REPORT ON THE SOUTHERN REGION PUBLIC HEARING ON RIGHT TO HEALTH CARE
Item
- Title
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REPORT ON THE
SOUTHERN REGION PUBLIC HEARING
ON
RIGHT TO HEALTH CARE - extracted text
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REPORT ON THE
SOUTHERN REGION PUBLIC HEARING
ON
RIGHT TO HEALTH CARE
29th AUGUST 2004
Jointly Organised By
NATIONAL HUMAN RIGHTS COMMISSION (NHRC)
&
JAN SWASTHYA ABHIYAN (JSA)
Venue: ST. THOMAS INTERNATIONAL CENTRE
ST. THOMAS MOUNT
CHENNAI
♦
I
REPORT ON THE SOUTHERN REGION PUBLIC HEARING ON
RIGHT TO HEALTH CARE
CONTENTS
Introduction
3
Inaugural Session
3
Inaugural Address
4
Presentation on Mental Health
5
Public Hearing - Parallel Sessions
5
Key Issues and Recommendations
6
List of Annexures
1) Programme Schedule
10
2) List of oral and written testimonies / cases from the southern region
12
3) Details of cases from Andhra Pradesh
17
4) Details of cases from Karnataka
40
5) Details of cases from Kerala
71
6) Details of cases from Pondicherry
81
7) Details of cases from Tamil Nadu
86
8) Brief Note on Justice V. M. Tarkunde
100
9) Brief Note on Justice Anandi Bai
101
10) Some Visuals of the Southern Region Public Hearing
102
11) State Reports (Karnataka, Andhra Pradesh, Kerala and Tamil Nadu)
105
******
2
I
INTRODUCTION
The Southern Region Public hearing on the Right to Health Care is one step in a process to promote
health rights being carried forward by the National Human Rights Commission (NHRC) and Jan
Swasthya Abhiyan (JSA). The NHRC has been actively involved in promoting the issue of health rights
by conducting workshops and issuing recommendations on key health issues such as Maternal Anaemia,
HIV/AIDS, and Access to Health Care in the last few years. The Jan Swasthya Abhiyan, which is a
national level coalition of networks, voluntary organizations and people’s movements involved in health
care delivery and health policy, has been active on issues related to health rights since it’s formation
during the People’s Health Assembly process in the year 2000.
RATIONALE FOR ORGANIZING PUBLIC HEARINGS ON RIGHT TO HEALTH CARE
•
To mobilize communities around the issue of right to Health care and to create awareness
amongst local communities about the various health services which the government at
different levels should provide.
•
1 o document and highlight specific instances of denial of health care.
•
I o present testimonies that details the instances of denial of healthcare to public health
officials and expert panelists, and to emphasize the structural deficiencies in health facilities
underlying such cases.
To present the larger structural deficiencies related to the health system, based on surveys and
analysis of key health issues.
Establishing the Right to Health Care and ensuring access to quality health care for all is an important
step towards realising the goal of “Health for All”. With this perspective, JSA had organised a National
Consultation on the Right to Health Care in Mumbai on 6th September 2003. The 2003 consultation also
marked the 25th Anniversary of the Alma Ata Declaration. Over 250 delegates from different
organisations and rights based groups; working on health issues from 16 states across the country
attended this public consultation. Justice Anand, Chairperson of NHRC, delivered the inaugural address
for the programme and heard testimonies of various persons who had suffered serious ‘denial of health
care’. I Ins event also constituted the launching point of Jan Swasthya Abhiyan’s ‘Right to Healthcare’
campaign. Subsequent to this, NHRC in collaboration with JSA is organising a series of Regional Public
hearings to highlight the denial of health care, with a view to clearly establish and operationalise the right
to health care in the country. The Southern Region Public Hearing in Chennai was the second in this
series ot public hearings, while the first was the Western region Public hearing held at Bhopal.
INAUGURAL SESSION
The inaugural session was held in Justice Tarkunde1 Hall. It commenced with a iwelcome
’
address by Dr.
G.K. Pandian, JSA, Tamil Nadu. He highlighted the objectives of the Public Hearingj on the Right to
Health Care, which were:
1. Strengthening the public health system.
2. Removal of structural deficiencies in provision of health care.
3. Improving the quality of public health care.
4. Creating awareness among the public about their right to quality health care.
Dr. B. Ekbal, the National Convener of JSA, in his introductory remarks, expressed his happiness in
welcoming all the participants. He said that this public hearing was unique in that a Government body
was co-organising the Hearing with an activist group and people’s movement. He expressed his
1 For more information on Justice Tarkunde, please refer Annexure 8
3
happiness at the fact that three important groups i.e., the NHRC, senior government health officials and
the JSA had come together to make the public hearing possible.
He recalled the genesis of JSA, which was formed as an outcome of people’s groups from across the
country meeting in Calcutta for the first national Jan Swasthya Sabha during 2001, prior to the global
People s Health Assembly held at Dhaka. The people’s health charter was discussed and adopted. JSA
has been functioning since the last four years. The aim of the movement was to make health and access to
health care a basic human right for of all people. He reminded the gathering that Public Hearings would
be held in five regions of the country which would culminate in a National Conference at New Delhi in
December 2004.
INAUGURAL ADDRESS
Justice Y. Bhaskar Rao in his inaugural address spoke about the different aspects of health and its
implication on the well-being of the society. He also spoke about the legal obligation of the state to
safeguard the health needs of its populace. He called for a collaborative effort between the government
and the non-government organisations to bring about a change in the existing situation. He made some
key recommendations, including:
>
The Public Health System should guarantee health services to all as a right.
>
Drugs should be made affordable for the common people.
>
Drug price control policy should be sounder and any violation of it should be tackled strictly.
>
Social Responsibility of the private sector - It should mandated that private hospitals, as part of their
social responsibility, should reserve 20% of their beds for poor patients.
>
While referring patients, transportation facilities must be ensured.
>
Visits of Mobile Hospitals to the difficult areas, at least twice a month should be ensured.
>
Health check-up should be done in all schools twice a year and the report should be submitted to the
District Health Officer.
>
Dieticians should be consulted and involved in preparing a proper diet chart for various areas, and
that should be published and circulated widely and should given to all panchayats.
>
Patients with disabilities should be reported immediately so that they can be treated and rehabilitated.
Information regarding signs and symptoms of disabilities, especially in children, should be displayed
in all maternity homes and other places. Many a times, the cases become more critical due to lack of
knowledge in parents.
>
Gram Panchayats have to monitor the heath services of the village. A committee for monitoring the
same should be formed, which can then prepare quarterly reports about staff presence, availability of
facilities in rural health centers and the report must be sent to the District Collector and District
Health Officer for action.
>
Health Secretaries, Health Directorates and NGOs should form a monitoring body at state level to
take actions based on reports from the Panchayats. The Secretary to Government (Health) may be the
chairperson of the monitoring committee, and the report of the committee can be periodically
presented to the legislature.
4
Justice Bhaskar Rao concluded his address by saying that the Public Hearing had been organised to look
at cases of denial and to recommend future actions. He congratulated all the organisations who were
involved in organising the hearing and those who were participating in this process.
For the benefit of the local people the inaugural address by Justice Y. Bhaskar Rao was translated into
Tamil by Ms. Kalpana.
After a brief introduction about the Kannada book Arogya Kalajalha (a book of health songs and cultural
material) by Dr. Thelma Narayan, the second edition of the book was released by Justice Y. Bhaskar Rao
and the first copy was handed over to Smt. Lakshidevamma, a grass root level health worker from
Doddaballapur taluk, Bangalore Rural district.
PRESENTATION ON MENTAL HEALTH
A serious and often neglected issue which cut across all the states in the Southern region, and the country
as a whole was that of mental health. Mr. Naidu of Basic Needs, an organization working on mental
iiealth in different parts of the country made a presentation on mental health issues. He highlighted the
various issues related to mental health including:
a)
b)
c)
d)
e)
f)
g)
h)
Shortage of psychiatrists and mental health professionals and centralisation of services.
Lack of trained human resources
Short duration of mental health posting for doctors during their training period,
No alternatives in mental health
Non availability of drugs
Physica l and sexual abuse of the menial health patients
Corruption in mental health facilities and
Stigma attached to mental illness, etc.
Me proposed that the right to mental health care should encompass:
•
•
•
Availability of essential drugs at the primary health center (PHC) level for the treatment of mental
health problems.
Primary health doctors must be trained in mental health issues.
District level facilities to assess, diagnose and treat people with mental illness.
PUBLIC HEARING
The Public Hearing was held in two parallel sessions to accommodate the large number of people who
had come from the five states of the Southern Region to present their testimonies on denial of healthcare.
I he parallel sessions were held in two separate hails and each session was chaired by an NHRC
tepresenlative and co-chaired by a JSA representative. The other members on the panel included
government health officials of the states from which the testimonies were being presented. Parallel
Session—I was held in Anandi bai' Hall in which cases from Andhra Pradesh and Karnataka were
P’-esented. Justice Y. Bhaskar Rao, Member, NHRC chaired the sessions while Dr. Thelma Narayan from
JSA was the Co-chair. Parallel Session—II was held in Justice Tarkunde Hall where cases from Kerala,
Tamil Nadu and Pondicherry were presented. The sessions were chaired by Smt. S. Jalaja, Joint
Secretary, NHRC and co-chaired by Dr. Sundararaman of JSA. The other members on the panel included
Dr. B. Ekbal, JSA, Shri. Y.S.R. murthy, NHRC and senior state health officials.
A brief write up of the oral and written testimonies received from Andhra Pradesh. Karnataka, Kerala.
Pondicherry and Tamil Nadu have been included in Anneures 3 to 7.
2 The five states included in the Southern Region were /Andhra
" Pradesh, Karnataka, Kerala, Pondicherry and Tamil Nadu
3 For more information on Anandi bai, please refer Anaexure 9
5
The Concluding Plenary was held in Justice Tarkunde Hall. Justice Y. Bhaskar Rao, Member, NHRC
shared his views about the public hearing. Having attended the first regional hearing in Bhopal too.
Justice Rao commented on the various kinds of denial that came from different states and different
regions of the country. He said that there was a need to deal with these issues immediately. He
appreciated the people who had suffered denial of healthcare, for their courage and willingness to share
their experiences in a public forum, with an expectation that things would improve. Justice Rao said that
their expectations had to be fulfilled and that NHRC would take all steps within its powers to see that the
Public Hearings had a positive impact on people’s right to healthcare. Dr. Thelma Narayan presented
some key issues that came up in the Public Hearing and recommendations to address the same. The
meeting concluded with a Vote-of-Thanks by Naveen Thomas of JSA.
KEY ISSUES AND RECOMMENDATIONS IN RESPONSE TO ORAL AND WRITTEN
TESTIMONIES
L
Access to Primary Health Care through the public sector health system
Primary health care is understood in a more limited way as services made available through Sub
Centre (SCs), Primary Health Centres (PHCs) and Community Health Centres (CHCs).
Pondicherry received positive community response regarding the availability and quality of
primary health care services.
•
There were no complaints from Kerala though issues regarding essential drugs, environmental
health and trauma care were raised which come within a broader understanding of primary health
care(covered in item 5,6,7).
9
In Karnataka and AP the irrational siting of PHCs (possibly under political pressure) made
access to health care very difficult and sometimes impossible. Some of the farthest villages were
40 - 50 kms away, and in other cases there was no easy bus access to PHCs / SCs. In AP
subcentres that were supposed to be there were non-existent on non-functional. In Tamil Nadu.
Karnataka and AP there were problems with regard to quality of care, referrals and staff attitudes.
Recommendation 1.
Rational siting / distribution and physical accessibility of PHCs and subcentes must be ensured.
They should provide good quality services during the prescribed timings. Indicators and
mechanisms for monitoring quality of care need to be developed and used. No money should be
taken for services that are to be provided free. The citizens’ charter for services at PHCs should
be prominently displayed and implemented. Staff vacancies need to be filled up and staff needs
such as quarters, toilets, water supply and electricity need to be ensured. Adequate provision of
medicines, laboratory equipment and consumables, registers etc is a basic requirement.
Maintaining staff motivation through good management practices will help improve the quality
of services and to foster a relationship of mutual respect and trust between providers and people.
•
2.
State and Central health budgets would need to be increased as per the National Health Policv
2002 and the Common Minimum Programme commitments. Distribution of the health budget
between the primary, secondary and tertiary levels of care would also need to follow norms, such
as 65%, 20% and 15% respectively.
Urban health care
There were several instances where the urban poor suffered adversely due to lack of access to health
care and to basic determinants such as lack of access to safe potable water and sanitation.
6
Recommendation 2.
•
The urban poor should have access not just to family welfare services but to comprehensive
primary health care through health centres which cater to 50,000 people.
*
Provision of safe potable water and sanitation is necessary to prevent morbidity and mortality due
to water-borne diseases.
User fees in institutions like NIMHANS need to be reconsidered as they have resulted in lack of
access to care. Urban poor families including migrants often do not have ration cards and BPL
*;.r<to n“ “"y ■" ,h'“
<if
Corruption and rude behaviour in institutions like Kidwai Institute of Oncology as well as in IPP
VIII Centres need to be checked.
•
Pouraka,-mikas from Hyderabad Metro Water Works and those in other cities and towns need to
eouhrment55
3.
C preVen"Ve’ Promotive and curative care, including safety gear and
Private sector health care
The case of death of a teenaged girl following treatment of gastroenteritis by a private practitioner
(with an unusual medical qualification) raised the need for:
Recommendation 3.
Reguiation of the private medical/health sector by government and professional bodies Liability
2™:,o™eXn”m'n'
•
4.
Xliiy
Unnecessary surgeries such as hysterectomies
fr„ impS2
as was reported from AP should be curbed.
Women’s access to health care and gender concerns
ANCTNCanl SnJr ^h10™65 frOm WOmen about lhe P00r treatment they received even for
ANC/PNC and family planning services and the lack of respect and privacy.
Recommendation 4
•
Medical and health care should be made available
to women and children as close to their
residence as possible.
treatment
u cd 11 iicn i.
Sll0U'd
enSUred
W°men a'ld girls durin8 medicai examination and
h1stif!e?tiAnUmb!tr °tf l!ysterect0l'lies at y°ung ages taking place in AP without adequate medical
practice does not benefit'perlons or''fomXrandVequires'siiaUon^
°f
7
1 here should be 24 hour PHCs functioning in every taluk for emergency obstetric care and CHCs
should have gynecologists and anesthetists. Due to the shortage of anaesthetists medical officers
with a 3 - 6 month training in aneasthesia could be authorized to give anaesthesia.
5. Environment and Health
Strong testimonies were presented from Kerala, Tamilnadu and AP on the adverse impact on human
health resulting from exposure to toxins from industries / factories, and pesticides. This problem
exists throughout the country.
Recommendation 5.
•
The Department of Health at state and central level needs to have structural mechanisms through
which it can function along with other agencies likes the pollution control board, ministry of
environment and forests etc. to implement regulatory and preventive measures, and to provide for
occupational health and safety, as well as access to medical care where environmental injury has
occurred. In short there is need for a public health response to environmental health problems.
6. Access to Essential Medicines and rational therapeutics
The use of irrational and sometimes harmful, banned and bannable medicinal drugs and preparations
was raised as an issue of concern in Kerala. This problem exists in all states.
Recommendation 6.
•
Rational drug policies, essential drug lists standard treatment guidelines and formularies need to
be adopted in the public and private sector, and more importantly they should be used and
regularly updated.
*
Existing and new imechanisms for continuing education of medical practioners and allied health
professionals need to be actively used for this purpose.
