very little time for individual
counselling and suggested more frequent
sharing sessions or ‘camp’ type sessions
which would be more intense and
continue for about six days. Doctors
suggested a day care centre where there
could be different activities.
The sessions should be longer so that
patients would be kept busy and have
no time for drugs
Counsellors complained that there has
dependents'on how I kicked my habit. I will try to build their confidence
. by sharing my experience with them. Also I want to help serve the people
in HIGH and others too - Manoj
,
To ensure one to one counselling, there
should be an additional counsellor
Counsellors agreed that the sharing
sessions would be more effective with
one to one counselling sessions and that
activities such as games and sport would
be good group building exercises
|
regularly at Jama Masjid provided me the means of getting rid of drug .
addiction. Now, I would like to share my experiences with other substance
vi)
Basic Medicines
The supply of medicines could be
increased.
HEALTH CARE
BEYOND
ZERO
45
New types of medicines especially
antibiotics and anti TB treatment could
be introduced after discussion on
common requirements.
Provision for dressing should be made
available
vii)
Doctors
It was suggested that only those doctors
should come who are familiar as well as
regular to the HIGH operations.
viii)
Registration at the Clinic
CWs suggested that registration should be
done in Hindi. They end up taking out
wrong patient cards sometimes.
ix)
Awareness about the Clinic
• In order to increase the awareness about
HIGH among the homeless and other
sections of society, the following methods
were suggested such as use of banner at
the sight, making announcement,
increased interaction with the patients
and increased more involvement of the
patients in the management of the
clinic. Also, the waiting time of the
patients can be used for information
dissemination on health issues,
motivating the patients to bring more
patients to HIGH clinics, use of role
models e.g. recovered patients in the
clinic for sharing information.
Paramedical staff should spend more
time with patients for rapport building.
The team needs to be more sensitive to
the needs of the homeless. Time spent
with the doctor needs to be more.
• There is a need to cater to wandering
mentally ill persons. This will enable the
doctors to examine a variety of patients
and reduce monotony.
'
• The HIGH must be equipped with
trained and competent staff. They should
46
HEALTH
CARE
BEYOND
ZERO
be sensitised so that the misconceptions
regarding the homeless are removed,
and they handle the patients well
• There should be a dedicated and a
constant team of doctors for the HIGH.
There are people who have reservations
about dealing with the homeless or
going to the community but they are
forced to go. Ifthings are forced, it is de
motivating. Therefore, a separate team
of doctors from IHBAS or Sahara
should be exclusively for the HIGH
• The changing or shifting of staff or
volunteers in the clinic should be
avoided as the new ones are usually
unaware of the conditions of the
homeless and it is likely that they work
with a negative attitude, which is
inappropriate. Even if a change is
necessary, the new comers should be
oriented to the situations the homeless
face and the functioning of the HIGH
• Some of the participants suggested that
the old doctors could sensitise the new
ones. Moreover, there could be a
sensitisation mechanism in the respective
hospitals. Also, general workshops on
homelessness/ AAA activities could be
conducted with all doctors in IHBAS or
elsewhere
• The involvement of AAA staff with the
homeless patients needs to improve. It
has gone down as compared to the
previous year. Also, the community
workers need to have meaningful
interactions with the homeless patients
than just following the routine.
x)
Basic Medical Equipment
• Facility for examining patients, e.g.
instruments like ophthalmoscope, etc
• Folding screen to enable doctors to
examine female patients and patients
with sexually transmitted infections
(STIs)
• Stretcher
• Testing faciliti-ies at the clinic.
xi)
Audio Visual Aids for I.E.C
(Information Education
Communication)
• Use of posters on health education
7 °f Health Care; to the
r xww...... -nd' around the Walled Ci
If©SHf® "Qj
•v .^heritable'
//^ .
• Policy level discussion on finding ways
to use audio visual IEC.
xii)
I .
i '
\
HSAr /j civir l
Trained and Competent Staff
Number of Supporters and Community
Workers to be increased, they should be
trained especially in follow up.
xiii)
‘
Appropriate Timings of
Registration and Clinic
The patients are registered for an hour
from the start of the clinic. The length of
time for registration of patients at the
clinic may be increased. This depends on
the number of patients being turned down
on a daily basis. However, the increase in
the registration should be accompanied
with an additional staff.
.......................................
(
’eople
HIGH
action. It was also to ascertain what the
grey areas were which as heads of the
partner organisations they felt needed to be
checked or improved upon. The process of
exercises was similar as with the others and
they came up with indicators along with
their scores.
Once the self evaluation had been
xiv) Dressing Facilities
done, the findings of the Participatory
HIGH staff suggested that to improve the
Reflection and Action (PRA) done with
services available, basic first aid should be
general patients, substance dependents and
provided e.g. simple dressings and
HIGH staff (Volunteers, Supporters,
preventive health education for common
Community Workers as well as doctors
illnesses could be undertaken.
were shared with the partner organisations.
Interestingly, the evaluation scores were
4.3.4 Evaluation by Heads and
very similar.
Coordinators
of
Partner
Like other stakeholders, this group of
Organisations
<r participants in PRA were satisfied with the
consistency, punctuality, easy access and
The coordinators as well as the heads of the
utilization of the clinic. Regarding some
partner organisations met in December
issues of concern like involvement of
2002, the last day of the PRA. The purpose
of meeting on the last day was to know
community, poor rate of follow-up, referrals
to the government hospitals, good relations
their views and also to appraise them about
between doctors and patients, participation
the findings of the PRA exercises done
of the community, there had been a general
with stakeholders so as to finalise a plan of
feeling that they need thorough planning
action for the smooth functioning of the
and immediate redressal.
clinic and determine a future course of
Length of arrow indicates
accessibility
HEALTH CARE BEYOND ZERO
47
*
48
All agreed that three factors namely credit
sharing, transparency and mutual sharing
are the key factors which have kept HIGH
going for three years despite having
problems. The heads of the partner
organisations also felt that these three factors
should also be a key to future collaborations.
A problem area that they encountered
was since there was no point of reference,
as no other model of this nature existed,
framing a policy was difficult. But the
experiences of the past three years and the
wisdom gained thereon could now help in
formulating a policy. This will also help in
the future expansion of work at HIGH
and enable other organisations to follow
this model. The partners reiterated that all
HEALTH CARE BEYOND ZERO
of them apart from AAA (since AAA is
already working on this) would also like to
play a more important role in the health
advocacy
for
the
homeless.
They all agreed that AAA is playing a
very important role in advocating the
health cause of the homeless but in some
areas where they are facing difficulties
partners could help/assist in finding
solutions. This is not happening and
sometimes partners feel left out of the
whole process hence it was suggested that
there could be an information pool which
can solve many of the existing problems.
The forum for sharing all relevant
information was considered to be the
monthly meetings.
1
Future Horizons:
Carrying the Initiative To Completion
-1
I
he future course of action has been
discussed among the partners from
time to time and especially at the
time of PRA exercise at the end of two
years as well as during the routine process
evaluation exercise in the third year. The
course of action thus identified involves
many levels of programmatic and
conceptual tasks, as described below. It is
clarified that the identified course of
action provides a broad and flexible
template, which will require being adapted
from time to time. The intent crystalised
and expressed in this chapter should be
possible to fulfill, if the cooperation and
assistance due from the multiple agencies
involved can be ensured.
5.1 Improvement in the
functioning of the clinic and
the services
As part of an ongoing process, the effort
to improve the functioning of the clinic
and the services, in terms of the logistics
as well as the programmatic elements
continues. The PRA exercises with the
users of the service has provided insight
into some aspects of the functioning which
required to be improved. For example the
need for better waiting facilities and
privacy for medical examination. The
insight about the programmatic elements
have been obtained from the PRA exercises
with the service providers as well as with
the users. The need for minimal diagnostic
laboratory facilities have been emphasized
by both the service providers and the users,
while the need for additional medical
equipment, and some more specialist
5
doctors specifically in pediatrics and
dentistry, was approved by the service
providers.
5.2 Fulfilling the Service Gaps
The initial period of two years has
provided some minimal health services, but
quite understandably there have been some
important gaps in the services. These have
been identified though the ongoing process
evaluation over the initial years as well as the
PRA exercises. The efforts made in the
initial years for fulfilling these gaps, havev
not been very successful due to various
reasons. These are enumerated here with the
possible strategies for fulfilling these gaps.
The possibility of correcting these gaps will
depend on the extent to which cooperation
and facilitation will be possible, to be
achieved from various agencies.
5.2.1 Treatment of Tuberculosis
Amongst the respiratory system illnesses,
which form the largest group of health
problems seen at the outreach health service,
many of the infections have been possible to
treat effectively at the street level, but effective
and sustained treatment regimen for
pulmonary tuberculosis has been difficult
to be implemented. The technical and
administrative difficulties in obtaining a
DOTS center at a non-hospital specially at
the street level have been attempted to be
overcome, without success. The possibility
of building a liaison with one of the
supporting organisations viz. the St.
Stephens Hospital is being explored. The
fact does remain that the service gap in
treatment of patients with tuberculosis
HEALTH CARE BEYOND ZERO
to
49
remains, and requires to be effectively
tackled.
5.2.2 Initiating Treatment for
Mentally III Homeless Persons
(MIHPs)
As outlined earlier, although identified as
a health service need from the outset, the
task of initiating treatment for the Mentally
Ill Homeless Persons (MIHPs), specially the
persons with Severe Mental Illnesses (SMIs),
has been difficult to achieve. The plight of
this group of persons has been described
earlier, specially the lack of support systems
and the lack of insight on the part of such
persons. The need for involuntary treatment
with this group of illnesses becomes more
difficult to be met with in homeless persons.