Measures to increase consumer awareness and good pharmacy practice need to be widely
instituted.
7. Trauma Care
This came up strongly from Kerala, but is applicable in all states.
Recommendation 7.
•
With the rising number of traffic and other accidents early trauma care using standard protocols
need to be ensured through provision of infrastructure and training. Preventive measures such as
use of helmets and seat-belts should be mandatory.
8. Mental Health
The following problems were experienced by groups working in the different states - lack of access
to mental health care by rural poor due to centralized mental health care available mainly in city and
town based institutions; stigma, discrimination and abuse; lack of medical and health personnel with
adequate training in mental health; non-availability of drugs; lack of public awareness about mental
health
8
Recommendation 8.
•
9
Medical and psychosocial care <and’ support for persons with mental illness should be available in
a decentralized manner.
... This will require adequate training and continuing education. Public
awareness and sensitivity also needs to be increased.
Public Health issues
pre''”'"“ Of v"' A
<AP>;
raced
required surgery (AP); death of TB patients due to lack of access to
treatment (Karnataka).
’
Recommendation 9.
’
rNna‘i0nal.8uideli"es regarding these public health issues need to be followed. Increasing
ommumty mvo vement and feelmg of community ownership of health institutions and
Eh'worSrs/ social'h '"it^
qUa'ity- Training and involvement °f community
health workers / social health activists would provide a valuable link.
10
”r —r™ .be ruNie
Recommendation 10.
Atthiy^and ofS ‘1° bf eStab'ished at Sta,e level for Joint monitoring by the Jan Swasthya
Abhiyan and officials from the state department of health regarding the follow-un of
monhoTThe^Zw™63' T" ''P01110
NHRC' NHRC °fflcials may also visit t0 observe and
Co™„„,;:s?s,xx:?z"."nece“s’rv'
.1,1,
*******
9
*
Annexure 1
SOUTHERN REGION PUBLIC HEARING ON RIGHT TO HEALTH
CARE
Jointly organised by
National Human Rights Commission (NHRC) &
Jan Swasthya Abhiyan (JSA) [People’s Health Movement - India]
on
29th August 2004
at
St. Thomas International Center for Retreat and Pilgrimage,
Hill Top, St. Thomas Mount, Chennai-600016
PROGRAMME SCHEDULE
INAUGURAL SESSION
Venue: Justice Tarkunde Hall (Main Hall)
TIMINGS
SESSION
09.00- 10.00 a.m.
Registration
10.00-10.45 a.m.
•
•
•
•
10.45 - 10.55 a.m.
Case Presentation on Mental Health - Basic Needs
10.55 - 11.20 a.m.
TEA BREAK
Welcome : Dr. G. K. Pandian, JSA (Tamil Nadu)
Introduction : JSA Representative - Dr. B. Ekbal, National Convenor, JSA
Inaugural Address : Justice Shri Y. Bhaskar Rao, Member, NHRC.
‘Kala Jatha' - Book Release by Hon’ble Justice Shri Y. Bhaskar Rao
PUBLIC HEARING (PARALLEL SESSION I)
Venue: Anandi bai Hall (Hall II)
States: Andhra Pradesh, Karnataka
TIMINGS
STATE
SESSION
PANELISTS
11.20 a.m - 12.50 p.m.
Andhra
Pradesh
1. Testimonies of the individual
cases of health care denial.
2. State Report on Public Health
Services by JSA state
representatives
3. Responses from the state
Health officials.
Chair:
Justice Shri Y.Bhaskar Rao
Co- Chair:
Dr. Thelma Narayan, JSA
&
Senior Health officials of
Andhra Pradesh
12.50 pm. - 01.20 pm.
01.20 p.m. - 2.10 p.m.
Responses of the panelists to the above presentations
Lunch Break
10
*
PARALLEL SESSION I
Cont’d...
TIMINGS
STATE
SESSION
PANELISTS
2.10-3.40 PM
Karnataka
1. Testimonies of the individual
cases of health care denial.
Chair:
Justice Shri Y.Bhaskar Rao
2. State Report on Public Health
Services
by
JSA
state
representatives
Co- Chair:
Dr. Thelma Narayan, JSA
&
3. Responses from the State Health
officials
03.40 p.m. - 04.10 pm
Senior Health officials of
Karnataka
Responses of the panelists to the above presentations
04.10 p.m. - 04.30 pm
TEA BREAK
PUBLIC HEARING (PARALLEL SESSION II)
Venue: Justice Tarkunde Hall (Main Hall)
States: Tamil Nadu, Pondicherry, Kerala
TIMINGS
STATE
11.20 am. - 12.50 pm
Tamil Nadu
SESSION
1.
Testimonies of the individual
cases of health care denial.
2.
State Report on Public Health
Services
by
JSA
state
representatives
3.
12.50 pm. - 01.20 pm
Responses from
Health officials
State
Chair:
Smt.S.Jalaja,
Joint Secretary, NHRC
Co-Chair:
Dr. T. Sundararaman, JSA
&
Senior Health officials of Tamil
Nadu, Pondicherry and Kerala
Lunch Break
Pondicherry
1.
Kerala
2.
3.
3.40-4.10 PM
the
Responses of the panelists to the
above presentations
01.20 pm - 02.10 pm
02.10 pm - 03.40 pm
PANELISTS
Testimonies of the individual
cases of health care denial.
State Report on Public Health
Services
by
JSA
state
representatives
Responses from
Health officials.
the
state
Joint Secretary, NHRC
Co-Chair:
Dr. S. Sundararaman, JSA
&
Responses of the panelists to the
above presentations
4.10-4.30 PM
Chair:
Smt.S.Jalaja,
Senior Health officials of Tamil
Nadu, Pondicherry and Kerala
Tea Break
CONCLUDING PLENARY
Venue: Justice Tarkunde Hail (Main Hall)
4.30 - 5.00 PM
1. Observations and responses by Dr. Thelma Narayan, JSA
2. Concluding remarks by Justice Shri Y. Bhaskar Rao, Member, NHRC
3. Vote of thanks by Naveen Thomas, JSA
11
Annexure 2
LIST OF ORAL AND WRITTEN TESTIMONIES / CASES PRESENTED FROM THE
SOUTHERN REGION
LIST OF CASES FROM ANDHRA PRADESH
SI.
No.
Case Code
Name of The Case
1
AP01
2
AP 02
3
APOS
4
AP 04
5
AP 05
Chegunta mandal- Medak district, Andhra Pradesh: Study on the
primary health centres and their sub-centres__________
Alarming prevalence of Vitamin A deficiency among children in
Chegunta mandal, Andhra Pradesh—
Healthcare for the gundala tribal population comes at a cost
—if not it does not reach them
Undetected and unreported cases of blindness among children
belonging to Scheduled Castes & BPL (below poverty line)
families
_
_____________________
Hysterectomies for money; ovaries are not spared
6
AP 06
Greenpeace health studyi Medak district, Patancheru/ Jinnaram/
Kohir mandal
7
AP 07
Case study: Pesticide use in Warangal
8
AP 08
Hospital environments control of infections
9
AP 09
The state of the public health system in Patancheru
and Jinnaram mandals of Medak district, Andhra
Pradesh
10
AP 10
Testimony of the Hyderabad Metro Water Supply & Sewerage
Worker's Union
11
AP 11
Testimony of a Person Living With HIV/ AIDS
12
LIST OF CASES FROM KARNATAKA
SI.
No.
Case Code
1
KA 01
Denial of health care in the PHCs of Hungund Taluk, Bagalkot
district
2
KA 02
Case Presentation on mental health
3
KA 03
User fees and denial of healthcare
4
KA 04
Campaign and struggle against acid attacks on women
5
KA 05
Testimony of MR’S mother
6
KA 06
Case Study of Mrs. S
7
KA 10
Testimony of Mrs. G
8
KA 1 1
Case Study of Sonnenahalli PHC, Vivekanagar, Bangalore
9
KA 12
Study on Austin Town Maternity Home
10
KA 15
Study on IPP VIII Center - Koramangala
11
KA 16
Testimony of Late P
12
KA 18
Testimony of Ms. D
13
KA 19
Case History of ER
14
KA 20
Case History' of H
15
KA 21
Testimony of Late Mr. H
16
KA 22
Testimony of Mr. K
17
KA 23
Testimony of Ms. L
18
KA 24
Testimony of Mr. D
19
KA 25
Testimony of Mrs. Da
20
KA 26
Testimony of Mrs. A
21
KA 27
Testimony of Smt. T
22
KA 28
User Fee & Denial of Health Care
Name of The Case
13
LIST OF CASES FROM KERALA
SI.
No.
Case Code
Name of Case
1
KL01
Eloor case study: Greenpeace Health Study Report in Aug 2003
2
KL 02
How prepared are the public health services to respond to
chemical exposure and disasters/ accidents?
3
KL 03
Testimony on improper management of trauma victims
4
KL 04
5
KL05
Endosulfan poisoning due to community exposure - failures in
responding to the health problems and providing public
health care and service.____________________________________
Testimony on use of irrational drugs
6
KL 06
Negligence in pesticide use and abuse - resulting exposure to
community & environment
7
KL 07
Lack of a forum
regarding treatment
where
patients
can
lodge complaints
14
LIST OF CASES FROM PONDICHERRY
SI.
No.
Case Code
1
PY01
Testimony of Mrs. M
2
PY02
Testimony of Mrs. IM
3
PY 03
Testimony of Mr. N
4
PY 04
Testimony of Ms. AK
5
PY 05
Testimony of Mr. DA
6
PY 06
Testimony of Mrs.K
7
PY 07
Testimony of Mrs.L
8
PY 08
Testimony of Mrs. R
9
PY 09
Testimony of Ms. S
10
PY 10
Testimony of Ms. T
11
PY 11
Testimony of Ms. ER
12
PY 12
Testimony of Mr. S
13
PY 13
Testimony of Ms. GS
14
PY 14
Testimony of Ms.S
Name of Case
15
LIST OF CASES FROM TAMIL NADU
SI.
No.
Case Code
1
TN 02
SIPCOT, Cuddalore: Special Needs of Pollution Impacted
Communities Ignored
2
TN 03
Industrial Accident Leading to Death
3
TN 04
Injury to Fishermen as a Result of Water Pollution
4
TN 07
Testimony of SJ.
5
TN 08
Testimony of Ms. G
6
TN 09
Testimony of S.G.
7
TN 10
Testimony of H.S.
8
TN 11
Treatment without Examination
9
TN 12
Testimony of M
10
TN 13
Testimony of NS
11
TN 14
Testimony of N
12
TN 15
Testimony of G.P.
13
TN 16
Bribery in Govt. Hospital
14
TN 17
Case Study of Theni, Tamil Nadu
15
TN 19
Testimony of Mrs. P
16
TN 20
Testimony of R
17
TN 21
Primary Health Center Study
Name of Case
16
Annexurc 3
DETAILS OF CASES FROM ANDHRA PRADESH
AP-01
CHEGUNTA MANDAL- MEDAK DISTRICT, ANDHRA PRADESH; STUDY BY
SANGHAMITRA ON THE PRIMARY HEALTH CENTRES AND THEIR SUB
CENTRES
In Chegunta Mandal like many other mandals of Medak District, the health staff do not visit
small villages with population below 1000 for immunization because they would waste some
amount of vaccine. This is the case of many small hamlets where knowledge of immunization is
less and coverage is low. Complaints lead to further denial in terms of intimidation and denial.
Attached are copies of the complaints to the District Medical and Health Officer and the District
Collector, Medak.
Sanghamitra studied the health system in Chegunta and finds it disturbing with each new case of
hysterectomy combined with appendisectomy, with each new case of Caesarean-section, and
every new case of Vitamin A deficiency in the below 8 age group.
In this direction.
Sanghamitra studied the system in four areas
1.
2.
3.
4.
5.
Functioning of the sub-centres and their resources
PHCs and their functioning, resources and supplies
Exploitative practices by private medical practitioners and surgeons
Denial of treatment or referral to Children suffering from curable blindness
Denial of Health to Children below 6 and 7 by denial of supplementation with adequate
Vitamin A supplementation
1. The sub-centres, a case of denial of health
9
The 14 sub-centres in Chegunta Mandal of Medak District in Andhra Pradesh are distributed and
organized totally failing to have the confidence of the people at large and the leaders of the
region. The location of 5 sub-centres within the PHC premises throws to light the lost purpose of
an outreach sub-centre. This is the case of many of the sub-centres in the region, clearly
indicative of failure of the public health system. Structurally the system is failing the people as
indicated by the extent of neglect of its infrastructure and outreach planning.
The subcentres do not have basic facilities such as a building, sign boards, time-table indicators,
electricity, toilets, water, examination tables, BP Apparatus, Stethoscope, boilers, stoves, gas
connections, sub centre kits, cupboards, and proper lighting. This is the condition of the observed
subcentres in Chegunta, and is indicative of the rest of the district and the Andhra Pradesh Slate
in general. Supervisory staff (Community Health Officers, health Supervisors, etc.) visiting these
facilities does not effectively report these findings to higher authorities and indirectly deny
village people the basic amenities.
The people in Chegunta Mandal are not aware that silently a public health system is failing them
- Vitamin A deficiency is being seen in a large number of Children, DPT and MMR Vaccines
17
are not being supplied to the PHCs regularly, some health and have still not a building or rented
house for the sub-centres and the coverage of immunization is still below standard. Women turn
to private practitioners for routine gynaecologic disorders and are treated often surgically instead
of primary medical treatment. This is not an isolated occurrence but regular. Normal deliveries
are not common anymore, like in most places. Caesarian-sections are common and regular. If the
public health system begins to act now, people will utilize the services far more than the existing
usage.
Regular clinics for women and child health could pave the way for better referral services and far
better utilization. The basic trust in doctors and paramedics is what anyone would look for and
assurance: alone would not be enough. Actions should be taken through sustained efforts at all
levels from the people up to the Authorities in each block or district.
AP-02
ALARMING PREVALENCE OF VITAMIN A DEFICIENCY AMONG CHILDREN IN
CHEGUNTA MANDAL, ANDHRA PRADESH
Investigating Team : Sanghamitra
Address :
Chegunta Mandal, Medak District
Andhra Pradesh 502 255
A detailed door-to door survey on the eye health status of people in the region is completed in
Chegunta Mandal and is being conducted in Toopran, Ramayampet Mandal’s of Medak District.
Medak is one of the most backward districts of the Telengana region of Andhra Pradesh. A
detailed eye health status of the area is being assessed for the first time in the entire region and
the position investigated is dismal. The biggest service provider in the region is the Lion’s Eye
Care programme and the coverage is about 15 percent, and that too through organized mass
camps. The rest of the services are unorganized and self financed. Knowledge about eye health
and diseases in the region is poor. Most children in their teens suffer from poor evenings vision
usually going undiagnosed or unnoticed. The below 7 children are the current sufferers of the
failing supplementation programme of the Governmental Public Health System. In Chegunta
Mandal alone there are more than 388 Children suffering from Vitamin A deficiency. Vitamin
supplementation programme supported by UNICEF, has been underway in the region since over
ten years.
According to past public health studies conducted in Andhra Pradesh the prevalence of Vitamin
A deficiency is approximately 5-7 percent in Children..
(Kapil U. and Bhavna A., (2002), ‘‘Adverse effects of poor micronutrient status during
childhood and adolescence”, Nutrition Reviews, May, Vol.60, no. (5 pt 2), pp,S84-90).
But little is documented in medical literature about this deficiency among children of our
country, the very eyes of those who have to mould tomorrow.