The possibility of initiating involuntary
treatment of these persons on the street,
with periodic depot injections is promising
in terms of clinical science, but has obvious
ethical and legal dilemmas and pitfalls. The
partner organisations of the HIGH have
often held internal discussions, and
consultations with some experts in the field
of law, for overcoming the ethical and legal
dilemmas. The possibility of seeking advice
and/or intervention from the Court of Law
has been actively considered and is expected
to be followed up.
5.2.3 Psychosocial Interventions for
Persons with Common Mental
Disorders (CM Ds)
<»
50
The need for psychosocial intervention
in many conditions is high, but certainly in
Common Mental Disorders (CMDs) like
Depression and Anxiety Disorders. The
identification and diagnosis of CMDs in
homeless persons involves its own conceptual
and pragmatic difficulties, since the
definitions and the criteria for diagnosis of
these disorders for the general populations,
are not easily applicable in the extremely
adverse circumstances of the homeless
HEALTH CARE BEYOND ZERO
persons. The perceived need and the
willingness for seeking help, in such persons
are also difficult. In spite of these issues,
there has been an initial success in ensuring
that some of these persons avail of the
outreach health services, but becomes
somewhat infructuous since the need for
psychosocial interventions have not been
possible to be met with. The limitations
have been in terms of the qualified mental
health professionals and the time available.
The idea of training volunteers from the
community of homeless persons in basic
counseling skills has been actively
considered, and is being pursued. The
resources for making trained counselors
available for this programme need to be
obtained, along side exploring the possibility
of developing technology and obtaining
resources of training of lay volunteers from
the homeless community. The screening of
patients who reach the outreach health ‘
service for general health problems and for
Common Mental Disorders has also been
planned and attempted, but was aborted
due to the shortfall in services for these
persons.
I
I
• I
5.2.4 Treatment Programme for
Childhood Substance Users
Specially Solvent Abuse
It has been difficult to evolve a meaningful
treatment programme for childhood
substance users with solvent abuse, for
reasons of lack of definitive scientific
incidence in this matter and the practical
difficulties for a programme at the street
levels. It is planned that a treatment
programme be initiated similar to the
programme for adult drug users, and if
required, in liaison with other agencies in
the field area, working with street children.
5.2.5 Minimal Laboratory Diagnostic
Facilities
As outlined earlier, the need for minimal
J.
i
I
I
I
laboratory diagnostic facilities has been felt
all through the initial years. That has been so
for persons with Gastro-Intestinal Tract
(GIT) problems, respiratory infections and
alcohol use problems, more specifically. In
addition to these conditions, the need for
laboratory diagnostic facilities has also been
felt for the assessment and treatment of
general medical conditions of deprivation
and malnutrition, most notably anemia.
The difficulties involved in initiating the
facilities available at the nearby government
hospitals have been outlined earlier. At the
same time, since the outreach health service
is being provided more as a “health service
on wheels”, the possibility of incorporating
laboratory facility as part of the outreach
health service, will be limited. Various
options are being explored to fill up this
service gap.
5.3 Enhanced Community
Participation
Although envisaged from the outset,
community participation has been possible
to a very limited extent. In the first year,
there was initially no involvement possible
beyond interest and appreciation. In the
second year, it has been possible to initiate
some participation in terms of contact
meetings and evolving of some volunteers
from the community of homeless persons.
These volunteers have played a useful role in
the logistical operation of the clinic and in
identification and motivation of persons
with mental health problems. The medium
term plans for community involvement are
for a stable work force of volunteers for
identification of patients, follow-up care,
networking for hospital based treatment,
operation of the clinic and provisions of
counseling and other psychosocial
interventions. The long term plan is to be
able to hand over the task of a large part of
the operation, if not the entire operation of
the clinic, and if possible, the outreach
health services, to the homeless persons.
The professional and scientific aspects of
the service will require to be carried out by
the partner organizations. As in many other
outreach efforts, this ultimate goal ofpassing
over the responsibility is likely to be difficult
to be implemented, but it should remain as
the goal and must be attempted. .
5.4 Comprehensive Health Services
The services in the initial two years have
been predominantly of therapeutic nature
in treatment of health problems. It is
recognized and planned that the expansion
of the services to a more comprehensive
level should include preventive and
promotive services.
5.5 Strengthening the Networking
Although a reasonably satisfactory
networking has been possible a lot more
needs to be done in strengthening the
networking. This is required for the service
gaps, which have been identified, as well as
for the more comprehensive health services
proposed above.
*>
5.6 Expansion of Services to a
Larger Population
As noted earlier, the experience gained
through this initiative needs to be applied in
other settings and expanded to a network of
similar services in the city-state of Delhi,
other parts of India, and possibly the other
developing countries. The cooperation and
participation of the government health
departments, and the facilitation required
from the policy makers, should be possible
to obtain considering the fact that this
collaborative initiative has been able to
demonstrate successfully the feasibility and
the usefulness of an outreach health service
for the homeless population.
HEALTH
L
P-H P
\ S M-o (>
CARE
BEYOND
n
c
■ SOCWJSA
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51
"T
Epilogue
he experience of the initial two
years of a collaborative initiative by
a government funded academic
institution, IHBAS, and two NonGovernmental Organizations (NGOs),
AAA (a project of ActionAid India) and
Sahara has been documented in this
report, in the background of the path
breaking report on the “Capital s Homeless”
by the AAA in 2001. Access to health care
has been recognized as one of the basic
rights, and the effort in the partner
organisations for ensuring this right has
been initial in the effort. The Health Needs
Assessment Survey (HNAS) carried out at
the early stage, led to the identification and
implementation of the strategy of an
outreach health service. The profile of
health problems seen at the outreach clinic
has been documented, along side
identifying the service gaps through
preliminary evaluation exercises. The
findings from the evaluation exercises are
phased with the future course of action to
be followed.
The Health Care Services for the
homeless population at zero level leading
to the collaborative initiative for taking
the situation beyond zero level, and
the satisfaction of making a difference,
has been associated with a constant
endeavor to make the difference more
meaningful and carrying the initiative to
its completion.
The dream of carrying the initiative to
its completion i.e. to ensure that all
52
HEALTH
CARE
BEYOND
homeless population in the state of Delhi,
and possibly in all of India, can be realized
only, and only if, it is recognized and
accepted, that health care is one of the
basic rights of the extremely disadvantaged
population. Such recognition and
acceptance should lead to initiative(s) by
academic institutions and hospitals, as well
as voluntary organizations and NonGovernmental Organisations (NGOs) for
application of this model Outreach Health
Service in different settings. The application
of this model, quite understandably, will
have to be with sensitivity to the local
situation and adaptation as per the needs
and the resources.
The model shared here need not be,
and should not be, the only one to be
followed. As the application gets a wider
base, the innovations and adaptations
will get documented. The individuals
and the teams in the partner organisations
await eagerly these developments.
Above all, it needs to be ensured the basic
right to health care is made available
to the homeless population. The
sustainability of any such outreach health
service, will require and must get support
from state health services. As per the
international conventions on right as
well as by the constitution of India, make
if incumbent upon the State to actively
implement outreach health services for the
homeless populations. In the meanwhile,
the possible collaborative efforts can be
initiated.
ZERO
1„.
I
-•S'
References
I
i
Aashray Adhikar Abhiyan (AAA), the Capitals Homeless. Delhi. January 2001
Association for Development. A Study on the Problems of Street and Working Children
Living at Railway Stations in Delhi. AFD. 2002
Chaudhry.V Living Conditions of Homeless People in Jama Masjid Area, Delhi. A
dissertation submitted for the Degree of Master of Philosophy of the University of
Delhi. Department of Social Work. 2002
Deodhar. N.S. Health Situation in India: 2001 with special reference to control of
communicable diseases. VHAI. 2001
Desai N.G., Shah B. Approach Paper for the Workshops on Urban Mental Health in
India, Delhi. 2002
Desai N.G., et al. Report of the National and Regional Workshops on Urban Mental
Health Service Needs, Delhi 2003
Don Bosco. A Study on the Street and Slum Children of Thiruvananthapuram C/zy.
UNICEF. 1998
Dupont. V. Mobility Patterns and Economic Strategies ofHouseless People in Old Delhi. Paper
presented to the International Seminar: Delhi Games: Use and Control of the Urban
Space - Power Games and Actors’ Strategies. Delhi. April 1998
England. J. The Disposables. Developments. Issue 19. Third Quarter 2002
Harpham T. Lusty T Vaughan P. In the Shadow of the City .Oxford University Press.
New York. 1988
Hindustan Times. ‘Minister promises free treatment for the poor’. 19 August, 2000
Hindustan Times. ‘No treatment for TB patient Mantu as he is from Munger’T?
September, 2000
Hindustan Times. ‘India has bad lungs’. 29 April, 2001
Indian Express. ‘TB treatment : WB sees need for change’. 27 September, 2000
Indian Express. ‘20 hour ordeal to get into hospital’. 7 August, 2002
Jaganathan N.V & Halder A. A Case Study of Pavement Dwellers in Calcutta. Economic
and Political Weekly, Vol XXIII, No. 23, June 4, 1988,No. 49, December 3, 1988
& Vol XXIV, No. 6, February 11, 1989
Kuruvilla. Pavement Dwelling in Metropolitan Cities: Case Study of Delhi. Unpublished
thesis. School of Planning and Architecture. Delhi. 1990
Mathur O. P. The Impact of Urbanisation on Children, in Urban Child Issues and Strategies
in Collaboration with Planning Commission, Ministry of Urban Development
UNICEF, New Delhi. 1993
HEALTH
CARE
BEYOND
ZERO
53
Menon. S. From Skilled Artisan to Rag Picking. Labour File. June-July, 2001
Ministry of Social Justice and Empowerment & UNDCP. Rapid Assessment Survey ofDrug
Abuse in India. 2002
Out of Mind, Out of Sight - Voices ofthe Homeless Mentally III. East West Books (Madras)
Pvt. Ltd. 2002
I
I
Panicker. R. Street Children and Drug Abuse in India. Paper presented at the Expert Forum
on Demand Reduction in South and South West Asia, UNDCP, New Delhi, 1995
Patel V. Poverty, Inequality & Mental Health in Developing Countries. Londons Institute
of Psychiatry. 1996
Planning Commission. National Human Development Report2001. Planning Commission,
Government of India. March 2002
Priya. K. R. A Report on Programme Evaluation of Sharans Harm Reduction Programme
for Drug Users. Sharan. Delhi. July 2000
Rajkumar. V. 2001 Vulnerability and Impact of HIV!AIDS on children in selected areas of
Delhi, Rajasthan, Tamil Nadu and Maharastra. Save the Children (UK), 2000
Ray SK, Biswas R, Kumar S, Chatterjee T, Misra R, Lahiri SK. 2001 Reproductive health
needs and care seeking behaviour of pavement dwellers of Calcutta. Journal of the
Indian Medical Association. Vol 99. No 33. March 2001
Roy S and Ray. S. Prevention of Malnutrtion. Journal of the Indian Medical Association.
Vol 98. No 33. 2000
Sainath. P. Everybody loves a Good Drought. Penguin Books India. 1996
Sarin. E, Singh. S, Saristsa. S, Deepak. V, Ahuja. G, Julian. G and Kole S. Female Drug
Use: Part of Rapid Situation Assessment of Drug Use in Delhi. UNESCO. Delhi.
March 2001 (Unpublished)
Sharan. 5 Cities Situation Assessment. 2001
The Telegraph. ‘The politics of being poor and unwell’. 31 January 2001
Times of India. ‘Mental Illness is as prevalent as cardiac disorders’. 10 October, 2000
Times ofIndia. ‘Less money for hospitalisation of poor from next fiscal year’. 13 March
2001
Times of India. ‘When Medicare Means Proving Poverty’. 25 October 2001
UNDCP. South Asia: Drug Demand Report. 1998
UNDP. Human Development Report. Oxford University Press. 2002
Voluntary Health Association of India. State of India's Health. VHAI. 1992
Voluntary Health Association of India. Delhi:Tale of Two Cities. VHAI. 1993
Youthreach. Help Delhi Breathe: A Guide to Your Role in Saving Delhi's Environment.
Youthreach. 2002
54
HEALTH CARE
BEYOND
ZERO
.
Appendices
.1.
i
List of Contents
!
1.
Abbreviations
2.
Topographical Map: Location of H I G H
3.
The High Partners and Supporting Organisations
4.
Hand Bill in Hindi distributed to the Homeless at the launch of HIGH Outreach
Health Service
5.
Outreach Health Service in Operation: Drug Abuse Treatment Outreach
6.
Format of form: Patients with General Health Problems and Psychiatric Illnesses
7.
Format of form: Patients with Substance Dependence
8.
List of Medicines Used in the HIGH Outreach Health Clinic
9.
Inventory of Logistical Requirements of Outreach Health Clinic.
10.
List of Clinic Personnel
11. Tables: Patients with General Health Problems
*
12. Tables: Substance Dependent Patients
13.
Tables: Patients with Psychiatric Illnesses
14.
Participatory Reflection and Action (PRA) Tools
15. Tables: Participatory Reflection and Action (PRA) Exercises
16.
List of Process Participants
HEALTH
CARE
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ZERO’
55
Appendix I
Abbreviations
56
AAA
Aashray Adhikar Abhiyan
AIDS
Acquired Immuno Deficiency Syndrome
ARMS
All India Institute of Medical Sciences
AIR
All India Reporter
SD
Substance Dependents
CEDAW
Convention on the Elimination of Discrimination Against Women
CMDs
Common Mental Disorder
COPD
Chronic Obstructive Pulmonary Disorder
CP
Connaught Place
CRC
Convention on the Rights of the Child
CSO
Civil Society Organisation
CST
Comply Same Treatment
CWs
Community Workers
DHSA
Delhi House Seva Ashram
SCEH
Dr. Shroffs Charity Eye Hospital
FGDs
Focus Group Discussions
GDP
Gross Domestic Product
GIT
Gastro Intestinal Tract
HIGH
Health Intervention Group for the Homeless
HIV
Human Immuno Virus
HNAS
Health Needs Assessment Survey
IEC
Information/Education/Communication
ICERD
International Convention on Elimination of all forms of Racial
Discrimination
ICESCR
International Convention on Economic, Social and Cultural Rights
IHBAS
Institute of Human Behaviour and Allied Sciences
ISBT
Inter State Bus Terminal
LHMC
Lady Harding Medical College
LNJP
Lok Nayak Jai Prakash
MIHP
Mentally Ill Homeless Persons
MR
Mental Retardation
NA
Narcotics Anonymous
HEALTH CARE BEYOND ZERO
f
t*s
I
NCAER
National Council for Applied Economic Research
NGOs
Non Government Organisation
NIAF
National Illness Assistance Fund
NSS
National Sample Survey
OPD
Out Patients Department
PRA
Participatory Reflection and Action
. RAS
Rapid Assessment Survey
RMLH
Ram Manohar Lohia Hospital
SCC
Supreme Court Cases
SKH
Sucheta Kriplani Hospital
SMIs
Severe Mental Illnesses
SMDs
Severe Mental Disorders
SPSS
Statistical Package for Social Sciences
SSH
St. Stephens Hospital
STIs
Sexually Transmitted Infections
TB
Tuberculosis
UDHR
Universal Declaration of Human Rights
UNDCP
United Nations Drug Control Program
URI
Upper Respiratory Infections
VHAI
Voluntary Health Association of India
VO
Voluntary Organisations
HEALTH CARE BEYOND ZERO
57
Appendix 2
Topographical Map: Location of HIGH
w
If
Ifl
landni
LAL QUILA
11 Vijay
[ Ghat
Lahori
Gate,z
♦’? =■
RED FORT
dni
HIGH
Outreach <
Health ?
x, Clinic
n,
cf »
3
a>
0
m.
Vijay
Ghat
!
Delhi
Gate
nil ya
Il Vttz
11 Jiss
Chi
Parda
Bagh
Iron
!
I
f
Camilla
Grounds
LEGEND
L Approach
' Routes to the Clinic
58
BEYOND
Delhi
Gate.
Map Not To Scale
ZERO
L .
Appendix 3
The HIGH Partners and Supporting Organisations
The Health Intervention Group for the Homeless is made up of the following partners:
Aashray Adhikar Abhiyan (AAA)
I
Aashray Adhikar Abhiyan (AAA), a programme of ActionAid India is a shelter rights
campaign for homeless people in Delhi founded in the year 2000. AAA believes that
homeless people (men, women and children) have the right to live in peace, dignity and
security just like other Delhi citizens. This belief is supported by the United Nations
Universal Declaration on Human Rights and the Indian Constitution. However,
homeless people s rights are violated every single day and night in the city of Delhi. They
are deprived of civic amenities such as water and sanitation; denied access to medical
treatment; forced to work for below the minimum wage; face daily beatings and
harassment from the police; and must sleep in the open because of a lack of shelter. AAA’s
aims are to empower, mobilise and strengthen the capacity of homeless people so that
they are able to assert their rights and live with honour and dignity; and to help the wider
public and government recognise that homeless people have inalienable rights and that
it is the responsibility of everyone to ensure these rights are protected.
Nodal person for HIGH
Jagdish Bhardwaje
Coordinator - Health
I
I
Paramjeet Kaur
Director
Aashray Adhikar Abhiyan
HIGH Secretariat, S-442, School Block, Shakarpur, Delhi 110092
Ph : 32368807 Email: righttoshelter@hotmail.com
Institute of Human Behaviour & Allied Sciences (IHBAS)
The Institute of Human Behaviour & Allied Sciences (IHBAS) is a multidisciplinary
institute which provides tertiary level services with a mix of primary and secondary care
in the form of community outreach programmes in psychiatry, neurology, behavioural
and allied sciences. The main emphasis of the institute has been to convert custodial care
into hospital care and finally to socio-therapeutic community or school for life. It is the
nodal agency for NCT of Delhi for drug de-addiction as well as for training social and
paramedical workers for drug de-addiction progranfmes.
IHBAS
Dr. Meena Gupta
Director
Dr. Nimesh Desai
Medical Superintendent
Institute of Human Behaviour and Allied Sciences (IHBAS )
Dilshad Garden , Post box -9520, Jhilmil, Delhi -110095, Ph: 22113395
E-mail: ngd2000@rediffmail.com
*
HEALTH CARE
i
I
BEYOND
ZERO
59
Sahara
Sahara, addresses the needs of chemical dependent persons through planned qualitative
programmes of treatment and rehabilitation. In addition, Sahara is involved in spreading
awareness of drugs and HIV/AIDS, its dangers and method of prevention on a regular
basis. Sahara provides long-term home based care for those people living with AIDS and
runs a hospice called Michaels Care Home for sero-positive individuals. Sahara’s
methodology is to first meet the individual’s need for treatment and then provide hope
and avenues for an alternative, healthy life. Sahara started as a pioneer organisation in
1978 and was registered as a non-profit NGO in 1985.