Criteria for Vitamin deficiency: Bilot spots, wrinkling of sclera, and skin lesions.
18
f
Many individuals were unaware of the Vitamin A supplementation programmes even though
they had children in the age groups (01-06 years age group).
•
•
•
•
•
•
Total population covered (public interviewed) Adult Males 14,216 + Adult Females
14,284) + (Children Male (below 15 years) 6,362 Male + 6175 Female Children)
Total population with eye problems - 7365
Children suffering from vitamin deficiency (below 8 years) in Chegunta Mandal - 388
This survey was done by 12 young individuals of the area aged between 20 and 24, with
adequate training on basic eye care and primary detection of eye diseases. They were
trained at LV Prasad Eye Institute, Hyderabad
They have been receiving continuing education on eye care and eye related rehabilitative
programmes
According to the general survey, eye related diseases were going undetected and cases of
vitamin. A deficiency were on the rise as a result of poor supplementation programmes
by both the ANMs and the Anganwdi workers in the programmes.
Denial of Health Care: Poor Vitamin A supplementation, even though it is a National
Programme.
Consequences : Poor Vision, including night blindness.
AP - 03
HEALTHCARE FOR THE GUNDALA TRIBAL POPULATION COMES AT A COST
-IF NOT IT DOES NOT REACH THEM
Date February 25th 2004
Mandal—Gundala
District—Khammam
People's voices raised the issue of gross neglect of the Primary health Centres in Gundala
Mandal of Khammam district. The people brought to the notice of the District Collector the state
of the PHC functioning in a public hearing in Februray. This was reported in ’The Hindu' on 25
February 2004.
The public hearing was organized to ask for basic amenities for the people in the tribal villages
of the Mandal.
It highlighted the poor functioning of the PHCs
1. No doctor in that area had served longer than a fortnight in that PHC.
2. PHCs functioned only once in a week, on Tuesdays, the market day.
3. The paramedical staffs were present on other days, and no deliveries are conducted there.
4. Private Medical practitioners demanded sums of Rs.6, 000/- to Rs. 10, 000/- from women
for normal deliveries. This had taken its toll on many of the people there. Most of them
who were affected by this were those below the poverty line (BPL families). Borrowing
paid off these sums from moneylenders. Many people’s hard-earned money was going in
for healthcare.
19
I his case study is being further investigated to see if there was any change in the functioning of
the PHC after the District Collector s reassurance. It would be extremely important to view this
case as a continuing fight against the laxity in the Public health system, and not a case by itself.
It needs to be viewed with a dimension of financial damages caused to people as a result of
denial. Cases like this do not occur in isolation—Most PHC doctors live in nearby cities and
often travel to and fro to their PHCs, some of them even cover up to 200 kilometres. This kind of
travel wouldn t in anyway help the efficiency of the doctor or his services, but kill the energy to
function normally.
Gundala tribals seek basic amenities:
Even after trying hard for many years to change the way in which the Government Health system
works, the Gundala Tribal population sill haven’t seen any change in which the Doctors in the
Public Health System Function.
The Gundala tribals in the forest areas of Khamman district of Andhra Pradesh have been silent
sufferers of the agencies of health care and all costs involved. The doctors posted there have
never stayed on beyond a fortnight. The PHC was built without conforming to the beliefs of the
local people and as they put it, it was having “some defects in the vaasthu’
The women were changed anywhere between Rs.6,000/- and Rs. 10,000/- for even routine
deliveries in the private hospital. (All because the Primary Health Centres were open only once
a week and otherwise managed by the paramedical staff).
Denial of Health Care : Absence of Government medical officer at the Primary Health Centre
Consequences :
- Avoidable Huge expenditure to be treated by the private practitioners.
- Poor functioning of the Primary Health Centre
AP-04
UNDETECTED AND UNREPORTED CASES OF BLINDNESS AMONG CHILDREN
BELONGING TO SCHEDULED CASTES & BPL (BELOW POVERTY LINE)
FAMILIES
Child 1 - Sukanya, Daughter of Satayya
Age - 5 to 6 years
Socio-Economic Status - Below Poverty Line, Scheduled Caste family
Diagnosis:
Near total blindness due to childhood cataract
Child 2 - Banu (Brother of Sukanya)
Son of Satayya
Age - 7 to 8 Years
Diagnosis: Near complete blindness due to childhood cataract with the cataract affected lens
in the left eye being dislodged.
Prognosis (both): Treatable cause of blindness—surgically with lens implants
Available Government programmes—National Programme for Control of Blindness
20
These children have suffered from adverse effects on physical, social and psychological
growth while trying to interact with other children with normal vision. Sukanya has a very
different style of walking, because of her constant extra-cautious walk (steps) fearing a fall, a
fall into a large open well near her house. This child has been denied the basic services for
normal living.
Banu, Sukanya’s brother, is also suffering from severe stress on his eyes because he cannot
see anything but blurred images of objects, yet he attends school and finds it extremely
difficult to find things, do his duties and cannot study. To the others around and to the health
department, Banu is a blind child with no hope. This is a lack of will to send this child to a
specialist’s facility in the District Hospital.
The primary health centre ophthalmic assistants in almost all areas are beginning to depend
upon private hospitals for surgical treatment of cataract cases, solely depending upon the
mass camps and occasional follow up.
This case study does not intend to personally attack a health worker or an ANM or an
Ophthalmic Assistant in the area (Chegunta Mandal of Medak District), but looks at a
paradigm shift of policy of the health department to look at basic indicators of health more
seriously, stress on local decision making by the PHC Medical Officer and improve
availability of the staff at actual duties. Effective reporting, quick response, and an effective
monitoring mechanism should be in place soon.
Denial of health care:
These children have been denied the Right to Sight because of the failure of the Public
Health System of having an effective surveillance system in place.
The reluctance of the staff to explore the whole simple world of Primary Health Care needs is
emphasized by such an occurrence.
Failure of School health programmes
Consequences :
Blindness in the young children (siblings), avoidable by surgery with implants.
Failure in Physical, Psychological and social development and well-being.
Needed :
Effective School health programmes, village awareness programmes, people contact
programmes, and health campaigns should be made high priority. The department of health
has to change tact to reach its vision 2020. It cannot be caught denying children their Right to
Sight.
AP-05
Hysterectomies for Money; Ovaries are not spared
Mrs. S is about 28 years and underwent a month’s ordeal with lower abdominal pain and
bleeding due to a uterine infection. She, like many others, did not go to the primary health centre,
as they were unaware that treatment was available. Instead, she went to a private medical
practitioner in the nearby town, Chegunta. She was advised an ultrasound of the lower abdomen.
Two days later she underwent a hysterectomy at the local medical practitioner’s clinic, which
21
was performed by a visiting surgeon. Mrs. S took a loan of 8,000 rupees for the treatment cost
and investigation and borrowed more money for medicines after she was discharged.
Mrs. S, thinks that the doctor did the right thing by performing a hysterectomy. But the
ultrasound diagnosed a normal study with absolutely normal uterus. The echo-texture of the
uterus, dimensions and the position of the uterus conformed to a normal anatomical structure.
Q. But why was a hysterectomy done in a 28-year-old woman who had a medically
treatable infection of the uterus?
Mrs. S is one of many such women who are undergoing hysterectomies as a primary treatment
for uterine infections. In Pothensettipalle, her village, there are 10 such women in the
reproductive age group of 20 and 35 who have already undergone the procedure. The belief that
hysterectomy is to take away a useless organ, and that it is a normal practice, is there among the
women. Some of the women believe that its reproductive function is over with a tubectomy or
ligation or the fallopian tubes. Many private practitioners not just in Medak District but also in
the entire state of Andhra Pradesh, are exploiting this belief among the women, which has been
ingrained in their minds by widespread practice of the procedure without warning women about
the long-term implications of a total hysterectomy.
Q. Why didn’t she go to the PHC for treatment?
She says that many in her village have been treated badly at the PHC in the past and therefore
they prefer to consult private practitioners.
Q. Was Mrs. S satisfied with the treatment given to her?
Yes. She feels it was better that she underwent the surgery, except that she suffered financial
loss. She feels the infection and pain came down only because of the procedure and could not
have been done with medicines, which she took for a while by prescription of the local registered
practitioners. But she definitely would have been happier if she had been rid of the infection with
simple medicines.
Q. Does this warrant a paradigm shift of the public health system to deal with a large social
issue of rejection of the public health facilities?
Yes. A people friendly and practical health department is necessary for people to come to avail
ethical treatment at the PHCs and sub-centres. A clear and acceptable method of referral of more
complicated cases to Area Hospitals and Community Health Centres should be practiced to
change the existing failure of the treatment referral system.
Note: Mrs. S was a signatory in the complaint in February 2004 to the Mandal and District
Health Authorities and the District Collector that the ANM (Auxiliary Multipurpose Nurse)/
Male Health Assistant from their sub-centre had not visited their village in two years. Mrs. S
feels that the ANMs could direct a lot of women with problems to Govt, facilities in the future
for cheaper and ethical treatment. The report obtained by the PHC authorities regarding the
complaint has been still not communicated with the SHG (Self Help Group members) and the
NGO (Sanghamitra), who were signatory to the complaint.
22
Denial of Health Care:
• Unnecessary operation, removing the uterus, when the condition could have been tackled
with simple medicines.
• No evidence of adequate information being given and informed consent.
• Lack of faith in the Public Health System.
Consequences: Removal of an organ, which was avoidable and unnecessary expenditure.
Case Study Prepared by: Dr. Abraham Thomas, Community health Cell, Bangalore
at Chegunta Mandal, Medak District, Andhra Pradesh
AP-06
GREENPEACE HEALTH STUDY: MEDAK DISTRICT,
PATANCHERU/JINNARAM/KOHIR MANDAL
Executive Summary:
Patancheru and the adjoining study areas are located on the North-Eastern part of Andhra
Pradesh. It covers an area of 222 Sq. Kms in Medak district and is 40 km away from Hyderabad.
It was predominantly an agricultural landmass located on the banks of river Manjira, a major
tributary of River Godavari, but transformed into an industrial area as part of the governments’
drive on industrialization. The Patancheru Industrial Estate was set up in 1975 as part of the
government initiative to bring in more industries to the state of Andhra Pradesh. Over a period of
29 years, about 320 industries that are manufacturing pesticides, chemicals, pharmaceuticals and
steel rolls have come up in this area. While arguments in favour of this expansion were and are
being presented from an economic standpoint, like always no consideration was given to the
possible environmental and public health impacts. Amongst communities located in the midst or
periphery of vast Industrial Zones, there is a strong perception that pollution generating activities
at these facilities result in a direct negative impact on the health of residents. Representatives of
the communities at Patancheru Mandal, Medak District, have repeatedly voiced statements to
this effect, but, citing absence of extensive hard data in existing records, no action has been taken
by concerned authorities to investigate further.
From it s inception to date, most of the Industries here, have not shared information regarding
pollutants, their chronic and acute effects, to the local residents, the local authorities -the village
Panchayat, workers and doctors, as envisaged by the Factories Act and rules under the EP act.
The plan for ‘disaster management and emergency preparedness’ inclusive of information on
products, storage of hazardous substances, effects and antidotes, again has not been made public
(with a few exceptions), as it should be. The medical fraternity of the local area is not oriented or
equipped for diagnosing and treating health problems due to environmental pollution. Despite
the fact that the pollution at Medak district has been established by sampling missions and
studies by various organizations in the past decade or so, there has been little action by the
regulatory authorities.
In the light of the failure to address this issue and the fact that community health problems of
Patancheru were quite apparent, Greenpeace decided to undertake an epidemiological, health
23
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■
.
.
.
.
■
study that would prima facie establish the problem1. Greenpeace initiated an alliance with
Occupational Health and Safety Centre (OHSC)- Mumbai and the Community Health Cell, who
have prior experience in epidemiological research. The broad framework was of OHSC taking
the lead with medical verifications of primary data collected using a questionnaire research was
arrived at jointly, with Greenpeace taking the primary role in the field based research and survey.
The results of this study demonstrate that all body systems without exception are adversely
affected in the Study areas as opposed to the control locations, a result of a cocktail of poisons in
the water and air of the study villages, which has had considerable effects on the health and well
being of the local population. The incidence of cancer and heart disorders is greater in the study
group at statistically significant rates. For respiratory disorders such as asthma and bronchitis,
the incidence is 4 times higher in the study group in comparison to the control group.
A stratified random sample of the study group (9 villages) when compared with those from the
Control group (4 villages) shows a significant increased disease incidence in many body systems.
These include
1. The presence of Diseases of skin and subcutaneous tissue in the study group is at least
two times higher than the control group.
2. One in every eleven, in the study group is afflicted with Diseases of the musculoskeletal
system and connective tissue.
3. Clinically confirmed cancer incidence and respiratory disorders are greater in the study
group at a statistically significant rate. While 1 leases of incidence were reported in the
study group, no such case was reported in the sampling set in the control group. The
occurrence of Asthma and Bronchitis is 4 times higher in the study group.
This report, further, uses available and existing research to demonstrate: o Fhe presence of a wide range of chemicals in the land, air and water in Medak.
o The ways in which the local community are being exposed to these toxins.
o The increased exposure has increased the potential for detrimental health impacts
The implications of these findings, amongst others, are serious. In brief, the study demonstrates
that serious damage is being done to the health of the residents of Medak at current levels of
Industrial activity, and this damage potentially correlates with location, a measure of exposure to
Industrial activity-generated pollution.
It is incumbent on State regulatory authorities
responsible for the public health to investigate this matter, to further define the scope and
severity of the problem, and initiate processes which will return the community to the state of
health enjoyed by them prior to this reckless industrialization era and pressurize industries to
follow all environmental and ethical norms and implement clean production and closed-loop
systems in their production cycle. The evidence presented here contributes to a growing
repository of research that reinforces the conclusion of this report that serious damage is afflicted
upon the local community potentially through the pollution stemming out of reckless industrial
activity and necessitates the need to ensure that Industrial estates of the nature of Patancheru, not
be replicated elsewhere.
Comments from the Visiting Team of Doctors:
1. Incidence of cancer in the affected area is significantly higher than in the control area.
The incidence of cancer was validated by senior surgeons from Mumbai. This is an
underestimation because; we did not add the cancer incidences which was detected in
1 The local people at Medak have been complaining of large-scale health problems.
24
^2^1
2.
3.
4.
5.
6.
7.
hospitals and nursing homes and autopsy data. It was based on house to house survey
with validation of pathology reports of all cancer detections in a year.
Lung function tests were affected significantly (p<0.01), both Fevl and Fvc of the
affected population as compared with the control group.
Environmental Asthma was validated in a few cases but due to logistic problems, could
not be confirmed by Lung Function tests in a larger population.
Allergic Contact dermatitis, which was validated by doctors from Mumbai, was
significantly more in the affected group.
• ’
The other medical conditions like mental health, gastrointestinal conditions etc... showed
a pointer to a possible higher incidence in the affected population, but a medically
validated comment cannot be made, at present, hence there is a need for a more elaborate
and validated study preferably with the governmental health infrastructure.
Local medical facilities are very inadequate and people spend a sizable percent of their
income on private, mostly irrational treatment. Only when it comes to the final advanced
stages, they are shifted to a major hospital in big cities like Hyderabad.
It is urgently required to upgrade local government medical facilities and provide free
medical treatment to people of the affected communities.
Dr Murlidhar V, Dr Ashwini, Dr Deepali, Dr Archana,
Lokamanya Tilak Municipal College and General Hospital, Mumbai.