I
I
Sahara
Mr. Neville Selhore
Director
E-453, GK-11, Ph : 26219147
E-mail: sahara@nde.vsnl.net.in
I
SUPPORTING ORGANIZATIONS:
Dr. Shroff’s Charity Eye Hospital (SCEH)
Dr. Shroff’s Charity Eye Hospital (SCEH) began in 1914 with the setting up of an Eye
Clinic for the needy in Daryaganj. Since 1999 through their outreach programme nearly x
2000 poor patients have been brought from Delhi and adjacent villages for sight restoring
surgery at SCEH.
Dr. Shroffs Charity Eye Hospital
Dr Stevens Roy, CEO
5027 Kedar Nath Road, Daryaganj
Delhi-110002
Ph:23251564
shroffhospital@vsnl.com
I
Delhi House Seva Ashram (DHSA)
Delhi House Seva Ashram (DHSA) is a multi-branched community dedicated to the
practical application of spirituality to the reality of suffering, present among destitute, sick
and dying homeless, street children and slum dwellers of Delhi. As such it focuses on handson service, community intervention, and action for relief from conditions and structures
that perpetuate dehumanization of the most vulnerable of the poorest of the poor.
I
Delhi House Seva Ashram
Gaby Gerlach
Kashra No.47/25> Krishna Nagar
Singhu Border Road, Narela, Delhi -110040 Ph : 27783256
E-mail: Gaby@delhihouse.org
60
HEALTH CARE
BEYOND
ZERO
*
1
19
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3
Appendix 5
Outreach Health Service in Operation :
Drug Abuse Treatment Outreach
A combination of pharmacotherapy and psychosocial therapy is undertaken in the drug
de-addiction outreach. The pharmacotherapy consists of prescribing patients a combination
of Proxyvon, Diazepam and Brufen. These drugs are used for the amelioration of
withdrawal symptoms (detoxification); decline of craving and prevention of relapse, and
restoration of normal physiological functions.
About six months after the start of the de-addiction outreach programme, it was found
that almost a third of patients coming to the clinic were substance dependants. However,
there was some concern that some of the patients were not practising abstinence and were
taking the prescribed medicine along with drugs or selling the medicines. As a result of
these concerns, psychosocial therapy in the form of group sharing/counselling was set
up in May 2001.
The group sharing counselling is run by former drug users and held every Wednesday
between 7-8pm in Urdu Park. Participants talk about their difficulties leaving drugs and
the problems they face in their daily lives. Together they try to find solutions to these
problems. Only those who participate in these sessions can get medicines from the HIGH
clinic. This rule has reduced the number of substance dependants coming to the clinic
dramatically. The decline in numbers is disappointing; however, it is thought that those
who are attending the sharing/counselling are more committed to giving up their
addiction.
This type of non-residential drug de-addiction outreach programme is particularly
challenging as many homeless people do not have an alternative to drug use, such as
meaningful employment, or family support and are unable to return to a drug free
environment but have to go back to the streets.
Over two years, 1158 drug users have participated in the sharing sessions
62
HEALTH CARE BEYOND ZERO
I
1
-?*1
.•At
Appendix 6
Format of Form : Patients with General Health Problems and Psychiatric lllnessess
Regn. No
Date
PATIENT
REGISTRATION FORM
200
ftH.I.G.O
■ »»NCE aooo
Name
Father's/Husband's Name
Dept
Age
General/Psychiatry
0-10
1
11-20 2
Graduate
Religion
Hindu
1
Marital Status
31-40 4
2
Sikh
Unmarried
1
Married
India
Nepal
1
Delhi LU UP
3
2
51-60
6 61-70
7
Female
2 Eunuchs 3
Over 70 8
Unknown 99
Sec. 10 |_4
H. SC 11-12 | 5 |
f~7~| Functional Literacy [V]
4
Christian
2
1
Male
Middle 6-9 | 3 [
Postgraduate
|~6~[
Muslim
Nationality
41-50 5
Primary class 1-5 |
Illiterate | 1 j
Education
3
21-30
Gender
Other
Separated 3
Divorced
3
Pakistan
Bangladesh
4
4
Widowed
5
Unknown 99
5
Unknown 99
Other
5
[_3j Bengal |_4j Maharastra |_sj Rajasthan |_ej
Bihar
MP
State of Origin
U Punjab |~8~| Haryana |~8^
Punjab [~9~[ Assam
Unemployed | 11Rickshaw puller | 2 | Hawke?
Occupation
Restaurant worker [7] Domestic worker
Other
| 4 | Ragpicker |_sj
3| Labourer
I
Beggar 6
Construction worker |~F|I
4
2501-3000
£
1501-2000
£
Over 3000*
8
501-1000
3
2001-2500
6
Unknown
99
‘Specify
Jama Masjid
1
Ajmeri Gate
7
Jamuna Bazaar
2
Naopul
8
Daryaganj
9
Chandni Chowk
J
Other place in Old Delhi
Turkman Gate
~ Other place beyond old Delhi
£ Old Delhi Shelter
£ Old Delhi Temp. Shelter 11
Delhi Gate
6
Old Delhi Rly st.
New Delhi Temp. Shelter 12 Unknown
Office use only
Follow up: (1) 1-5 (2)6-10 (3) 11-15
Follow up:
® HIGH, Delhi 2002.
~
(4) 16-20
0
2
1001-1500
1-500
Sleeping Area
Loader
pH
No income
Income
[T
[io| Other
(5) 21-25
0
[99
(6) More than 25 visits
(7)
“
HEALTH
CARE
BEYOND
b
ZERO
63
Duration
Complain:
[
Family/Personal Histor:
Yes/No
Psychiatric Illness:
Specify, if required:
Past History
Yes/No
Psychiatric Illness:
Specify, if required:
Physical Examination
Psychiatric Illness:
Yes/No
Specify Physical Problem:
Mental State Examination
Psychiatric Illness:
Yes / No
Specify Problem:
Provisional Diagnosis-Psy
Provisional Diagnosis-Gen
No Illness
Anaemia
Arthritis
Back Problem.
Fracture
Joint Pain
Heart Problem.
Respiratory
Skin
Muscular Pain
Nerve Pain
Vertigo
STD/STI
AIDS
TB
0
1
2
3
4
jT
6
7
8
9
10
11
12
11
14
Nausea/Vomiting
Cold & Fever
Malaria
Dental Problem
Ear Problem.
Throat Problem.
Eye Problem.
Gastro Int.Trck. Inf.
Haemorroids
Hepatitis
15
16
17
18
19
20
Worms
Testicular Problem.
Urinary Tract Infection.
Injuries/Wound
Unknown
21
2L
AL
22
23
24
2?
21
29
Organic Mental Disorders
Mental and Behavioural Disorders due to substance use
Schizophrenia & related Disorders
Psychosis
Bipolar disorder, incld. Manic episode
Depression, incld. Manic episode
Anxiety Disorder
Somatoform Disorder
Adjustment Disorder/Severe Stress
Disassociative Disorder
Psychosexual Disorder
Dhat Syndrome
Mental Retardation
Childhood Psy. Disorder (Onset before 16 years)
Other (Specify):
2^
_4_
_5
6
7
8
9
10
11
12
11
14
15
Final Diagnosis (If same as Prov. Diagnosis specify code only)
Treatment Advd. Psy.
Treatment Advd. Gen
Pharmacological Treatment
(as per prescription)
Non Pharmacological Treatment
(as per prescription)
□
s
Phclg. Agt used
Anti Psychotics
Anti Depressants
Anti Anxiety
Anti Epiliptics
I
Mood stabilizers
Opridagonists
Subt. Plan. S. Abuse
Suppt. Plan: S. Abuse
Adjunctive Medicines
Other
!
Non Pharmacological Treatment
Psychoeducation
FT
Counselling
2
Supportive psycho-thpy jj
Behavioural Advice
Other
a
_________
Referrals (with reason)
Doctor’s Signature
I Doctor's Name:______
Date:
©HIGH, Delhi2002.
64
HEALTH CARE
BEYOND
ZERO
Patient
Regn. No.
PRESCRIPTION
DATED
PRESCRIPTION
DATED
PRESCRIPTION
DATED
PRESCRIPTION
DATED
DOSES
DOSES
DOSES
k
DOSES
Summary of follow-up evaluation till date. (Important observations)
i
©HIGH, Delhi2002.
HEALTH CARE BEYOND ZERO
65
*
Appendix 7
Format of Form : Patients with Substance Dependence
PATIENT
REGISTRATION FORM
Regn. No.
Date
200
SH.I.G.HJ?
2000-
Name
Father's/Husband's Name
Gender
Male
1
Female
11-20 2 21-30 3 31-40 4 41-50 5 51-60
6 61-70
7
Over 70 8
Dept. Substance Dependence
Age
0-10
1
Education
Religion
Primary class 1-5 | 2 |
Graduation
Pel
Marital Status
Nationality
Sikh
Muslim 2
1
Unmarried 1
India
1
Occupation
Income
CARE
Divorced
2 Separated 3
Married
1^ Delhi
2 MP
UP
W. Bengal 3 Assam
5
Unknown 99
98 Unknown 99
7_
8
Other.
]98
6
Punjab
9
Unknown
[99
Restr. Wrkr.
Domestic Wrkr.
7^
8
Loader
Other .
Beggar
6
Const. Wrkr.
9
Unknown
4
5
2501-3000
Over 3000*
2
501-1000
3
2001-2500
6
Unknown
99
Jama Masjid
Jamuna Bazaar
Chandni Chowfc
2 Ajmeri Gate
Old Delhi Rly st.