Denial of Health Care:
- Increased incidence and prevalence of diseases such as cancer, asthma and dermatitis as a result
of pollution of the environment,
- No effective control of pollution by the industries. Inadequate public health care facilities to
deal with the health problems posed by the industrial pollution.
Consequences:
- Increased death and disease among the people living/working in the area.
- Increased expenditure on health care by the people of the area.
AP-07
CASE STUDY: PESTICIDE USE IN WARANGAL
Warangal in Andhra Pradesh is the second largest pesticide-consuming district in the state.
Compared to other states like Punjab, pesticide use in this district is a relatively recent
phenomenon and this is borne out by the number of years of exposure reported by the mothers of
the children studied in the Greenpeace health study “Arrested Development.” Warangal shot into
national headlines with the large number of suicide deaths that cotton farmers in the area
committed during the last decade.
Many deadly pesticides still continue to be used in India. Exposure to even low doses of
pesticides is associated with a wide variety of health effects. Since regulations are not adhered to
and monitored, not only public health and the environment pay the price but the livelihood of
farmers is also jeopardized.
The health care scenario in Warangal is extremely poor. The RMP is able to provide only basic
medical treatment like vaccinations, vitamin and mineral deficiencies and maternity advice.
25
The PHC has barely any facilities and so he farming community has no choice but to go to the
private hospitals for treatment.
The practitioner of the. PHC comes in for only about a few hours and leaves before 5 o’clock in
the evening leaving the community with no medical facility available in case of emergencies.
During the pesticides spraying season the rate of acute poisonings increases drastically and lack
of timely medical health often leaves farmers in extremely grave situations.
ARRESTED DEVELOPMENT - An Executive Summary
In the cotton-growing season between April and December 2003, Greenpeace India studied the
chronic effects of pesticides on the development of children growing up in cotton cultivating
areas of six states of India. The results of this study, published in April 2004 as Arrested
Development, reveal that exposure to small doses of pesticide during childhood years has
severely impaired the analytical abilities, motor skills and the concentration and memory of
children from farming communities. The 1648 children who participated in this study are
representative of the population of India.
Most studies in the past have focused on pesticide residues in food and water, instead of which
this study attempts to correlate the indiscriminate use of pesticides with the health of
unsuspecting little children (4-5 years) and older ones (9-13 years); children who appear normal
and happy but whose mental development lags far behind their counterparts in pesticide-free
environments. The study focuses on children, as they are particularly vulnerable, given their
physiology and behaviour patterns
A total of 899 children from six locations in the cotton-growing belts of the country, (which
implies the intensive and high use of dangerous pesticides cocktails) were compared with 749
children of the same age, economic background and ethnicity in a different location (within the
same state) where the pesticides usage was far less.
The researchers arrived at the data for this study through using a Rapid Assessment Tool.
Through this tool, the children were asked to participate in a wide range of tests using a play
approach, where the tools were individually and verbally administered to each child.
Widespread documentation on neurological effects of pesticides including effects on memory,
judgment and intelligence as well as personality, moods and behaviour determined the kinds of
tests administered.
The tests included the use of wooden blocks and jigsaw puzzles to measure mental abilities, ball
catching and balance tests to test motor abilities and memory games to assess the level of
concentration and memory.
The study found a remarkable difference between the abilities of the two groups of children, with
more or less consistent trends across different locations in both the age groups. With all other
possible confounders controlled for, the only significantly accountable reason for these
disturbing findings is the children’s exposure to pesticides.
The findings of Arrested Development make a strong case for the application of the
Precautionary Principle. In the case of hazardous and toxic substances like pesticides,
Precautionary Principle needs to be applied in their manufacture, distribution, marketing, storage
26
•
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and use. The current legislations, policies and practices in India do not adhere to this
precautionary principle.
The report strengthens the evidence against pesticides and calls for a ban on all pesticides,
starling with those banned in other countries. As cleaner, safer alternatives for farming have been
well demonstrated by farmers in the country, the study is a wake up call to the government and a
demand for them to provide greater support to organic farming in terms of resources,
mechanisms for more research, extension and crop Ioan support and infrastructure.
AP-08
HOSPITAL ENVIRONMENTS CONTROL OF INFECTIONS
A hospital is place where good hospitality with no extra sufferings and infections is given to the
patients. To achieve this, it is essential that the staff should be aware of infections acquired in
the Hospital and its environment and must be in a position to control the infection to a maximum
possible extent.
Hospital Environment & Planning of Ward:
The wards as well as the special rooms should be designed in such a way to allow free entry of
fresh air and sunlight as these naturally available sources cure many of the infections. The
floors, walls and ceilings of the rooms including its surroundings should be easily washable, so
that it provides no room for dust or moisture. The hospital should have an isolation ward or
room for badly infected patients, this isolation can control cross infections. The bed should be
laid in the centre of the room, to facilitate free approach of staff from all sides of the patient.
Control of Infection:
Many patients admitted in the hospital are getting infected during their stay in the hospital. Such
infections are called Nosocomial Infections. The causes of such infections are :
Endogenous: In which the causative organism comes from another part of the patients body.
The causative factors are :
Debilitated condition of the patient.
- Extremities of age (Paediatrics & Geriatrics)
Compromising the person's immune system (by disease of following immune suppressive
therapy).
Breach of the individuals skin/mucous membrane barrier. (Severe bums. Surgical wounds,
catheterization, intubation).
Following Diagnostic and treatment procedures.
- Malignant disorders and Diabetes mellitus.
Prolonged broad-spectrum antibiotic therapy.
Exogenous: In which the causative organism comes from outside the body and acquired from
another person or object. Also referred to as Cross-Infection or hospital acquired infection. The
causative factors are :
- Improper aseptic environment, equipments and instruments.
Poor sterilization and disinfection techniques.
27
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Invasive monitoring and therapeutic procedures.
Transmission of infection by staff.
Consumption of infected food and water.
Epidemics arising in the community and spreading to the hospital.
Nosocomial Infection:
The Nosocomial Infection commonly occurring arc :
Urinary tract infections.
Respiratory tract infections.
Wounds/Burns
Gastro-Enteritis/Dysentery
Bacteraemia and Septicaemia.
Routes for transmitting exogenous infections:
Air Borne: Dusty particles, droplet nuclei are common modes of transmitting respiratory
infections and wound infections.
Contact with cases or carriers especially applicable for wound infections.
- Through contaminated food, water etc., enteric infections.
Instrumentation, usage of contaminated/un-sterile instruments cause wound infection, urinary
tract and respiratory tract infections.
Prevention of hospital acquired infections:
1. The greatest single factor in the spread of nosocomial infections is the failure of health care
workers to wash their hands often enough between patient contacts. It effectively prevents
most of the cross-infections which tend to occur between patients.
2. Adequate disinfection of the environment and proper sterilization of instruments, and other
materials is a necessity. The use of a large number of disinfectants especially without
knowing the proper concentration should be discouraged. In situations when the use of
disinfectant is indicated it is important to ensure thatThe choice of the disinfectant is appropriate.
The concentration used must be adequate.
The contact time should be enough.
3. Adhere strictly to aseptic techniques. These are :
A strict "NO TOUCH" technique while changing surgical dressings, insertion or removal
of a drain, catheterization.
Use of properly sterilized material.
- Periodical removal and reinsertion of sterilized catheters and drains.
Proper handling of catheters, suction tubings and other equipment.
4. Keep the contaminated instruments aside for disinfection, cleaning, repacking and re
sterilization. Infected materials should be discarded and incinerated wherever possible.
Soiled infected linen should be washed separately using steam and sterilized. Sputum cups
to be incinerated (it disposable) or disinfected and autoclaved. Bed pans and urinals to be
washed and disinfected between uses.
5. Isolation ward facilities should be available for admitting patients with communicable
diseases.
6. Indiscriminate and inappropriate use of antibiotics should be discouraged as this leads to
spread of drug resistant strains of bacteria. The following are the main points in determining
an antibiotic Use of antibiotics, only when clearly indicated.
Use of antibiotics in adequate dosage, for sufficient period of time.
28
’Wft!*'.-
7. Staff with infections should be discouraged from operating on a patient,
Monitor all the
personnel employed in high risk areas bacteriologically.
8. Control of movement and number of personnel mainly in theatre and also in the wards.
Infection Control Committee:
The hospital infection control committee plays an important role in laying down policies for the
control of Nosocomial Infections.
The members of the Committee are:
- Medical Superintendent
- Surgeon & Physician
- Operation theatre In-charge
- Nursing Superintendent
- Microbiologist
The committee formulates policies to be followed in relation to :
- General cleanliness.
- Maintenance of proper aseptic techniques.
- Disinfection procedures, including uses of chemicals disinfectants.
- Antibiotic use, control of indiscriminate use.
- Periodical immunization of personnel.
- Notifiable disease.
And the Committee will :
- Conduct periodical review of statistics on nosocomial infections.
- Supervise epidemiological investigations.
- Review Current Policies.
- Convey infection control information to hospital staff.
For achieving better control of infection, brushing up classes should be conducted to all health
care workers periodically and by rotation. Thus we can achieve Vision 2020 without any extra
investment.
AP-09
THE STATE OF THE PUBLIC HEALTH SYSTEM IN PATANCHERU AND
JINNARAM MANDALS OF MEDAK DISTRICT, ANDHRA PRADESH
The preliminary study was done to understand the functioning of the Public health system in the
Industrial Blocks of Medak District and to understand the relevance of the health system in light
of the health report made by Greenpeace India. Patancheru and Jinnaram Mandals were covered
in the study.
For this...
The distribution of the Primary Health Centres (PHCs) and Rural health Centres (RHCs)
in the area were examined
The services rendered at the PHCs and RHCs were examined
The functioning and efficacy of the sub centres were taken into consideration
A preliminary tool evaluation of services rendered to women and children were evaluated
thorough a screening for Vitamin A deficiency
29
*■
Observations were made on the availability of staff of the health centres - PHCs, RHCs
and Sub centres
The Investigator’s Chief Observations
I he area is most certainly in chemical crisis with all water sources being polluted by a variety of
cocktails of chemicals. 1 he stench in the ground water and the colour speak clearly of the
pollution without the aid of studies and reports. There are many children, women and men, both
young and old having many health disorders affecting all body systems. There are children
laving arthritic pains, allergies, eczema, rashes and scabies. Many women whom we came
across complained of severe skin allergies and rashes and reproductive disorders, which were
chronic, and they had little money to approach private doctors for medical or surgical care. This
certainly speaks of a lack of primary health care and lack of awareness among people of the
neglect. I here is big need for a change in tact of the health services in Patanchcru to make
healthcare available to those already under tremendous pressure from pollution, lack of
livelihood opportunities, and the lack of clean air to breathe. Staff should be trained to report
different cases of pollution related health risks and monitor the quality of life of the people in the
Mandal by assessing the situation regularly with the necessary tools.
The whole of IDA Bollaram area of Jinnaram Mandal has a combined population (migrant
population plus local population) of more than 30,000. The official figures of the PHC show it to
be less than one fourth that figure. To add to it, there is no sub centre building or staff member
posted in the IDA Bollaram area (the post remains vacant). The interior location of the Jinnaram
Mandal PHC makes it inaccessible to the far-off sub-centre areas. On the brighter side, the
Jinnaram Mandal PHC medical officer is residing at the PHC staff quarters and is one of the very
rare doctors in the public health system to do so. He is available at the PHC on at least 350 days
of the year, as some locals put it. He is one of the very rare Government Doctors who do so in
Medak District.
1 he RHC at Patancheru is manned mainly by staff from the Osmania Government Hospital in
the Hyderabad city and has no direct binding to share responsibility with the staff of the sub
centres under the Bhanur primary health centre. On enquiry, the RHC staff didn’t have data on
sub-centres fall under the purview of the Bhanur PHC.
If I was a doctor in the Public Health System, I should constantly build awareness among locals
about the dangers of living with such toxic chemicals and also report these findings regularly to
officials to act immediately, but this is not easy for a doctor in a system that does not give that
kind of leverage for free thought and feedback. I think the staff and doctors in the Public Health
system in all these areas need to be motivated to wake up the health system in the Industrial
Areas and deliver now. First cover the backlog, and then keep the system crisp and sharp.
The need of the hour is an apology from the Government to its little children for neglecting them
and their healthy futures to such a great extent that they have permanent damage to eyesight,
their psyche and to each cell in their body that has taken chemical insult that was preventable. 1
wish these children wouldn t have to feel guilty for being so helpless, really helpless.
The Profile of the number of health facilities in Medak District
30
S/.A/o.
Units
1
'2
3
4
5
6
7
Item
ELECTRICITY
No. of villages electrified
Domestic services
Commercial
Agricultur
Substation 33/11 KV
Substation 132/33 KV
Substation 220/132 KV
No.
No.
No.
No.
No.
No.
No.
1262
2445804
21598
130531
153
16
3
1
2
3
4
RURAL WATER SUPPLY
Habitations covered with P.W.S.
Habitations covered with C.P.W.S.
No. of Handpumps
No. of seasonal Borewells
No.
No.
No.
No.
1464
13
12753
263
No.
No.
No.
No.
No.
No.
No.
No.
No.
No.
No.
No.
1687
622
389
5
23
1
8
1
3
5
1
2
No.
No.
No.
No.
No.
No.
No.
No.
No.
No.
No.
12
4
57
331
869
180
1
2
2
4
15
1
2
3
4
5
6
7
8
9
10
11
12
1
2
3
4
5
6
7
8
9
10
11
EDUCATION
Primary School
Upper Primary Schools
Secondary Schools
Higher Secondary Schools
Junior Colleges
DIET (TTC)
Degree Colleges
Medical colleges
Engineering Colleges
I.T.I.
TTI
Polytechnic colleges
MEDICAL FACILITIES
Government Hositals
Civil Deispensaries
Primary Health Centres
Sub centres
Bed strenth in Hospitals & Dispensaries
Docts
Hospitals for Lepracy
T.B.Control Centres
malaria units
Urban Health Centres
Round the clock women health centres
Particulars
2
I. PATANCHERU MANDAL
Structural Deficiency
Lack of planning on the distribution, location, and services Patancheru and Jinnaram Mandals
are located in the southern part of Medak District adjacent to Hyderabad. The distribution and
functioning of the Health facilities in the area was found to be quite illogical or inadequately
planned considering various factors. In addition, they were grossly inadequate.
In view of the local population and a large additional migrant population in the region
2 The Profile of (he number ofheahh facilities in Medak District. | w v w .a pi nd .co m/med a k. pd f (commissionerate of industries. Govt of Andhra Pradesh)
Accessed on 22 August 2004|
31
At the Rural Health Centre (RHC), people from the Patancheru town and many other
little towns are refused treatment and referred for treatment follow up to the Bhanur PHC
because the town area does not come under the jurisdiction of the RHC. .
I he Mandal Primary health Centre is located deep inside the southern half of the Mandal
and very far from its sub centres located in the northern part of the Mandal. One could
simply put it as “inaccessible” without much research.
Primary healthcare and messages of primary health is not reaching a large target
population in Patancheru Mandal
Refer: The screening of children from around Patancheru area (lylapur and Gandigudem,
Photos attached)
The Patancheru Mandal has one small PHC catering to 20 sub centres and to a population of
more than 80 thousand (each sub centre catering to approximately 4600 to 5000 population). 3
Since the industrial area is catering to heavy traffic, the roads are extremely bad and the people
have very few transport facilities. The system therefore has not taken this into consideration
before making Bhanur the location for the PHC. Added, the PHC infrastructure should have been
set up beginning operations.
The location of the Bhanur PHC makes it totally irrelevant and unused. This PHC was set-up a
year ago and has no services to offer (surgical or medical). The PHC is simply located wrongly.
n
Al
ila
^pnatapalO-
IndiaX
0
7^
W
r
4 km
R.F 1.2,00,000
Z-M'
Lakdaram
2
kJ?.
ctflapotharam Jndole
■^50^
.(
Isnapur
... ------Indreeiham
-
!
‘’^Beeranguda
Bhanur (PHC)
Nandigaon
Buffy zone (metre)
S wo
__
Rural Health
Centre
y
/
\
msoo
I
!
* industrial location
/\yWatershed boundary
A/Stream
I
Sulfanpur
I
Ameenpur
Kistareddipet
P0Caharam
Muthangi
J
3 NHFS report 1999
32
Hf.
-if
Source: GIS FOR ENVIRONMENTAL AUDIT OF HYDERABAD METROPOLITAN REGION, RANGA
REDDY & MEDAK DISTRICTS OF ANDHRA PRADESH, INDIA
Source: GIS FOR ENVIRONMENTAL AUDIT OF HYDERABAD METROPOLITAN REGION, RANGA
REDDY & MEDAK DISTRICTS OF ANDHRA PRADESH, INDIA
The RHC (rural health centre) run by the Osmania Medical Hospital is located in an old building
in Patancheru caters to 2 sub-centres in the Mandal and one in the adjacent Sangareddy Mandal.
NB: The RHC refuses treatment to those hailing from villages that fall under the Bhanur PHC.
Please refer the Map of the area.
The structural deficiency in the Public Health System in the Mandal is obvious to everyone
except the department.
Lack of services for Women’s Health
The RHC has 70 staff members on its rolls including gynaecologists, paediatricians, medical
officers, senior house surgeons, staff nurses, administrative staff members, Male health workers,
peons, ayahs, and paramedical staff members like lab technicians and pharmacists.
Here DPL (family planning operation) camps are conducted regularly to meet family planning
operations and a few deliveries are done. The 70-staffed health centre does not have an
anaesthetist to aid in hysterectomies, other emergency operations like C-sections. The private
hospitals in the neighbourhood have 5 staff members but have theatres to cater to the people,
though at a cost. Hysterectomies are being performed in the area indiscriminately for costs
between 7 and 10 thousands.
The RHC timings are very arbitrary and often unsuitable for use. The days our investigators went
to the RHC (2011 and 21st August, 2004), the RHC closed services at 12:15 pm sharp. When we
took some pictures of the RHC, the peons were offended and made a big scene.
The RHC evidently did not deal with treatment of people living with HIV/AIDS. The stress was
completely on DPL camps and tubal ligation procedures and uncomplicated deliveries.
Lacunae specific to Patancheru, Jinnaram and Gummadidala PHCs
The PHCs and RHCs do not assess the health status of the people in the Mandal in view of the
increased pollution. They are not geared or equipped to do so, while they could best perform
surveillance, referrals, and follow-ups and also monitor and assess the impact of industrial
pollution on the people’s health in the region. This is again a deficiency because of the
uniformity with which all PHCs and RHCs are treated with their duties in view.
The responsibility of the PHCs and RHCs to regularly make impact assessments on the health of
women, children, men, young and old, has significance when they are under tremendous
pressures from environmental damage and livelihoods are drastically changed.
None of the sub centres have examination tables, adequate illumination, signboards, tables,
chairs, delivery tables, and adequate” infrastructure to cope with an emergency to provide primary
care. The sub centre rent provided monthly to the sub-centre staff is being grossly
misappropriated. No health education camps were conducted in the sub-centre areas of Sultanpur
and Ameenpur and Kishtareddipet in the last one-year. (Date: Aug 20 2004)
33
I. A
Screening of Children with Vitamin A deficiency in Gandigudcm Village in Patancheru Mandal
Total screened 36 children
Examined on Saturday, 21 August 2004.
Dr. Abraham Thomas, Community Health Fellow, CHC Bangalore.
The examiner is Telugu speaking
The Criteria for identification of Vitamin A deficiency arc
Bitot Spots (small white plaque-like patches on the sclera)
Brown to black discolouration of the sclera with wrinkling and dryness
Severe if- an Infected eye with damage to the sclera and the cornea
Children who give a history of poor vision and night blindness
Available resources for examination and documentation
Torchlight
Good sunlight
Camera
NB: All children came along with their parents for the screening
Chart showing the details of the screening
I
I
Name of child
1.
Bitot Spots
Brown Wrinkling
of Sclera
Negative
Negative
Negative
Positive
Vitamin A Deficiency
Positive
Vitamin A Deficiency
Wrinkling
Vitamin A Deficiency
1 Vi
Wrinkling, Severe
Vitamin A Deficiency
Yrs
lyr
Discoloration_______
Age
Pothagiri
4 ’/2
Divya_______
yrs
2. Santu
5 yrs
3. Golla Anusha
3 yrs
4.
4 yrs
Mouinika
Positive
Rcmarks/Diagnosis
Godugu
5.
6.
Aslam Sheik
Akram Sheik
Wrinkling, Severe
Discoloration
Age
Bitot Spots
Brown Wrinkling of
Sclera______________
Vani_________
5 yrs
Negative
Negative
Baby Shalini
8 yrs
Positive
Discoloration
Shashi Kumar
5 yrs
Negative
Negative
10. Sai Kumar
3 /i
yrs
Positive
Positive
I 1. Lahari
lyr
Negative
Negative
12. Shaheen
11 -
Positive
Positive
Name of child
7.
8.
9.
Vitamin A Deficiency
Remarks/Diagnosis
Vitamin A Deficiency
Vitamin A Deficiency
Severe Vitamin A
34
12
Yrs
13. Nusrat
14. Sravanti
15. Shabbir
16. Tarun
17. Pinky
18. Tayyab
19. Sai Kumar
20. Anusha
21. B Mounika
7-8
Years
5 yrs
4 yrs
4 yrs
Positive
Positive
Positive
Positive
Deficiency with vision
defects and Night
Blindness. Insensitivity
to light Excessive Tears
Severe case of Vitamin
A deficiency_________
Vitamin A Defficiency
Negative
Positive
Vitamin A Defficiency
Positive
Severe discoloration of
Sclera
1 Vi
yrs
3 yrs
Negative
Negative
Positive
Positive
Vitamin A Defficiency
7 yrs
Positive
Positive
Severe case of Vitamin
Deficiencx
5 yrs
Positive
Negative
11 12 yrs
6 yrs
Positive
Positive
Vitamin A Deficiency
Positive
Positive
Positive
Poor Health, with
Scabies, fever and
cough_____________
Vitamin A Deficiency
Positive
Vitamin A Deficiency
22. Naresha
25. Navaneetha
2-3
yrs
12
month
_s____
7 yrs
Nil
Nil
Nil
26. Kalyan
4 yrs
Positive
Positive
Vitamin A deficiency
Positive
Weakness in limbs,
inability to walk, and
Vita A deficient
23. Priyanka
24. Nazeema
2yrs
27. Madhhu
Name of child
28. Poojitha
29. Harish Yadav
30. POChiaiah
31. Radha
32. Sruthi
33. Pravalika
34. Meena
Age
Bitot Spots
11
month
s____
Negative
Brown Wrinkling
of Sclera________
Negative
3 yrs
Negative
Positive
3 yrs
Positive
Positive
3-4
Yrs
10
month
s____
4
years
4 yrs
Negative
Negative
Negative
Negative
Negative
Negative
Positive
Positive
Remarks/Diagnosis
Severe joint aches
(non specific??)_____
Vitamin A Deficiency
Severe case of Vitamin
A deficiency (belongs
35
35. Anisa
D/o Anganwadi
Teacher Ms.
Hussein Bi
36. Madhuri
2 yrs
Negative
Positive
3 yrs
Positive
Positive
to Dayaram village
under Sultapur
Subcentre)___________
Mild case of Vitamin A
deficiency
Vitamin A Deficiency
Our assessment showed that most children 3 years and older suffered from severe Vitamin A
deficiency. On enquiry, it was found that the ANM, as a practice, visited the village only once a
month and the Anganwadi was set up only 2 years ago.
Observation: This kind of occasional visits to villages is dismally inadequate keeping in mind the
necessity of community awareness building. These are the reasons for poor access and poor
utilization of services from the government too.
Gandigudem is a little village of 1400 people with around 170-200 households. The Anganwadi
centre caters to around 34 children below 6 years. The Anganwadi Worker, Ms. Hussein Bi, was
posted there two years ago, when she came to the village after her marriage. She has reduced the
incidence of Vitamin A Deficiency since the last two years.
Question: What is the fate of the children in the villages/hamlets that do not have an Anganwadi
centre and an Anganwadi Teacher like Hussein Bi as yet?
The Jinnaram PHC and Gummadidala PHCs are located in the Northern half of the industrial
block. The Gumadidala PHC is catering to a thirty thousand people and the Jinnaram Mandal is
officially catering to about 35,000 people.
36
Service/Infrastructure
Village
Each covering
approximately
population of five
thousand
o
-O
2
Z
<
2
o
o
>
Z CJ
Ji
sn
'5 o S
s
.22
1.
> -2
111
I
s1
11 il
3 -s
o
CO O
w
PHC
Equipment
Not
Avbl.
Not Avbl.
Not
Avbl.
o
h 1
■y>
u
2
2
i
S'
!
c v
□ M
1
e g
< s-
.i > 1
u3
Not Regularly
Supplied
NO
No
NIL
f- £
Available
Old
None are
own and
functional
2. Nandigaon
ANM Available
Old
No own
building
No
Equipment
Not
Avbl.
Not Avbl.
Not
Avbl.
Not Avbl.
NO
No
8-10
3.
Rudraram
Available
Old
No own
building
No
Equipment
Not
Avbl.
Not Avbl.
Not
Avbl.
Not Avbl.
NO
NO
10 kms
4.
Lakdaram
Both Available
New
No own
building
No
Equipment
Not
Avbl.
Not Avbl.
Not
Avbl.
Not Regularly
Supplied
NO
NO
11 kms
5.
Isnapur
Available
Old
No own
building
NjoEquipment
Not
Avbl.
Not Avbl.
Not
Avbl.
Not Regularly
Supplied
NO
NO
8 kms
6.
Muthangi
Available
New
No own
building
No
Equipment
Not
Avbl.
Not Avbl.
Not
Avbl.
Not Regular!}
Supplied
NO
NO
5 kms
7.
Patancheru A
ANM Available
Old
No own
building
No
Equipment
Not
Avbl.
Not Avbl.
Not
Avbl.
Not supplied
regularly
NO
NO
10 kms
1.
Bhanur PHC
/Sub centre
37
z
<
8.
Patancheru B
Available
Old
9.
Patancheru C
ANM Available
Old
10. Patancheru D
ANM Available
New
11. Patancheru E
ANM Available
New
12. Patancheru F
Available
New
13. Ameenpur
Available
Old
14. Beeranguda
ANM Available
New
15. Kistareddipet
ANM Available
Old
16. Sultanpur
ANM Available
Old
17. Indreesham
Available
Old
18. Pocharam
Available
New
19. Kcsharam
ANM Available
20. Indreesham
ANM Available
Old
No own
building
No own
building
No own
building
No own
building
No own
building
No own
building
No own
building
No own
building
No own
building
No own
building
No own
building
No own
building
No own
building
i
e3
O
CD
S)
d
>
No
Not
Equipment Avbl.
No
Not
Equipment Avbl.
No
Not
Equipment Avbl.
No
Not
Equipment Avbl.
No
Not
Equipment Avbl.
No
Not
Equipment Avbl.
No
Not
Equipment Avbl.
No
Not
Equipment Avbl.
No
Not
Equipment Avbl.
No
Not
Equipment Avbl.
No
Not
Equipment Avbl.
No
Not
Equipment Avbl.
No
Not
Equipment Avbl.
o
-o
I in
C5
S
. ° S
3
£
’3"
E
Not Avbl.
Not Avbl.
Not Avbl.
Not Avbl.
Not Avbl.
Not Avbl.
Not Avbl.
Not Avbl.
Not Avbl.
Not Avbl.
Not Avbl.
Not Avbl.
Not Avbl.
<u
Not
Avbl.
Not
Avbl.
Not
Avbl.
Not
Avbl.
Not
Avbl.
Not
Avbl.
Not
Avbl.
Not
Avbl.
Not
Avbl.
Not
Avbl.
Not
Avbl.
Not
Avbl.
Not
Avbl.
5
s
v
_____ ______
Not Regularly
Supplied
Not Regularly
Supplied
!
1
■h. l
Lili 11 1=
NO
NO
10 kms
NO
NO
lOkms
Not Avbl
No
NO
10 kms
Not Avbl.
No
NO
21 kms
Not Avbl
NO
NO
10 kms
Not Regularly
Supplied
NO
NO
11 kms
Not Avbl.
NO
NO
5 kms
Not Regularly
Supplied
Not Regularly
Supplied
Not Regularly
Supplied
Not Regularly
Supplied
Not Regularly
Supplied
Not Regularly
Supplied
30 kms
28 kms
33 kms
5 -7 kms
PHC. Bhanur and ANM available at the lime of visit. Since no doctor or other administrative staff members were available on Friday. 20 August 2004
38
AP 10
TESTIMONY BY HYDERABAD METRO WATER SUPPLY & SEWERAGE
WORKERS UNION
The representatives of the Hyderabad Metro Water Supply & Sewerage Workers Union
presented their case of "denial of healthcare’ and poor working condition.
The workers presented their case with emphasis on:
1) Poor working conditions
2) Poor healthcare facilities and access to healthcare
3) Compensation for workers who died on duty.
They also presented to Justice Bhaskar Rao, a memorandum urging speedy disposal of cases and
action on their plight.
AP 11
TESTIMONY BY A PERSON LIVING WITH HIV/AIDS
The testimony was presented by a person living with HIV/ AIDS. He was from Khammam
district in Andhra Pradesh. The person narrated how he was denied surgery at the Government
Hospital in his district because his HIV Positive status was known to the care-providers of the
hospital.
An NGO representative from Andra Pradesh, in her intervention from the floor, also raised the
issue of women who were positive being denied in-patient care or even minor surgeries.
39
Annexure 4
DETAILS OF CASES FROM KARNATAKA
KA 01
DENIAL OF HEALTH CARE IN THE PHCS OF HUNGUND TALUK, BAGALKOT
DISTRICT OF THE KARNATAKA STATE
Nature problem-Denial of treatment:
1) Inaccessibility
2) Infectious diseases and treated
3) Immunization incomplete
Type of Denial:
1) Treatment not given
2) Vaccinations not given
Consequences:
1) Death
2) Financial Loss
3) Spread of Chronic diseases like TB, children not vaccinated
Severity of the denial:
1) Serious
What is needed:
1) Re-structuring & Re-distribution of their PHC’S needed
2) Upgrading the PHC’S staff.
An appeal to the NHRC by two villagers and their signatures. This will be submitted at the
time of hearing.
Denial of Health Care
(Inaccessbility)
Denial of health care can occur in various forms. Denial of health care occurring in
Hunagund taluka of bagalkot district causing great inconvenience to the thousands of people and
preventing them from getting the most necessary medical care is being brought to the kind
attention of NHRC.
Kindly refer to the the attatched map of Hunagunda taluka. There are four PHC’S at a
distance of 3 k.m. from one another.
PHC HAVARAG1
PHC MAROL
PHCDHANNUR
PHCTANGADAG1
Villages of HA VARAGI PHC are 40-50kms away from HAVARAGI, but ver nearer (2lOkms) to KARADI.
40
Villages of KARADI PHC are 25-30kms away from KARADI.