Turkman Gate
£
Delhi Gate
8
Other place in Old Delhi
13
8
9
5
Old Delhi Shelter
Old Delhi Temp. Shelter
10
11
6
New Delhi Temp. Shelter 12 Unknown
(3) 11-15
(4) 16-20
10
98
99
‘Specify
Naopul
Daryaganj
3
Unknown 99,
Other
5
2
98
Maharastra
Rajasthan
1001-1500
1501-2000
ZERO
Unknown 99
4_
5
1^
2
BEYOND
4 Widowed
Labourer
Ragpicker
Office use only
Follow up: (1) 1-5 (2)6-10
Follow up:
HEALTH
Other
No income
1-500
Sleeping Area
66
4
Nepal 2 Bangladesh 3 Pakistan 4
Unemployed
Rkshw. puller 2
Hawker/vendor 3
3
Middle 6-9 | 3|
Christian
3
Bihar
State of Origin
Eunuchs
H.sc 11-12 I 5
Sec. 10 4
Postgraduate p/l Functional Literacy | 8
Unknown
Illiterate | 1 |
Hindu
2
(5)21-25
Other place bynd. Old Delhi------
{99
(6) More than 25 visits (7)
© HIGH, Delhi 2002.
FOR PATIENTS OF SUBSTANCE DEPENDENCE ONLY
Drug(s) in current use
Street Name of
Drugs in use:
None
Smack
Buprenorphine
Codeine
Proxyvon
Doda
Benzodiazepine
1_ Cannabis
2^ Alcohol
99 Tobacco
Inhalants
Multiple
Withdrawal
Symptoms:
Yes
No
Unknown
1
i
,1
Route:
Inhaling
Injecting
Both
Oral
Unknown
2.
3
_4
99
Antihistamine
Promethazine
Avil
Other
Unknown
Duration:
0
1
2^
3
Frequency:
9
10
11
12
13
14
98
99
Drug(s) used in past
Duration:
Street Name
of Drugs
1
None
Smack
1
Buprenorphine
2^
Codeine
Proxyvon
Withdrawal
Doda
5
Symptoms:
Benzodiazepine 6
Yes
Cannabis
7_
No
Alcohol
Unknown
99 Tobacco
9
Inhalants
10
Route:
Multiple
11
Inhaling
Antihistamine
12
Injecting
Promethazine
13
Avil
Both
14
Other
98
Oral
_4
Unknown
99
Unknown 99
2
I
-I
Injection use:
Needle sharing now:
Needle sharing past:
Not applicable _1_
No
99
Not applicable
No
Yes
Frequency:
Less than a week
15-30 days
2- 6 months
7-11 months
1 -2 years
3- 5 years
6- 10 years
11-15 years
16- 20 years
over 20 years
Unknown________
Once daily
2 times a day
3 times a day
More than 3 tms. dly.
3 times a week
Once a week
Once in a fortnight
Once in a month
Dly. no. unknown
Other
Unknown
Less than a week
15- 30 days
2- 6 months
7- 11 months
1 -2 years
3- 5 years
6-10 years
11-15 years
16-20 years
over 20 years
Unknown_________
Once daily
2 times a day
3 times a day
More than 3 tms. dly.
3 times a week
Once a week
Once in a fortnight
Once in a month
Dly. no. unknown
Other
Unknown
0
1
2
Unknown 99
Yes
1
Unknown 99
1
2
_3_
4
_5_
6
7
8
9
10
99
1
2
3
4
5
6
7
8
9
98
99
1_
2
3
4
5
6
7
8
9
10
99
1
2
3
4
5
6
7
8
9
98
99
Typl. Intake Qty:
Less than 1 gm
1 -2 gms
3-4 gms
5-6 gms
7-8 gms
9-10 gms
More than 10 gms
Unknown
2
11-15
16-20
21-25
Ji
4.
5
0
1
2
Not applicable
Less than 1 gm
I- 5 gms
6-10 gms
II-15 gms
16-20 gms
21-30 gms
Over 30 gms
x Unknown
3
4
5
6
7
99
Typl. Intake Qty:
Less than 1 gm
1 -2 gms
3-4 gms
5-6 gms
7-8 gms
9-10 gms
More than 10 gms
Unknown
1
2
3
4
5
6
7
99
Heaviest Intk. 1 day:
0
1
2
3
Not applicable
Less than 1 gm
I- 5 gms
6-10 gms
II-15 gms
16-20 gms
21-30 gms
4
5
6
7
99
Over 30 gms
Unknown
Method of abstinence
|Yes/No|
No. of attempts
5
6
7
99
Heaviest Intk. 1 day:
Attempts of abstinence - past
None
1-5
6-10
1
2
3
4
5
26-30
Unknown |99
Not applicable
On own
With medical help
Unknown
0
1
2
99
©HIGH, Delhi2002.
HEALTH
CARE
BEYOND
ZERO
67
Drug(s) used last on
Date:
Time:
Primary drug
of abuse
Other drug of abuse
Drug related problems
Drug related health problems
am / pm
None
Daily
Weekly
F. Nightly
Monthly
Yearly
Unknown
Seizures
Frequency
0
1
2
3
4
5
99
Not applicable 0
Less than 1 month 1
6 month 2
1 year 3
More than one year 4
Unknown 99
Specify
None 2
Job loss 3
Irregular job 4
Ineffective sex 5
Financial debt 99
Physical fights 99
Police arrests 99
Marital problems 99
Family problems 99
______ Other 99
Unknown 99
Current Illness
Specify
None 0
Abcesses 1
Seizures 2
Gangerene 3
HIV/AIDS 4
Accidents 5
Cough 6
Septicaemia 7
------ Other 98
Unknown 99
Regn. No:
PRESCRIPTION
DATED
DOSES
DATED
DOSES
*
PRESCRIPTION
I
I
©HIGH, Delhi2002.
68
HEALTH
CARE
BEYOND
ZERO
Patient
I
Regn. No:
PRESCRIPTION
DATED
PRESCRIPTION
DATED
PRESCRIPTION
DATED
PRESCRIPTION
DATED
DOSES
DOSES
!
i
||
DOSES
DOSES
I
I
Summary of follow-up evaluation till date. (Important observations)
<S)HIGH, Delhi 2002.
HEALTH CARE BEYOND ZERO
69
Appendix 8
List of Medicines Used in the HIGH Outreach Health Clinic 2000-2002
S.No. Generic name ofdrugs
Brand Name of Drugs
Category
Schedule
1.
2.
Tab. Acetylsalicylic acid - 325mg
Disprin
Non Opioid Analgesic
Schedule-H
Tab : Activated charcoal fungal
diastase pain
Unienzyme
Digestive Enzyms
Preparation
Schedule-H
3.
Tab. Albendazole - 400mg
Zentel
Anthelmintic
Schedule-H
4.
Cap. Amoxycillin - 250/500 mg
Mox - 25O/5OOmg
Antibiotic
Schedule-H
5.
Tap. Atropine Sulphate - 0.025 +
diphenoxylate - 2.5 mg
Lomotil
Carminative
Schedule-H
6.
7.
Lotion Benzyl benzoate
Lotion Benzyl benzoate
Antiscabies
Schedule-H
Oint. Povidone Iodine
Betadine Cream
Broad Spectrum
Microbicidal
Schedule-H
8.
Cream Betamethasone + Neomycin
Betnovate -N Cream
Topical Steriod
Schedule-C
9.
Tab. Bisacodyl sodium - 5mg.
Tab. Dulcolax - 5mg
Laxative
Schedule-H
10. Tab. Calcium Carbonate - 500 mg
Tab. Shelcal
Nutrient
Schedule-H
11. Tab. Carbamazepine - 200/400 mg
Tab Tagretal-200/400mg
Antiepileptic
Schedule-H
12. Tab. Cetrizine - 10 mg
Tab. Antrizine/trizine-lOmg Antihistaminic
13. Tab. Chloroquine Phosphate - 250 mg
Tab. Larlago - 250 mg
14. Tab. Chlorphenaramine Maleate -4mg
Atnihistaminic
Tab CPM
Tab. Chlorpromazine-lOOmg Antipsychotic
15. Tab. Chlorpromazine - 100 mg
Antimalarial
Schedule-G
Schedule-H
Schedule-G
Schedule-H
16. Tab. Dextropropaxyphene +
Acetaminophen - 65mg + 500mg
Proxyvon
Opioid and Non Opioid
Analgesic
Schedule-X
17. Tab. Diazepam - 5mg
Tab. Valium - 5 mg
Antianxiety
Schedule-H
18. Tab. Diclofenac Sodium - 50 mg
Tb. Voveron - 50mg
Non Opioid Analgesic
Schedule-H
19. Tab. Domperidone - 10 mg
Tab. Domstal - 10 mg
Antiemetic
Schedule—H
20. Tab. Etophyiline +
Theophylline - 77 mg + 23 mg
Tab. Deriphyline
Bronchodialator +
Mastcell Stabilizer
Schedule-H
21. Cap. Fluoxetine HCL -20mg
Cap. Fludac - 20mg
Antidepressant
Schedule-H
22. Tab. Fluphenazine - 1 mg
Tab. Anatensol
Sedative amid Tranquillizer
Schedule-H
23. Inj. Fluphenazine Decanoate-25mg/ml
Inj. Prolinate
Sedative and Tranquillizer
Schedule-H
24. Tab. Frusemide - 40mg
Tab. Lasix
Diuretic
Schedule-H
25. Tab. Furazolidone + Metronidazole
Tab. Dependal - M
Drugs used in protozoal
Infestations
Schedule-H
26. Inj. Gentamycin
Inj. Garamycin
Antibiotic (Broad Spctrum) Schedule-H
27. Eye Drop Gentamycin
Gentycin Eye Drop
Antibiotic (Broad Spctrum) Schedule-H
28. Tab. Haloperidol - 5mg
Tab. Haloperidol - 5mg
Antipsychotic
Schedule-H
Table contd.