Villages of MAROL PHC are 30-40kms away from MAROL, but very nearer (2-lOkms)
to HUNAGUNDA General Hospital.
Villages of DHANNUR PHC are 25-30kms away form DHANNUR, but nearer to
AMINGADA.
Villages are far away from PHC’S. They belong to, but nearer to other PHC’S.
This causes great inconvenience for people to go and get medical care from their PHC’S. They
have to spend 30-50 rupees per person per visit on bus fare to attend to their PHC’S. It takes
almost a full day for a person to come and go back to their village.
Meanwhile there are other PHC’S nearer to the PHC, they belong to. People are often refused
medical care on the grounds that they belong to other PHC’S.
People in the locality have tried various methods to convince the authorities to include them
under nearest PHC’S.
Eg: 1) Hcmavadagi:
Population - 687
PHC-HAVARAGI.
Distance from PHC - 45 kms.
Nearest PHC-KARADI.
Distance from the nearest PHC - 3kms.
2) Palathi:
Population - 600
PHC - HAVARAGI
Distance from PHC - 50kms.
Nearest PHC - KARADI
Distance form the nearest PHC - 2kms.
3) Amaravadi:
Population PHC-MAROL
Distance from PHC - 30kms.
Nearest PHC - HUNAGUND
Distance form the nearest PHC - 2kms.
4) Islampur:
Population - 693
PHC - HAVARAGI
Distance from PHC - 55kms.
Nearest PHC - KARADI
Distance form the nearest PHC - lOkms.
Therefore there is a need for reorganizing and redistributing PHC’S and their villages otherwise
this leads to denial of health care.
41
DENIAL OF HEALTH CARE
(Infectious Dieseases untreated)
1) Name of the patient - Rajappa Amarappa Walikar,
Age - 45 years
Village - Amarawadagi.
He was suffering from pulmonary TB for 1 year. He was not able to come to the
HAVARAGI PHC which is 50kms away. Because of financial difficulties and geographical
inaccessibility. People from these villages are denied treatment at KARADA (8kms away)
Hence he couldn’t get the treatment and ultimately he died. Many others are also facing
same kind of problems since many years.
Because of long standing untreated illness like this many such communicable diseases are
transmitted in communities.
2) Name of the patient - Amarayya C. Math
Age - 55 years.
Village - Lavalasar.
PHC-HAVARAGI.
He was diagnosed as having Pulmonary TB at district TB hospital, Bijapur. He was asked to
go to the nearest PHC for treatment. He was unaware that to which PHC his village belongs
to. One and half months passed before the treatment for TB was started.
3) Name of the patient - Chandravva
Age - 60 years.
Village - Palathi.
PHC-HAVARAGI.
Having pulmonary TB since one and half years, she is not able to go to the PHC and get the
treatment because of financial difficulty and geographical inaccessibility.
DENIAL OF HEALTH CARE
(Immunization incomplete)
As the villages are far away (40-55 kms) from PHC’S, people are not coming to PHC for
vaccinating their children and also there is inadequacy of health staff, hence majority of the
children are not getting fully immunized. This amounts to denial of health care to the
children.
Eg: 1) Dasabal Village:
Children born after 2000 : 044
Children completely immunized : 04
Percentage of immunization : 09 %
2) Amaravadagi:
Children born after 2000 : 079
Children completely immunized : 014
Percentage of immunization : 17.7%
42
KA 02
CASE PRESENTATION ON MENTAL HEALTH
Issues:
1. Centralized Mental Health Care Eg. N1MHANS -KIMHS
This does not help the poor especially the rural poor, as they don’t have access to these
facilities. The problem becomes even worse in the case of OPD patients as they are not
able to come every month on the fixed day (money and non availability of the care giver)
hence miss their treatment and get back to their pervious state-loose trust in the medical
profession
2. Stigma and Discrimination
People are chained and locked in even hospitals and care homes in all the 21 districts
where Basic Needs operates.
3. Lack of Awareness about Mental Illness
No public education or awareness programme even though the prevalence is around 1015%
4. Lack of training for Medical Professionals
Non-identification at an early stage leads to chronic illness and disability.
5. Non availability
In Koppal district there is not a single qualified govt, psychiatrist where many cases have
been identified by Basic Needs
6. Non Availability of drugs
In Karnataka there have been instances of Doctors not indenting drugs for treatment of
psychiatric patients. Recently there was a case of psychiatric drugs lying at the Central
Stores and getting expired without being supplied by the Govt, of Karnataka
7. Ignorance among Medical Professionals
Another important issue is that the very curriculum for MBBS has the bare minimum on
mental health. Plus interns are giving only 15 days of posting in a mental health facility
and this is optional.
8. Physical & Sexual Abuse
9. Denial of Property rights
43
KA 03
USER FEES AND DENIAL OF HEALTHCARE
Introduction
The ingestion of alcoholic beverages for their so-called “enjoyable” effects is a very common
phenomenon especially among youngsters. Later on, it leads to chronic abuse of alcohol An
enormous amount of damage can be attributed directly to alcohol abuse. It results in the ruin of
the physical, social and mental health of individuals and families, besides eating into the family
income of the drinkers. Alcohol also contributes to other problems; an estimated 25% to 40% of
hospital patients have problems caused by, or recovery delayed by alcohol abuse (Maltzman
2000).
Alcoholism is a chronic progressive illness, which manifests itself as a behaviour disorder. It is
characterized by repeated and excessive drinking of alcohol beverages. If not treated in time, an
alcoholic can die of medical complications like gastro intestinal, liver, pancreas, central nervous
system and cardiovascular system problems, accidents and even to suicide. The treatment
consists of detoxification, counselling after care and rehabilitation.
Case Study
Das (name changed to conceal his identity) was denied access to de-addiction treatment at
National Institute of Mental Health and Neuro Sciences, Bangalore.
Das is a 54 years old male, who currently resides in a registered Sudhamanagar slum (very near
to Hindustan Aeronautical Limited, Bangalore). As the result of numerous years of drinking to
excess, he has severe physical, social and economic problems. Das is a construction work mason
and is going for job, which is seasonal. Now, he works for the .sake of fulfilling his alcohol
needs. He frequently falls sick and eats at most once a day. He starts drinking soon after he
wakes up. Around 5 a.m., he walks directly to alcohol retailers and consumes one quarter i.e.,
180 ml of brandy or whisky (Rs 28) to help his hangover. When he goes for work if there is no
problem in the working place, he consumes another quarter at noon and again in the evening and
at night. He earns Rs. 150/- for a day and spends all the money for alcohol consumption. If he
has no money he tries his best to get it from his wife, who is the breadwinner of the family doing
domestic work. His wife and children are psychologically affected. His wife says that she finds it
difficult to provide one meal a day for the family. Their only 14 year old son stopped going to
school due to poverty. Social stigma makes them keep away from the community and their
relatives. Now Das feels helpless, isolated by the community and has no plans for the future.
Patient History
Das was the youngest child of eight children in a small farmer family in Mugaur, Villupuram
district, TamilNadu. At the age of six, he was sent to Bangalore to live with his elder brother,
doing plumbing work. His brother consumed alcohol each day in the evening; sometimes he
asked Das to get alcohol beverage from the shop. On Sundays, his brother used to drink toddy
and offered toddy to Das a few times, saying that it was “good for health”.
44
Thus he started to taste alcohol and whenever he went to the retail shop to get alcohol beverage
for his brother, his thinking was “why shouldn’t I drink as well?” Day by day this urge was
increasing with him and finally one evening he got the courage of experimenting it by
consuming 90 ml of Brandy. He felt good and thrilled. Slowly he started to drink twL in a
week and it increased to « daily evening basis. At this stage, his family people became alert and
arranged a marriage for him as a solution to this problem. After the marriage, for two years he
did not consume alcohol. When his wife was sent to her parent’s place for delivery of the first
baby he started to drink again. As a result, he was forced to move out from his brother’s home
I his was a very sorrowful matter to him, and he started consuming alcohol even more (from
mo™ngJ° evening, i.e. morning 180 ml (quarter) afternoon one quarter and the same in the
night). I he heavy consumption continued through the following years.
Then, onec day his
disappeared: she
1115 teenage
leena8e daughter
daughter d.sappeared;
she ran away with a boy who lived in the
nearby slum. It made him miserable and he started ‘binge drinking’. (Psychologically daughters
ong or at er s love and affection, when they do not get this affection and love, they try to get it
from others of the opposite sex. It happened to Das’s daughter as well; at the age of 16, she
eloped with the teenage boy.) Today, Das’s health condition is very poor and he cannot live
without alcohol. Delaying consumption also creates heavy withdrawal symptoms in him which
is an advanced or chronic stage of alcoholism. When the social workers tried to motivate’him to
quit nnking, he never accepted that alcohol consumption was a problem. But at the sessions of
the cohol Anonymous members sharing, he finally did accept that his drinking is a mistake
ana a problem, and he was willing to get treated.
Denial of Health Care
Das went to NIMHANS on 1 7.5.03 to get the treatment. Since Das was a chronic alcoholic with
severe withdrawal symptoms, Das needed admission for treatment of his physical and
Psycho logical dependency. But he was denied the inpatient treatment, reason given being “no
beds in the de-addiction ward. A prescription for medicine was given to him. He was asked to
come next week for inpatient treatment. When he went to NIMHANS the following week he
was asked to deposit Rs.2, 000/- for the treatment. The World Bank’s prescription of ‘user fee
method was introduced at NIMHANS from this financial year. The policy of NIMHANS was
that the patients submitting BPL (Below Poverty Line)card would get the treatment with a
eposit ot Rs.250/- and all others including the urban poor (migrants people) not holding BPL
cards should pay for treatment, with a deposit of Rs.2000/-. Das could not deposit Rs.,2000/tor the treatment. Since Das did not have ration card even though he was living in one of the
angalore slums and could not provide BPL (yellow) card, health care was denied to him. Das
is now suffering from fits due to his alcoholism, being not able to receive the treatment due to
the user fee’ method set in motion at Government Hospitals. He is miserable and sick. There
!S no health program or scheme to deal with this important and widespread public health
problem. His wife is the main earner working as a domestic help in three houses They have 3
children.
gpnclusion: Most of the slum dwellers do not have a BPL card. So, in the scenario of ‘user
lee pay system in the Government hospital, most of the slum dewellers are denied health care
even though they have all the rights to get it. Because Das could not pay, he returned home
rustrated that he had gone to the hospital but denied treatment. He says that he has given the
nope of getting treatment and is prepared to die.
45
KA 04
CAMPAIGN AND STRUGGLE AGAINST ACID ATTACKS ON WOMEN (CSAAAW)
No. LF 17/6, BDA Flat, Opp. MICO layout Police Station, B.T.M. Layout, Bangalore - 560 078.
Ph: 9448444252,6786754. csaaaw@rediffmail.com
"This ear is burnt completely. I can hear in only one ear now. Even this eye is partially burnt, I can 't see
very clearly. My eyelids were also completely burnt. They were replantedfour times with skin from
elsewhere. My lips were also burnt and I had to have several operations to gel it reconstructed. The skin
around my neck had also tightened, with my head being pulled to one side. Another four operations to
straighten my neck, but even now without this belt, the skin pulls my head to one side. When that happens,
the skin around my lips and lower eyelids are also pulled downwards. That is why I have to wear this
collar all the time. ”
-Shanthi M.G., Mysore District, Karnataka
Following 14 years of sustained domestic violence, Shanthi was attacked by her husband in 2001
with concentrated sulphuric acid at her residence in Periyapatna Taluk, Mysore District,
Karnataka. Immediately following the attack, Shanthi was taken to the taluk level government
hospital in Periyapatna and shifted from there after the medical staff at the hospital admitted to
their inability to treat Shanthi. She was taken to the K.R. Govt. Hospital in Mysore where she
remained for the next 19 days.
“They did not give me any first aid, just wiped my face, my eyes were fully red and my face was
burnt black. They gave me IV fluids for the next nineteen days. They didn’t do anything else.
They didn’t dress it or apply any ointment. Yes, this was K.R. Govt. Hospital.”
Mother of two children, 32-year-old Shanthi today is struggling to live by herself and bring her
two children up. Her problems both physical and psychological have been compounded by acute
lack of medical attention immediately following her attack. Several doctors have confirmed that
not receiving appropriate immediate medical attention has infact worsened her condition.
Growing medical costs and lack of adequate facilities required for functional plastic surgery in
public health institutions has meant that Shanthi today struggles to live. Shanthi, however
considers herself lucky. Four other acid attack survivors across Karnataka, all of them women,
have in fact succumbed to their injuries.
The initial fact finding reports from Campaign and Struggle Against Acid Attacks on Women
(CSAAAW), a coalition comprising several organisations, academicians, lawyers, journalists,
women’s rights activists, reveal that there are 35 women who have been attacked by acid in the
past ten years across Karnataka. CSAAAW activists categorically maintain that this number is
only an indicator, there are / were many others who have been silenced by society and are
unwilling to come out in the open with the horrifying facial distortions.
CSAAAW is committed to action on two fronts - seeking legal and socio-economic justice for
the survivors and more importantly to fight for prevention of such attacks on women. 4*Acid
attacks is only a more violent extension of the existing crimes on women like rape, dowry
harassment, sexual harassment by the patriarchal society.
46
KA 05
TESTIMONY OF MR’S MOTHER
Ms MR aged 14 years daughter of Mr. M, Koramangala slums. Bangalore -560 042 went to Dr.
Sumangala Hiremath of Vibhava Clinic 270, 5lh Main, Ambedkar Nagar Koramangala 111 stage
Bangalore- 560 042 with complaints of vomiting and diarrhoea on 1st June 2004 at about 5.00
pm. MR’s mother was interviewed by S.J.Chander of Community Health Cell on 4.8.2004 at
about 3.00 pm and on 12th August 2004 the same time.
MR’s was busy the whole day washing clothes and cleaning the house. At about 3.45 pm she
complained of stomach pain and had diarrhoea (the stool was like water, the quantity was about
2 liters). After 15 minutes she vomited, she complained to her mother that all that she ate in the
morning (chithranna) she vomited. After vomiting she complained of pain all over her body (she
explained the pain as pulling)
At 5 pm her mother took her to Vaibhav Clinic. The mother said though she did not have good
report about the doctor at Vaibhav Clinic, she chose to go to her because as she was passing bv
the clinic was empty. She was not sure if the other clinic near by would be free. As soon as MR
was taken to the clinic the doctor, without examining MR; she started IV fluids. Four bottles of
IV fluids were given before 9.00 pm and five injections were given through the IV fluid bottles.
The doctor promised that the girl would be all right.
In the meantime MR’s mother called up the father who is a daily wager at city market and
informed him that their daughter was very ill and asked him to bring some money immediate]}-.
The father arrived at about 5.30 pm with Rs. 500 which he borrowed from his employer. He sent
away his wife home and stayed with the daughter in the clinic. At about 9.00 pm when it was
time for the doctor to close the clinic, the doctor demanded Rs.500 be paid to her for consultation
and medicines. He replied that he did not have that much money and said he would pay Rs.300.
She did not agree and scolded him. She insisted that he paid Rs. 500. The father had to pay all
the money that he had borrowed and took the daughter home on his shoulder.
The mother said, as soon has her daughter was brought home, she made the bed in the room
(only small room the house has). Before the bed could be made she was asked to stand for few
minutes, while standing she passed again watery stools. “ Seeing this I shouted what is this even
after getting the treatment from the doctor and paying so much money she is having diarrhoea ".
Her husband told her to be quiet.