70
HEALTH
CARE
BEYOND
ZERO
fltt-
S.No. Generic name ofdrugs
I
I
29. Tab. Ibuprofen-400mg
Brand Name ofDrugs
Category
Schedule
Tab. Brufen-400mg
Non Steriodal
Antiinflammatory Drug
Schedule-H
Nutrient
30. Cap. Iron (Ferrous Sulphate)-!50mg
Cap. Fefol
31. Tab. Liv - 52
Liv - 52
32. Tab. Metoclopramide - lOmg
Tab. Perinorm
33. Tab. Metonidazole — 400 mg
Tab. Tab. Metrogyl-400 gm
34. Tab. Mutivitamins
Tab. Multi-Aid
Schedule-H
Hepato Biliary Preparation Scheule-H
Antiemetic & Antinauseatic Schedule-H
Anthelmintic
Schedule-H
For Prophylactic use
Schedule-Cl
35. Tab. Nimesuilde
Tab. Nise
36. Tab. Norfloxacin - 400 mg
Tab. Norflox
37. Tab. Paracetamol - 500 mg
Tab. Pacimol
38. Tab. Phenytoin Sodium - lOOmg
Non Opioid Analgesic
Schedule-H
Tab. Eption
39. Tab. Ranitidine - 150 mg
Antiepileptic
Schedule-H
Rab. Rantac
40. Tab. Salbutamol - 4mg
Anti ulcer
Schedule-H
Tab. Asthaline — 4mg
Bronchodilator and
Mast Cell Stabilizer
Schedule-H
Tab. Septran
Sulphonamid
Schedule-H
Inj. Tet-vac-0.5ml
Vaccine for Tetanus
Schedule-C&Cl
Tab. Tiniba
Anthelmintic
Schedule-H
41. Tab. Trimethoprim - 80mg +
Sulphamethoxazole - 400mg
42. Inj. TetanusToxoid - 0.5ml
43. Tab. Tinidazole - 500mg
Schedule-H:Warning: To be sold by
retail on the prescription of a RMPs only.
Non Opioid Analgesic
Schedule-H
UTI Infections,
Antidiarrhoeal Antiinfective Schedule-H
Schedule-G: Caution: It is dangerous to
take this prepartion except under
medical supervision
Schedule-X: Warning: To be sold by
retail on the prescription of a RMPs only.
Schedule-C: Vitamins and preparations
containing any vitamin not in a form
to be administered parenterly.
HEALTH CARE BEYOND ZERO
71
Appendix No. 9
Inventory of Logistical Requirements of Outreach Health Clinic
□ Van - One
□ Banners - Two
□ Medicine Box - One
□ Box for Storing Registration Forms — One
I
□ Doctors’ equipment Box (small)
□ Folding table for medicine distribution and registration counter - Two
□ Folding canvas camp chairs - Ten
□ Plastic stools - Ten
□ Plastic jars for medicine (assorted sizes) — Thirty
□
Plastic trays for multiutility - Six
□ Spot lamp with stand with automotive 12V batteries for each lamp - Three
□ Wooden container for transporting the lamps — One
□
Container for drinking water - One
□ Large flask for tea (for staff) - One
□ Clip Boards — Ten
□ Polyvinyl canopy/Plastic sheeting required during monsoons
♦♦♦ Contents of Doctors* equipment box
•
•
•
•
•
•
•
•
•
72
HEALTH
CARE
BEYOND
Stethoscope - Three
Blood Pressure Instrument - Two
Rechargeable torch — Two
Otoscope - One
Injection box: 6 disposable syringes, small bottle of methylated spirit,cotton
Liquid soap dispenser - One
Hand towels - Two
Writing Pens
Doctors’ note pad
ZERO
I
Appendix 10
List of Clinic Personnel
Registration Counter
i
• Volunteer to facilitate New Registration of General and Psychiatric Patients - One
• Volunteer to facilitate Re-admission of Substance Dependent Patients - One
• Volunteer to facilitate Re-admission of old Patients and card sorting - Two
Consultation Area
• Volunteers to facilitate sharing session of substance dependents’ prior to treatment
• Volunteers to maintain queue for General, Psychiatric and Substance
Dependent Patients
Dispensary
• Full Time Health Community Worker - One
• Trained Nurse - One
• Volunteer to assist in queue-up and explain the dosage
Professional Personnel
• Psychiatrists - Three
• General Psysician - One
HEALTH CARE
BEYOND
ZERO
73
Appendix 11
Tables: Patients with General
Health Problems
Table 3.1: AGE GROUP
(N=2955)
Age in Years
No. of Respondents
of Respondents
0-20
816______
________ 27.70________
21-40
1476
________ 50.10________
41-60________________
^60
555
________ 18.84________
Information Not Available
________ 9_______
99_______
Total
3.36
2955
100.00
Table 3.2: SEX
Sex
No. of Respondents
Males
2737
________ 94.57
Females
157
5.42
Information Not Available
61
Total
%age of Respondents
2955
100.00
No. of Respondents
of Respondents
Table 3.3: MARITAL STATUS
Marital Status
Married
672______
Unmarried
949
58.44
________ 3
0.18
Others
________ 41.38
Information Not Available
1131_______
Total
2955
100.00
No. of Respondents
of Respondents
Table 3.4: RELIGION
Religion
Hindu
1529
________ 52.58
Muslim
1364_______
_______ 46.90
Sikh
Christian
Information Not Available
Total
74
HEALTH CARE. BEYOND
*
Z.ERO
________ 2_______
13
'
0.07
0.45
47_______
2955
100.00
r
Table 3.5: EDUCATION
Educational Qualification
No. of Respondents
o/oage of Respondents
Illiterate_______________
Primary
Middle
Sec/Hr.Sec_____________
Graduation
285
203_____
207_____
_____ 86_____
_____ 5
2169_____
2955
36.26
25.83
________ 26.34
________ 10.94
0.64
No. of Respondents
°/oage of Respondents
Information Not Available
Total
100.00
Table 3.6: SLEEPING AREA
Name of the Area
Jama Masjid____
Yamuna Bazaar
Chandni Chowk
Turkman Gate
Ajmeri Gate_____
Naya Pul
Darya Gunj_____
Old Delhi
New Delhi______
Other (part of periphery of old Delhi)
Information Not Available
Total
777
184_____
52
41 _____
4
34
42 _____
74
16
911
820
2955
________ 36.39
_________ 8.62
_________ 2.44
________ 1.92
_________ 0.18
_________ 1.59
_________ 1.97
_________ 3.47
_________ 0.74
42.68
100.00
Table 3.7: STATE OF ORIGIN
Name of the State
No. of Respondents
%age of Respondents
Bihar
UP
West Bengal_______ •
Delhi
MP
Maharashtra
Rajasthan____________
Assam
Punjab
Other
Information Not Available
Total
400_____
647_____
125
79
71_____
42
_____42_____
37
_____22_____
185
1305
2955
________ 24.24
________ 39.21
_________ 7.58
_________ 4.78
_________ 4.31
_________ 2.55
_________ 2.55
_________ 2.24
_________ 1.33
11.21
100.00
HEALTH
CARE
BEYOND
ZERO
75
Table 3.8: COUNTRY OF ORIGIN
Name of the Country
No. of Respondents
of Respondents
1059
105
4
0
1787
2955
90.67
8.99
0.34
0.00
100.00
Type of Occupation
No. of Respondents
%age of Respondents
Unskilled
Skilled
Unemployed
Information Not Available
Total
1432_____
_____ 88_____
93
1342_____
2955
India
Nepal
Bangladesh
Pakistan
Information Not Available
Total
Table 3.9: OCCUPATION
88.78
5.45
5.77
100.00
Table 3.10: MONTHLY INCOME
Monthly Income (in Rs.)
No. of Respondents
%age of Respondents
Nil
1310
50.81
1-1000
447
17.34
1001-2000
589
22.85
2001-3000
209
8.11
>3000
23
0.892
Information Not Available
377
Total
2955
I
100.00
r
L
”1
k
76
HEALTH CARE BEYOND ZERO
1
Table 3.1 I: DIAGNOSIS
Health Problem
Orthopedic______________
Respiratory______________
Skin_____________ _______
STD____________________
TB______________________
Malaria__________________
Dental__________________
ENT
_____________
EYE____________________
GIT____________________
Wounds_________________
Unspecified______________
Pregnancy_______________
Other___________________
Information Not Available
Total
No. of Respondents
87
568
159
32
51
51
24
46
61
88
98
_____ 5
539
943
2955
°/oage of Respondents
4.32
_________ 28.23
__________ 7.90
__________ 1.59
__________ 2.54
__________2.54
__________ 1.19
2.27
__________ 3.32
203______________ 10.10
__________ 4.37
__________ 4.87
__________ 0.25
26.79
100.00
Table 3.12: DURATION OF ILLNESS
Duration of Illness
No. of Respondents
793
559
204_____
193_____
1206_____
2955
0-30 days________________
2-11 months_____________
1-5 years________________
>5 years_________________
Information Not Available
Total
%age of Respondents
45.34
_________ 31.96
_________ 11.66
11.04
100.00
Table 3.13: REFERRALS
Hospitals Referred to
IHBAS__________________
LNJP___________________
SHROFFS_______________
Other________ ___________
Information Not Available
Total
No. of Respondents
60
^oage of Respondents
_________ 24.0
124____________ 49.6
_________ 13.6
_____ 34_____
12.8
32
2705
100.00
2955
Table 3.14: FOLLOW UP VISITS
Follow up Visit
No Follow-up Visit
1-5 Visit
>5 Visit
Information Not Available
Total No of visit
No of Follow up visits
2303
1328
180
3811
Percentage of visits
60.430
34.846
4.723
100.00
HEALTH CARE BEYOND ZERO
77
Appendix /2
Tables: Substance Dependent Patients
Table 4.1: AGE GROUP
(N = 1184)
Age in Years
No. of Respondents
1-20
°7oage of Respondents
84
________ 7.68_________
._____________
783
_______ 71.64_________
41-60________________
213
19.49
>60__________________
13
1.19
Information not available
91
21-40
Total
1184
100.00
Sex
No. of Respondents
%age of Respondents
Males
1134
98.95
Females
12
1.05
Information not available
38
<•
Table 4.2: SEX
Total
1184
100.00
No. of Respondents
%age of Respondents
Table 4.3: MARITAL STATUS
Marital Status
Married
Unmarried
Other
Information not available
Total
291
653
50
190_____
1184
2^.27
•
65.70
5.03
100.00
Table 4.4: RELIGION
Religion
No. of Respondents
°d>dge of Respondents
Hindu
611
54.45
Muslim
503
_______ 44.83
Sikh
3
________ 0.27
Christian
_5
0.44
Information not available
62
Total
78
HEALTH
CARE
BEYOND
ZERO
1184
100.00
I
Table 4.5: EDUCATION
Qualification
No. of Respondents
Non-Illiterate
633
133
127
50
9
232
1184
Primary
Middle
Sec/hsc
Graduation
Information not available
Total
%age of Respondents
_______ 66.49
_______ 13.97
_______ 13.34
________ 5.25
0.95
100.00
Table 4.6: SLEEPING AREA
Sleeping Area
Jama Masjid
No. of Respondents
_______ 81_______
Yamuna Bazaar
161
Chandini Chowk
23
18
19
8
14
58
Turkman Gate
Ajmeri Gate
Naya Pul
Darya Gunj
Old Delhi
22.15
3.16
2.48
2.61
1.10
1.93
7.98
0.96
100.00
No. of Respondents
%age of Respondents
Other ______________
Information not available
I
11.14
__ 7
338
846
1184
New Delhi
!
%age of Respondents
Total
46.49
Table 4.7: COUNTRY OF ORIGIN
Name of the Country
India _____ _________
730
_____97.99
Nepal
11
________ 1.48
__ 3
1
439
1184
0.40
Bangladesh
Pakistan
Information not available
Total
0.13
100.00
HEALTH CARE
BEYOND
ZERO
79
Table 4.8: STATE OF ORIGIN
Name of the State
No. of Respondents
of Respondents
10.19
43.39
8.67
20.25
2.34
Bihar
74
UP
Delhi
315
63 .
147
MP
17
Mahasrashtra
Rajasthan
23
14
Assam
7
Punjab
17
1.93
0.96
2.34
Other
49
6.75
Information not available
458
Total
1184
West Bengal
3.17
100.00
Table 4.9: OCCUPATION
°f Occupation
No. of Respondents
of Respondents
Skilled
166
_______ 23.41
Unskilled
365
51.48
Unemployed
25.11
Information not available
178
475
Total
1184
100.00
No. of Respondents
%age of Respondents
0
42.19
1001-2000
99
186
8.74
16.42
2001-3000
338
29.83
>3000
32
2.82
51
1184
100.00
Table 4.10: MONTHLY INCOME
Monthly Income (in Rs.)
No Response
1-1000
Information not available
Total
80
HEALTH CARE BEYOND ZERO
Table 4.11: PRIMARY DRUG OF ABUSE
Primary Drug of Abuse
Smack
____________
Buprenorphin_________
Alcohol____________
Cannabis___________ __
_Other____________ __
Information not available
Total
No. of Respondents
%age of Respondents
967
116
17
16
_______ 17
51
1184
85.35_________
_______ 10.24_________
________ 1.50_________
________1.41_________
1.50
100.00
Table 4.12: SECONDARY DRUG OF ABUSE
Secondary Drug of Abuse___ No. of Respondents
Buprenorphine___________ __________72_______
Tobacco____________
43_______
Cannabis__________________________ 38______
Alcohol_______________
34_______
Other_____________________________ 85______
Information not available
912
Total
1184
o/oage of Respondents
_______ 26.48
_______ 15.80
_______ 13.97
_______ 12.50
31.25
100.00
Table 4.13: DURATION OF USE
Duration in Years_________ No. of Respondents
<lyr___________________________ 165________
1-5 yr_________
198_______
6-10 yr ___________
164_______
>10 yr_________
236_______
Information not available
421
Total________
1184_______
%age of Respondents
_______ 21.63_________
25.95_________
_______ 21.49_________
30.93
100.00
Table 4.14: SUBSTANCE DEPENDENCE
Duration in Years___________ No. of Respondents
Past ____________________________ 73_______
Present______ ________ » ________ 121_______
Information not available
990
Total____________________ 1184______________
°/oage of Respondents
_______ 37.63
62.37
100.00
Table 4.15: FREQUENCY OF USE
Usage Number of Times!day
No. of Respondents
1-3_______________________________Z8
>3______________________ 67
Information not available
1039
Total________________ _________ 1184________
%age of Respondents
53.79_________
46.21
100.00
HEALTH CARE
BEYOND
ZERO
81
Table 4.16: USUAL DAILY INTAKE
Usual Daily Amount (in gms.) No. of Respondents
Voage of Respondents
<!
9
________ 6.08
1-2__________________
88
59.46
3-4
39
26.35
8
________ 5.40
5-6
____________
>6________________
4
'
2.70
Information not available
1036_______
Total
1184
100.00
No. of Respondents
°d>age of Respondents
Table 4.17: HEAVIEST INTAKE
Heaviest Intake (in gms)
<1
9
________ 6.16
l-5gm
120
_______ 82.19
11.65
>5gm_________________
17
Information not available
1038
Total
1184
100.00
No. of Respondents
Voage of Respondents
Table 4.18: REFERRALS
Hospitals Referred to
IHBAS_______________
21
_______ 63.64
LNJP_________________
___7
_______ 21.21
Others
___ 5
15.15
Information not available
1151
Total
1184
100.00
No. of Visits
Voage of Visits
Nil
684
26.91
Table 4.19: FOLLOW UP
Follow up
*
82
1-5
1389
54.64
6-10
356
14.01
>10__________________
113
444
Information not available
2542
Total
1184
HEALTH CARE BEYOND ZERO
100.00
r
Appendix 13
Tables : Patients with Psychiatric Illnesses
Table 4.1: DISTRIBUTION OF PATIENTS - with Mental Health Problems
No, of Respondents
_____________ (N = 34)
Qd>age of Respondents
CMDs
28
82.35
SMIs___________
5
________ 14.7
MR
1
2.94
Total
34
100.00
Common Mental Disorders
J
Table 4.2: COMMON MENTAL DISORDERS (CMD’s)
Common Mental Disorders
No. of Respondents
%gge of Respondent!
Dhat Syndrome
10
3571
Erectile Disorder
2
714
Anxiety Disorder *NOS
4
1429
Somatoform Disorder
3
1072
g
2g57
Hypochondriasis
13 57
Depression
Information not available
Total
6
34
100.00
Table 4.3: SEVERE MENTAL ILLNESSES (SMIs)
Severe Mental Disorders
No. of Respondents
°^oa^e of Respondents
Schizophrenia
2
_______ 40,00
Psychosis NOS
1
_______ 20.00
Epilepsy
2
40.00
Information not available
29
Total
34
100.00
*Not otherwise specified
r
HEALTH CARE BEYOND ZERO
83
Appendix 14
Participatory Reflection and Action (PRA) Tools
• Pair wise Matrix
With the help of this tool the indicators of the appraisal were identified. The participants
were asked to list the important criteria for an effective mobile health clinic. Through
this tool, the Health well-being ranking (to ascertain what homeless people consider ‘good’
health) emerged.
• Rank Scoring
This exercise identified the priority areas for any mobile heath clinic. The identified
indicators in the pair wise matrix were given scores on the basis of their importance
followed by a detailed discussion.
• Force Field Analysis
This exercise helped in identifying the factors that pull the homeless towards the HIGH
as well as the factors that restricts them from participating in the HIGH. It also identified
the areas of improvement along with the suggestions to make HIGH more effective.
•
Venn Diagrams
Through this exercise we were able to identify the needs of the homeless and the resources
available for them. It also highlighted the importance of the resource and reasons for the
inaccessibility to the homeless.
• Problem Matrix :
Through this tool problems in HIGH and their respective solutions emerged.
• Focus Group Discussion: A group of 10 to 12 persons, discussing the theme provided
to them.