While sending MR home, the doctor told them to give 4 tablet once at 1.00 am and another time
at 3.00 am. She also told them to give her hot coffee and keep her warm. As she could not eat
anything, they continued give her glucose water, but she continued having watery stools. The
mother made a sanitary pad of cloths and put it on her. She- kept checking if the pad was wet.
Every time it was wet she cleaned and changed. She does not know how many times she had
watery stools. At 1.00 am four tablets were given, MR with difficulty opened the mouth and
swallowed the tablets. The mother sat next to her observing the daughter. She found her daughter
restless, not sleeping. At about 3.00 am they gave the second dose of tablets. This time she took
the tablet with difficulty. She appeared very tired to the mother. The mother noticed few minutes
after taking the tablets, her body movements were almost stopped and she appeared to be in deep
sleep. She poured little glucose water but the daughter did not drink. “ I thought the tablets
47
were working and she is sleeping, I was checking at her nostrils if she was breathing". At 5.00
am when she tried calling her daughter by name she did not respond. The mother said she was
holding a candle in one hand and holding her daughter in her arms and started praying asking
mother Mary to spare her life. Her body became chill, she stopped responding. Her husband told
her that their daughter is no more. As she heard this she fainted. She recouped after few minutes.
By the time she gained consciousness it was about 5.30 am. The father took his daughter in an
auto to isolation hospital in Indirinagar. She said the staff at the hospital checked and said ’ she
had died half an hour ago, why have you brought her here. "
The mother said “ the doctor could have told us that she would not be able to manage my
daughter, we would have gone to another doctor, or she should have guided us to another
hospital or doctor" The mother said the lady doctor’s husband is also a doctor and he was also
with her when her daughter was treated, in front of the clinic where the address is mentioned
there is a board carrying the following information “ Vaibhav Clinic” Dr. Sumangala Hiremath,
clinic timing. No degree of the doctor was mentioned on the board.
Denial of health care:
Consequences:
- Incompetent and negligent care; ‘doctor’ not qualified to practice
allopathic medicine.
- Not informing patient and guardian/relative of the position.
Death of the patient; avoidable with proper care.
KA 06
CASE STUDY OF MRS. S
Mrs. S, 23 years was admitted in the Jagjeevanram nagar Maternity Home in October 2003 for
delivery. There was no doctor on call and she was attended by the attendants and duty nurses.
Two pain killers were given which had to be bought from outside for Rs. 120/-. Later when she
developed severe labour pain, the night duty nurses were called. But they were asleep and
refused to attend to Mrs. S. The baby was delivered with the help of the attendants.
But the
baby slipped from the delivery table and fell in the bucket at the foot of the table. The baby died.
To add further misery, her husband had suffered an accident during the wife’s pregnancy and it
has been confirmed that he will not be able to produce any more children.
The deficiencies were:
a.
b.
c.
d.
e.
Lack of attention.
Gross negligence on the part of the nurses and attendants
No medical care on time
Doctor not informed
Patient had to purchase medicines from outside.
This resulted in
a. The baby's death
b.
Mental trauma to the mother due to loss of the child.
c. Financial loss
d.
1 rauma suffered by family as they are unable to have another child.
48
KA 10
TESTIMONY OF MRS. G
Smt. G, aged 58 years residing Anandapuram slum went to Kidwai Memorial Institute of
Oncology for treatment of cancer of the esophagus. She went there five days in a week for the
past three months. The last visit that she made to KMIO was on 19th July 2004.
Initially she paid Rs. 50 for the registration after that for every visit she had to pay Rs. 10 as bribe
to send her chart to the treatment room. Failing to pay Rs. 10 would lead her to waiting for long
hours. Many days in order to avoid paying Rs. 10, she had brought the chart back home and took
the chart directly to the treatment room the next day. For IV drugs she had paid Rs.400 and
administering charges for the person who did, she paid Rs 1 10.
Every time when she went for radiation therapy, the nurse told her to find herself wherever there
was an empty bed and lie down. " Many days for putting Intra Venous line they allowed the
ti ainee nurses, they could not do it properly, as a result I suffered with swollen hand (rattham
kattipochu) veins with blood clot. "
She said the doctor who gave her the radiation therapy, when he saw her wearing mangalsuthra
(thaali) he was irritated and told her " it is only a traditional symbol, remove it, do you know the
disease you got is dying disease, why do you need all these ornaments."
The person who gave the radiation demanded Rs. 100. he shared the amount with other staff with
him. The next time when she went she did not have money, she offered to give him the sarees
tied to the statue of mother Mary. The staff took two such sarees from her.
She said the person who did the X-Ray too did not talk to her with respect. He asked her to buy
her the powder for Rs.90 from private medical store. She had to pay Rs. 20 for the auto for
transportation to get the powder. The powder is given orally before taking the X-Ray. When she
brought the powder, after the taking the powder she was asked to go. The x-ray technician
demanded money. She gave him Rs. 10. She said saw using the powder that she brought for other
patients and took Rs. 100 from them. During the last stages of her treatment she said she was
given radiation without putting a shield around the unaffected area. " Ifelt the burning so severe
and I had boils all around the area"
She had to get her blood test done twice in two weeks. She paid Rs.275 for the blood test. Next
time when the blood test was asked she did not have the money. The doctor told her to get it
done from any hospital. Since her husband was an ex army man, she went to army hospital and
got it done. I he doctor at the army hospital had given her a prescription but the person at the
drug store did not give her the drugs. She said she went about 25 days for radiation. The doctor
would come at 12.15 p.m. and go away at 1.00 p.m. the doctor came back later some time after
4.00 pm "Some time I had to wait from 9.00 am to 4.30 p.m. to meet the doctor. ”
She said the total amount that she spent during the past three months would be about Rs. 25.000,
which includes money paid for medicines, bribes, and travel cost. "In spite of the fact that I was
introduced to KMIO by an organization known to them and I am a social worker I had to go
through so much ofsufferings, how about people who do not know anything". She said she liked
49
the doctor. Dr. Govind Babu, who treated her well. There was an attender who told her not to pay
money to any body for anything.
Denial of health care: bribery.
Disrespect; psychological trauma.
Incompetence/negligence care
Payment, when it should have been free.
Consequences: excessive expenditure; loss of time, awaiting the doctor
KA II
CASE STUDY OF SONNENAHALLI PHC, VIVEKANAGAR, BANGALORE
Population: 22,000
1.
2.
3.
4.
5.
Male Multipurpose worker is not available.
Disposable Delivery kit is not available.
No specific date and time of the visiting Doctor.
No prior intimation regarding doctor’s visit to residents of the locality.
Traditional / trained dais do not get any co-operation from ANM while
conducting home delivery.
6. t^^HC00 SUPP,y °f diSp°SabIe de,iver>' kits t0 the TBA (Gained brrth attendant) by
7. Emergency obstetric care is not available round the clock.
8. No ANM or trained dais accompany the women in labour while shifting from PHC
to other referral hospital for further treatment.
9. Facility of blood smear examination is not available to confirm Malaria.
Survey form: VHAK, Co-op Aid Trust
KA 12
STUDY ON AUSTIN TOWN MATERNITY HOME
Date of Visit: 12-07-2004 & 16-08-2004
Austin town Maternity Home is easily accessible for people belonging to Jayaraj Nagar,
Koramangala, Vivek Nagar and Neelachandra area. In these areas majority of the population
belongs to lower stratum of society economically. It is not easy for them to pay 5 to 6 thousand
rupees for a normal delivery in a private hospital. (The nearest private hospital in this area is
St.Philominas hospital; here the patient has to pay 5 to 6 thousand rupees for a normal delivery).
So, the people need and depend on this maternity home for delivery and other health care
services.
The services offered at the above centre are as follows.
50
Out patient
Ireatment of minor ailments, immunization for women and children, antenatal and post
natal care for women.
H
In patient
1. Deliveries
2. I ubectomies (Every Wednesday)
3. Cesarean sections and Hysterectomies, where indicated.
Personnel allotted for maternity' home
• One doctor (gynecologist)
• One pediatrician for two maternity homes
• Four staff nurses
• Three ayahs
• Three pourakarmikas
•
Five peons
■» One Lab technician
• Second division clerk
• One Dhobi
Persons available in this maternity home
Doctors
Dr. Shobha is the Lady Medical Officer. She is available in the centre from 9.00 am to I 00 pm
(duty hours are from 9.00am to 4.00 pm). In addition to her a Paediatrician is also available In
their absence in case of an emergency a corporation Doctor (Dr.Siddappaji, working in other
corporation hospital) who resides nearby is called.
Staff Nurses
fipe°dStaff nUrSeS arC °n duty Whi,e two posts are vaca"t. Among the three posts of AN Ms two are
In addition to the above the following personnel work at this centre.
Lab Technician -1
(In charge available on Mon and Fri from 9.00 am to 1.00 pm. Regular
Technician is on Maternity leave)
Pourakarmikas While there are three posts of Pourakarmikas only one was
available on duty
First Division Clerk- 1
(The post is vacant for almost 5-6 years)
Second Division Clerk-2 (O:
(One is deputed to DHO Malleswaram and another works for 4 hrs here
and 4 hrs at another centre)
Aayas-3
-Three Aayas are available in the home
Dhobi-1
- One dhobi is available in the home
Peon
- Three peons are available in
i the home and Two posts are yet
to be filled.
The peon whom we met stated that the deliveries were conducted by the staff
nurse herself (we
are not sure whether this was in the presence or absence of the doctor).
51
Infrastructure
I he centre operates out of a corporation building. Regular water supply and electricity was
available. The building suffers from leakage. Due to this, the plaster has started to peel off from
the roof and the walls. The toilets arc in a very dirty condition and in one of them the taps were
leaking. The numbers of beds available arc thirty (The allotted beds strength is 34) and all of
them seemed to be in a usable condition. The lockers provided for the inpatients were in a rusted
and dirty condition. While the Labour Room was in a working condition, the Labour Cot had
begun to rust and the rubber sheets used were in a very bad (unhygienic) state. The staff put it to
a shortage in the supply of these rubber sheets. The Garbage bin in the Maternity ward was full
and not emptied. Hot water provided for the patients was very little and only in the mornings.
The inpatients said that clean drinking water was not available at the centre and hence they
preferred to bring water from their homes.
When we had a look at the registers we found something interesting. On certain days (4-5 in a
month) a large number of outpatients had come to the Maternity Home whereas on other days the
number dwindled to a handful. The Staff nurse with whom we interacted had no explanation for
this surprising phenomenon. We were left wondering whether it could be because of the
availability of the doctor only on those days for outpatient services.
Service Charges
According to the staff present the following were the services that were charged,
• Lab Tests
Rs. 10/• MTPs
Rs. 100/- (these are the actual amount fixed by the corporation)
All other services were offered free of charge.
However on enquiry among the inpatients one of them told us that they had to pay money for the
delivery that was conducted there. Beyond this they were not willing to divulge any information
as to how much they had to pay.
Access of the center by the people
While visiting the center on 16th August the following details were collected.
From 9/08/2004 to 13/08/2004 the following number of people access different services;
OPD services
-81
No. of ANC patients
-78
No. of In patients
-18
No. of deliveries
-16 (The baby delivered with highest weight is 4.4
Kgs on 9,h August 2004)
No. of referrals
-03
NO. of MTP services
-03
No. of IUD services
-08
NO. of TO services
-2
Apart from the above services immunization services were also given.
Community Visit
While visiting the maternity home the question as to why only a minimum number of people
were using this maternity home arose. This was in spite of the services being provided free.
Neither the doctor nor any of the other staff of this maternity home had an answer for this
question. The only answer the doctor had was that the patients were not staying in the home for
more than a day after delivery. Hence, beds were always vacant. This points io the fact that the
52
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patients are very poor and even after delivering a child, they couldn't take rest in the hospital,
hey had to go back to earn money for their daily living. So, obviously poor people should show
much interest in making use of the services, but the picture is just opposite.
To know this on I3,h July 2004 Mr.S.D.Rajendiran, member board of visitors of Bangalore
Mahanagara Palike health centers and community health cell team and Ameerkhan.K. Fellow in
community health cell were visited Jayaraj Nagar, which is besides the maternity home. Four
women ( Ms.D, Ms.I, Ms.S, Ms.Sa) were selected randomly and interviewed, Some of the
comments collected from them are.
A pregnant women says positively that she is going regularly for Anti Natal Check up, she is
getting folic acid tablets and checking at free of cost, but she is receiving treatment for
maximum of two minutes, where as the pregnant women has to get blood test, urine test
every month, detailed advice from the doctor about nutrition, anemia, sexual relationship
with husband, bleeding and other problems are missing.
•
The other woman who delivered a male baby one year ago at Indira nagar hospital is not
using the home for her child immunization but all the other women are accessing the facility
of immunization from maternity home.
Most of the women said most of the time they have to buy medicine and disposable needles
from the medical shop. There is a strong feeling among them that the staff are not showing
even a small amount of concern.
One lady got a slap from the staff nurse at the time of delivery, when she was crying due to
the labor pain.
A woman who stayed for two weeks in the home for delivery and tubectomy was given one
bed sheet for the whole period of her stay. This has happened even though there is a dhobi
appointed especially for this home.
User Fee in the Maternity Home
This information has been collected from the women who were interviewed.
The amount they paid for accessing the services in the home are as follows,
Services
Amount Paid by the
Patients (In Rs.)
1. Male child delivery
500
2. Female child delivery
300 to 400
3. MTP
400
4. Tubectomy
400
5. Blood test
20
6. Urine test
20
7. Polio drops
2
8. Any Injection (If the patient doesn’t
carry any disposable needles)
5
Government
Fixed charge (In Rs.)
Nil
Nil
100
Nil
10
10
Nil
Nil
53
Apart from these while the patients are discharged
('
from the maternity home they have to pay to
each hospital staff about 25 to 30 rupees.
Suggestions for Improvement (Staffs view)
On being asked if there if they had any suggestions to offer for improving the service at the
Maternity Home, the staff who interacted with us said that availability of more medicines
(antibiotics), and equipment (Warmer), a contract dhobi (as the government appointed dhobi was
not doing the work properly), Availability of rubber sheets and repairing the leakages would
help them to serve the people better.
Visitor’s observation and suggestions
After many interactions with the Dr. Shoba, we felt that she is keen to improve the
quality of the services provided in this home. The opinion has been further strengthened at that
time of second visit to the maternity home on 9,h August 2004. The water filters are cleaned and
Tilled with water. Bed sheets are washed and dried under the sunlight and home is maintained as
dirty free environment.
People who are on duty are not available. Vacant posts need to be filled up. It looks like an
abandoned hose and three dogs were making the OPD department their resting place It seems
■ that the people coming to this place are coming there only when they have no other alternatives.
Tough the Maternity Home has a very big infrastructure; the number of patients making use of it
is very low. It could be because of the patients are provide only a room and a trained birth
attendant. There is no facility for a caesarian delivery. The patients also have to pay for a
delivery in spite of the services being free (We arrived to this conclusion after met the
community). On the whole they don’t seem to be getting many benefits and hence they prefer to
pay and make use of private nursing homes. The Lady Medical Officer seems to be unavailable
and probably it could be one of the reasons why the poor people are staying away.
The Maternity Home we visited was an example of the extent to which the Government Health
Sector could do for the marginalized as well as its failure to rise up to the situation. With the
infrastructure and facilities available at this centre they could very well cater to the needs of the
poor women from the surrounding slums. It had/has the potential to develop into a centre for
women run by the Government. Instead of providing infrastructure, I feel the need is a change in
the attitude of the service providers, be it the doctor, staff nurse or anyone who works here.