• Observation: Non-participatory general observation of the functioning of HIGH Clinic
• In Depth Interview: Intensive, detailed interview about their perceptions of HIGH
Clinic
f
84
HEALTH
CARE
BEYOND
ZERO
<*b-
Appendix 15
Tables : Participatory Reflection and Action (PRA) Exercises
___________Table <= Scoring Matrix for Health Outreach
Indicators
Year Score 2000 Year Score 20021
Punctuality of the Clinic
Good behaviour by all Service Providers
Easy Accessibility
Quality of Medicines
Effectiveness of Treatment
Reduced Police Harassment
Follow Up
Appropriate & Permanent Location of the Clinic
Availability of Lab. Diagnostic Facility
Feeling of Belonging/Back up support of the
organisation
User Participation in the Clinic
Clinics Outreach to the Poor
Availability of Specialist Doctors
Availability of Ambulance
Availability of Effective Referrals
Arrangement of drinking water for Patients
i
10
10
10
9
9
8
9
9
6
6
6
6
*
5
4
4
*
4
0
2
1
*
0
• Indicator did not figure out in that exercise.
expS Obfel™1,i'in8 thC
U‘illly’lnd 'hC SCOP' f°r fUrthCr imProv'm'"'’ th' Palpatory exercise was adopted
i)
“!
in)
The participants listed down the indicators which form a good clinic.
]?crc wcrc
in
exercise but only 10 to 15 were selected for evaluation (as shown in Table 1)
They evaluated each indicator with all other indicators. This was done in order to give priority scoring.
Table 2: Scoring Matrix by Substance Dependents for Drug Outreach
Indicators
(
Availability of Free Treat)ment and Medicines
Suitability of Timings
Utility of Sharing Sessions
Sensitive Doctors
Prescription of medicines
Misuse of Medicines and Registration Cardsbythe Patients
Adequate Sitting Arrangements
Day Care Facility
Recovery of Patient with SubstanceDependence
Facility of Hospitalization
c
_______ ocore ________
2001
2002
*
*
g
*
*
2
1
0
10
10
10
10
9
7
6
0
*
Substance dependent patients were separately asked to score the effectiveness of the drug outreach including rhe sharing/
counselhng sess.ons and the outreach for patients with substance dependence, against the indicator provided during
tne group discussions.
r
6
HEALTH CARE BEYOND ZERO
85
Table 3 : Scoring Matrix of Effectiveness of Existing
Facilities at HIGH by HIGH team
Indicators
Quality of Medicines
Behaviour of Team
Appropriate Location of the Clinic
Dispensing of Medicines
Satisfaction Level of Patients
Punctuality of the Clinic
Doctors
Availability of Dressing Facilities
Effective Referrals
Consistency of Activities/Services
Availability of Free of Cost Treatment
Accessibility to the Clinic
Catchment Area of the Clinic
Awareness of Existence of the Clinic
Logistics (light, seating arrangement, etc)
at the Clinic
Trained and Competent Staff at the Clinic
Usefulness of Sharing Sessions
Scope for Expansion of the Clinic
Adequate Clinic Operation Days
Adequate Composition of Staff
Availability of Basic Medical Equipment
Timing of Registration & Clinic
Regular Source of Funding for the Clinic
Need Oriented Services
Voluntary Participation of Local Community
Availibity of Minor Surgical Items
Sensitising Leaders
Audio Visual aids for I.E.C
Regular Monitoring by the Community
CWs,
2002
9
8
8
8
6
6
6
5
0
♦
♦
♦
♦
*
♦
*
Score by
______ Doctors____
2001
2002
♦
8
8
7
♦
8
7
4
9
9
7
7
7
7
6
6
5
♦
*
♦
*
8
*
♦
*
u
4
7
*
8
8
6
7
5
8
7
7
7
7
7
6
5
4
2
2
‘Indicators not mentioned by the participants
The participatory exercises adopted are explained below:
>) The parucipants listed down the indicators which form a good clinic.
ii) There were many indicators in each exercise but only 10 to 15 were selected for evaluation (as shown in table 6).
iii) They evaluated each indicator with all other indicators. This was done in order to give priority scoring.
In order to decide the basis for evaluation, the patients were asked to list the factors that contributed to what they
considered to be good medical facility (tablel). There were two rounds of these exercises and the variables in each exercise
varied.
i)
Participants listed down indicators forming a good clinic.
ii) On the basis of listed indicators, participants scored HIGH on each indicator
iii) Final score was taken as an average of scoring of all the participants. Finally the score was rounded to the nearest number.
iv) Then each indicator and its scoring, was analysed by the participants. Emphasis was on the indicator scoring less
than 5. Simultaneously solution / suggestions were sought against them.
Indicators with a score of 2, were further discussed/ debated and solutions were prioritised with scoring for further action.
86
HEALTH CARE BEYOND ZERO
i
a,
Table 4: Scoring Matrix with
Heads / Coordinators of the Organizations
Indicator
Average Score
Consistency of the Clinic
Easy access and Utilisation of the Clinic
Punctuality of the Clinic
Follow-Up
Belongingness of the Clinic
Need Oriented Service (towards homeless)
Good Relation between Patients and Service Providers
Referrals
Financially and Organisationally sustainable
Sensitise Patients about Utilisation of Medicines
(not to sell, etc and to take medicines regularly)
Good Relation between Doctors and Patient
Encourage Patients to Return to Clinic
Participation of Community
Community Ownership
9
8
7
7
7
7
6
6
6
5
4
4
3
3l
The process of (his exercise was also the same as followed in the previous exercise.
Table 5 : Factors needed for the
smooth functioning of HIGH as a Network
Factor
Average score
Policy
3
5
5
Common Understanding
Information Sharing
Mutual Accountability
Problem Solving
Credit Sharing
Transparency
Mutual Respect
Cohesion
6
5
7
6
6
5
The participants (Heads of the particular organization/coordinator listed down the factors needed for the smooth
functioning of HIGH partner network and then scored them on a scale of 1-10
(
HEALTH
CARE
BEYOND
ZERO
87
Appendix 16
List of the Process Participants
PARTICIPANTS
Participatory Reflection and Action (PRA) Exercises
Health Needs Assessment Survey
Facilitation of PRA (With Patients)
I.
Aditya Nath J ha - (A. A. I)
Cherian K. Mathew - (A.A. I)
Dhananjay Tingal - (A.A.A)
Indu Prakash Singh - (A.A.A)
Jagdish Bhardwaje - (A.A.A)
Paramjeet Kaur - (A.A.A.)
Dr. Arvind Gupta - (IHBAS)
Dhananjay Tingal - (A.A.A)
Indu Prakash Singh - (A.A.A)
Jagdish Bhardwaje - (A.A.A)
Dr. K.P.Rana - (IHBAS)
Dr. N.G. Desai - (IHBAS)
Paramjeet Kaur - (A.A.A)
Pradeep Kumar - (N.A)
Shalini Vatsa - (A.A.A)
Dr. Sumeena (IHBAS)
A)
Babloo, Nirmal, Meena, Md. Ismail,
Mukesh, Raju, Ram Dhani, Sheela,
H. I.G.H — Evaluation
Shohaib
I.
Aditya Nath Jha - (A.A.I)
Cherian K. Mathew - (A.A.I)
Dananjay Tingal - (A.A.A)
Indu Prakash Singh - (A.A.I)
Jagdish Bhardwaje -(A.A.A)
II.
Dhananjay Tingal - (A.A.A)
Indu Prakash Singh - (A.A.A)
Jagdish Bhardwaje - (A.A.A)
Dr. N. G. Desai - (IHBAS)
Paramjeet Kaur - (A.A.A)
III.
Dhananjay Tingal - (A.A.A)
Jagdish Bhardwaje - (A.A.A)
Dr. N.G. Desai - (IHBAS)
Dr. N&rindra Singh - (IHBAS)
88
HEALTH CARE BEYOND ZERO
Participants of PRA Exercise on general
health problems
B)
Participants of PRA Exercise on
Substance Dependence
Bhanumati, Gopal, Navneet Singh
Pawan, Poonam, Rajinder, Ramesh
Ram Kishan, Rafiq and others
II.
Facilitation of PRA with Service Providers
Dhananjay Tingal - (A.A.A)
Indu Prakash Singh - (A.A.A)
Paramjeet Kaur -(A.A.A)
Trudy Brasell -(A.A.A)
III.
Participants of PRA (Heads and
Cordinators) of Partner Organisations
Indu Prakash Singh
Jagdish Bhardwaje
Dr. N.G. Desai
Sanat Shukla
&
1
...
WE NEED YOU!
|||||
■
r y:
’A'C-"
t-x--"
A-
-. ||
W
S
■
■
r
FI I /* orking with the homeless has been the most
A/A/rewarding time of our lives. Struggling to ensure access
AA to health, to the homeless, has been the most challenging
area of our work. But this work of ours became a joy,
for YOU ALL did support us.
As we enter a very crucial phase of reaching out to every
j
homeless person: children, women, men, destitute, disabled,
J
elderly, mentally ill; we know for sure that YOU ALL
U
are still there. And with YOU, the support of your friends,
jg
relations, staff too is there, for this work with the homeless.
We need YOU! Your further support will allow us to
accomplish our dreams, the dreams of the homeless.
Of a society where they are accepted as a citizen, where
they are nursed back to health, where they get empowered
to take health in their own hands, where the language of
speech is no longer the stick of the police, but the language
immersed in love and concern for them.
j® ■ ;
»
ffl
||
|||
J We express our gratitude to all of YOU.
Do join us. Do support us. Do be part of this campaign and
movement.
i gf
From all of us at the HIGH'.
Aashray Adhikar Abhiyan (AAA)
Institute of Human Behaviour and Allied Sciences (IHBAS)
and
Sahara
rL J/
BL .'
/
g . . . .p,..
_________
ogti
■
_______ i__
.■
■■
■■■
j
.
■.
■
■
.ilP: -
IsP
ive me ■he strength never to
is own th e poor or bend my knee?
herore the inso lent might.
. 11
-
p’-'
■■I '"'. till
';p'' 't-i it
Rabindranath Tagor
:■
■
. M.'7
lit
4
<p
cn
since 2000
■n ihbas raa
o
SAHARA
- Media
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