Unless the staff have the right motivation things will continue to be the same. The tap that needs
to be turned off is the corruption and mindset that is present among some of the Government
employees that they are Lords and Masters and others have to pay respect and adoration to them.
Unless they have a sea change in their minds and hearts and decided to serve the people nothing
much can be done. We may provide any number of material resources but the condition will
continue to be the same.
Actions to be taken
1. Create awareness among people about the services of the maternity home.
2. A Monitoring system by the people themselves should be created.
3. Each centre should have a governing body comprising of the local people that includes the
corporators, ward member and leaders of various people’s organization working in that area.
4. The Corporation should rank the maternity and medical centers and arrangement should be
made to give awards tor the people who render good service to boost their morale.
5. According to the people the staff should immediately stop of getting unofficial money for
deliveries.
54
KA 15
STUDY ON IPP VIII CENTER - KORAMANGALA
Back ground
Koramangala slum is one of the biggest slums in Bangalore. More than 70,000 people are living
in this slum. More than 10 Non-Governmental organizations are working in this slum for these
people s development. 1 his shows the status, need of the koramangala area people and the extent
oi the area. One IPP-VIII health center is located inside the slum. The Center is situated in a
strategic place; from center the peripheral point of the target area is one Kilometer far away from
the center. In Jansunwai, which is going to be held in koramangala slum with officials and
people, the denial of health care testimonies and the status of this area health center will be
presented, for this purpose S.D.Rajendiran, member, board of visitor of BMP and Community
Health Cell team and Ameer khan .K, fellow in Community Health Cell visited this health center
on 20/07/04 and 03/08/04. They met the health center staff and documented the current status of
the health center.
Purpose of the Visit
Jan Swasthya Abhiyan (India chapter of People's Health Movement) has organized a country
wide public hearing along with NHRC. The theme for the public hearing is 'Denial of health
care”. This campaign is part of the Right To Health Care (RTHC) campaign, initiated by Jan
Swasthya Abhiyan. Joining in the National movement the NGOs working in the Koramangala
Slum decided to conduct public hearing for Bangalore slums. The purpose of study about IPP
VIII center is to contribute to this campaign.
Need of the Health center
In this biggest slum there is no hospital (includes private hospitals) other than this IPP -VIII
health center. In the slum 4 clinics are run in the daytime by non-qualified persons and one clinic
m the evening by a qualified allopathic medical practitioner. Due to this reality Koramangala
people are much dependant on this health center. For this locality people this health center is the
first contact point and for any emergency these people have to first step into this health center.
For any kind of Government initiatives in preventive, promotive and curative health care this is
the only government institution as a medium for intervention.
Expected Services from IPP VIII Health center
1. RCH/Antenatal services / Post natal services
2. Family Welfare services like Copper T", Oral Pills & condoms
3. Immunization services
4. Outreach programmer
5. School Health Services
6. Awareness Programme
-Environmental Health
-Nutrition / Breast feeding
-Epidemic diseases
- Gastro entities
-Malaria, Tuberculosis
-HIV/AIDS
7. RNTCP
55
8. Referral Services
9. IEC / Counseling
10. Camps for HIV/ Eye Defects / Cancer Detection, etc.
11. Minimum Laboratory services
12. Family Health Awareness Campaign for HIV / AIDS.
Services Available in the IIT-VIII Center- Koramangala
This in formation was elicited from the health center staff.
1. Ante - natal care, post natal care for the pregnant women, includes the medical care and
lab medial investigations. Family welfare Services like Copper T, Oral Pills & condoms
are available in this center.
2.
3.
Immunization services to the Children.
Regular medical check ups (once in a year) for school going children with immunization
program. For this year the center has not done the program and they don’t have planned
to do at that time of visiting.
4. Referral services. But this center is not provided with ambulance, staff will refer the
patients to the Austin town maternity home and other hospitals.
5. Services for TB patients.
6. Minimum laboratory services are available in this center like Urine test for Pregnancy
confirmation, blood test for hemoglobin, and blood group identification by the laboratory
technician from Austin town maternity home. But due to the lack of lab technician the
tests are not done for more than 3 months. (Lab technician went on maternity leave). So,
all the patients are referred to Austin town maternity home for these tests, which is
located at one - and- a half kilo meter away from this center.
7. Apart from these services center has provided assistance and space for the health camps
(for instance, in July month Jain Mahaveer hospital conducted surgical health camp in the
premises of the center with the help of the staff) and other health related programs.
8. The last family health awareness camp (STD identification camp for Ladies) was done on
August 2003.
All the above services are provided at free of cost. For lab services user fees are
collecting. (Information about the User fees is given separately)
Services not available in the center
1. This center had nutrition promotion program many years ago, now this center is not
having any nutrition promotion program.
2. This center is not equipped to provide treatment for any type of minor ailments.
3. Neither the health center staff got any training on environmental and sanitation
management nor the center have program on environment and sanitation.
4. The center did not form any Social Health and Environment (SHE) clubs.
5. Though the center is formed for preventive and promotive care now-a-days center did
not involve with any kind of awareness program.
6. One of the responsibilities of the center is referral service it does not have ambulance.
7. Center does not provide any counseling services and IEC activities.
8. Center is not equipped for conducting camp for identifying eye defect and cancer
detection.
9. The previous doctor was doing Medical Termination Practices services. The in charge
doctor is not showing interest to do MTP, and the reason they said was, they are not
56
provided with any emergency medicine and services. So, they don’t want to take any kind
of risk.
Poor Utilisation
The out patient register shows very small numbers of people were accessing the facilities
provided in this center (population of this slum is more than 70,000).
Information gathered on 20~ July 2004; Number of users : OPP
20/07/04
-None of the ANC & PNC patients were treated (All the ANC &PNC patients
were asked to come on Thursday because the doctor went on leave). 25 general
patients are treated by ANM.
19/07/04
-Eight patients
18/07/04
-Sunday
17/07/04
-32 patients
16/07/04
-17 patients
15/07/04
-18 patients
Information gathered during on 3— August 2004; Number of users: OPD
26/07/04
- 27 general patients. All the ANC patients were sent back due to the non
availability of the doctor.
27/07/04
-19 general patients
28/07/04
-No patients
29/07/04
-30 patients
30/07/04
r5 patients
All the general patients are looked after by the ANM. Through the dialogue with her we were
able to understand that most of these patients are given only paracetamol tablets.
Allotted staff member for the center
Lady Medical Officer
-1
Lady Health Visitor
-1
ANM
-3
Link Workers
-10
Peons
-3
One Pourakarmika and one helper is deputed from Bangalore Mahanagarapalike
Availability of staff member
1. Lady Medical Officer
One lady doctor was appointed. Now she is on maternity leave. Instead of her one doctor
was deputed to this center. Both the days of the visit, the doctor was not available. She
was on casual leave. Due to the doctor’s non availability, center is not able to do its duty.
All the ANC patients were not treated for long. No drugs requirement was sent from the
center. All the patients were referred to the other centers.
2. Lady Health Visitor
One lady health visitor was appointed; she was not available in the center during both our
visists.
3. Junior health assistants / ANM
57
4.
5.
6.
7.
9.
I wo junior health assistants were appointed: one has gone on maternity leave and no one
is deputed on her place, one post is yet to be filled. Both the days we were able to meet
the ANM present.
Pourakarmika
One Pourakarmika was available in this center while we visited.
Helper
One helper is available in this center while we visited.
Lab technician
One lab technician will come once in a week from Austin Town Maternity home. Now
she is in maternity leave.
Peon
Three peons were appointed for this center. When we visited first time to this center, both
the peons were not available, while at the second time one peon was available. Staff said
that, one peon is always irregular and nobody is able to control him including the doctor.
One post is vacant.
Link worker
This center had link workers at the time of running of the center under IPP-VIII scheme.
As soon as that scheme period was over, the link worker concept was stopped.
Infrastructure
Phis government building is provided with regular electric supply, water supply, autoclave
facilities, refrigerators and toilet facilities. When we visited the center, inside of the center
premises was clean and maintained properly.
Between the center compound wall and the building there was lot of bushes. People used the
open place as lavatory. Health center wastes are burned in one corner of the building The
drainage was fully blocked. Health center is affected with severe water scarcity. There is no bore
well in the center. The center has to meet its water need through the corporation water supply.
There is an over head tank but the tank is not capable of storing the water. Toilets are not in
useable condition due to the non-availability of water. There is no drinking water supply too.
There are no drainage or rain water pipes and drainage tank iron covers. It is probably stolen and
not replaced. All the window glasses were broken.
a
Investigation facilities
Health center is providing investigations facilities for urine test for pregnancy confirmation and
blood test for Hemoglobin, blood group identification and VDRL test. But due to the non
availability of the lab technician from last 3 months there is no test is done. Patients are referred
to Austin town maternity home for the blood and urine test.
For Urine test (User fees)
- Rs. 10
For Blood test (User fees)
- Rs. 10
Availability of medicines
Health center is supplied with anti rabies medicine, drugs for TB, antibiotics and other drugs for
the services that they offer. Medicines for ear and eye infection are not available. The health
center offers temporary family planning services through issuing condom, pills and providing
copper - T facilities. List of the medicines available at the center on the day of visit is enclosed.
58
Suggestions for improvement (Staffs View)
When staff were asked to give suggestions to improve the health center, they are able to tell us
the need of the link worker and big walls to prevent the people coming into the premises in order
to keep the premises clean.
Community’s view
There is strong dissatisfaction among the people about this center. They said that, by 12 noon
they would not get treatment from this center (The working time of the O.P unit is 9.a.m to
l.p.m). Usually they will get treatment only after waiting long time. Two pregnant mothers
complained that one day they waited more than two hours. When they were waiting staff do not
look after any other patients too, they added. Some gave five to ten rupees for injection. All of
them are not satisfied with the way they are treated in the center. As a whole, there is no surprise
that the center does not get any co-operation from the people.
Visitor’s Observations
• Though the center’s doctor is on leave, the ANM seems to be committed to run the center as
much as she can.
• The surroundings of the health center are in dreadful condition; it is stinking and people are
using the place as toilets.
• 1 wo men were lying besides the building and playing cards at the time we visited.
• 1 he behavior of the peon and inability to control him seems to be because of some vested
interest of the authorities on him. So, the burden of work is shared by the other staff.
• There is no community participation in the center’s activities.
• There is no citizen’s or patient’s charter available.
Denial of Health care
Antenatal care denied to those who came to the centre as also other health care, because of
absence of medical officer. No laboratory test because of absence of laboratory technician. No
school health program. Poor environment and no water supply.
Consequences
Non — utilization of services, dissatisfaction with the services and non co-operation with the
centre.
Suggestions
•
•
•
Doctor should be available on all the days and the center should create confidence
among the people about the services and the doctor’s availability.
The link worker concept would be useful to provide effective services to this big
slum.
Developing proper relationship between the center and the Community is very
important for the smooth functioning of this center.
59
I
KA 16
TESTIMONY OF LATE P
u5'//,3, y°Unf woman aged 20 residing at Srirampuram slum in Bangalore went to Primary
Health Unit in Srirampuram for her antenatal check up. The patient’s aunt said, as thev could not
conduct the delivery there they referred her to Vanivilas Hospital. When she went to Vanivilas
Hospital on 28 June 2004, the junior doctor came and examined her and said she would deliver
the next day But the senior doctor came and told that she had to undergo an emergency surgery
as he felt the foetus not ok. The junior doctor came and said she would do the next day the
surgery.
4
7
They gave her glucose the whole night. The next day before they could do the surgery her
stomach bloated, they informed the doctor, and he came and saw and went away. About 7.3o am
apu died in the hospital. When She ate well her dinner in the night and went to bed and she
passed away in her bed. When hospital authorities came to know that she is dead, they told the
relatives to take the body immediately.
Though the senior doctor told to do the emergency surgery, since the junior doctor delayed the
surgery, Papu died on 1 July 2003. The doctor or nurses were not available during emergency
They were not aware of the moments when she breathed her last. The family sources said they
spent about 3000 rupees during her hospitalization. It seems the family members questioned the
authorities for the negligence but did not get any satisfactory responses. " They did not even do
the cut open her stomach (post mortem) to remove the baby. In the grave yard we had to get one
man to cut open the stomach, remove the baby and bury the mother and the baby separately "
Now it is just over since the incidence took place, her husband has been married to Papu’s
younger sister.
H
Denial of health care: Negligence
Delay in health care in the emergency
Non -peformance of postmortum and delivery of the ‘dead’ baby.
Consequences:
Death of the baby and mother
Psychological trauma
Unnecessary expenditure.
KA 18
TESTIMONY OF MS. D
Ms. D, aged 25 years, residing at Thippasandra, Bangalore -560 074 went to the Austin town
maternity home to deliver her Third child on 25,h July 2004. She said she went around 6.30 am
immediately she was taken to labour room and was asked to lie down on the labour table She
requested the nurse on duty that she would like to walk around for some time, as the pain is not
severe The nurse forced her to he down on the table and started doing PV which was very
Pa^
1
t0 thtt I*16 nUrSe Called the ayah and other female worker Press her stomach
and forced her to push the baby. Finally a boy baby was pulled out around 10.30 am.
60
She said the nurse forced her like this because she wanted to finish conducting the delivery
foe wa th ,
d
m°ney- She Sa'd She Was afraid that she would die for
he uay they treated. " I was suffering from pain. I was exhausted, when I dosed, they sprinkled
^ho^nr^ ""I W°t
y°U “ WOman’ y°u wo-ld
tired I
7 O.n,y^!e,1y°u 8,ve alms 10 lhe P^r. go first give aims to the poor. I was very
tued they pinched wuh hands and the instruments, and there were scars on my legs. " She said
she says all these because she doesn’t want these things to happen to other women.
s"sp. .'“ l“ppe,“d
•*>
.
o---------J out by the
lor explanation she was told it was nothing but dirt. “ / am
worried if my child would have any problems infuLfure because of this”
I he nurse demanded Rs.500. Her husband works
as a coolie, he had borrowed Rs. 250 from his
work place and
ointment and tablets for pam, which she had to buy from the private medical store for Rs. 50.
Finally while leaving the hospital she had paid Rs. 250 for the
•nd
Denial of health care:
Incompetence and negligence
Forcing delivery, leading to harm to baby.
Bribery
Consequences:
Psychological trauma to mother
Possible trauma and after effects to baby
KA 19
CASE HISTORY OF ER
I am a widow with 4 children and am a victim of H1VAIDS. I was happily married to Mr. V an
auto driver. Though we hailed from KGF and Jolarpet we settled in Bangalore to earn a living.
Our family life
h was g°od untl1 my husband started falling ill often . He started getting fever and
handaches and was taken to a Private hospital where he was treated for jaundice " Later the
we coul^norff d VV'50
we could not afford.
eteXrouZ-t^cX0"10"^ and
aZ a
W' th T B’
retUmed 10 Ban8a,°re- By n°W * W3S
Xf nleid01 bOth.erht0.attend °" US in sPite ofour Pleading
cheek on I
check on him.
t0 buy the medicines’ which
We then went to Jolarpet to seek help from his people. His brother took
-d
them to give us admission,
r 8
, L"8; my hUSband WaS pUt
tbe Ward’ where no one even came to
Even though beds were available he was asked to sleep on the floor This
experience was very painful and frustrating. My husband did not want to stay there and we got
im discharged and went back to the concerned doctor at NIMHANS who then referred us°to
61
Freedom Foundation where he was admitted and treated. It was here that I was tested positive,
however my children were tested negative. I lost my husband two years ago.
Positive people undergo a lot of difficulties. They not only have to face the trauma of being
positive but also face stigma and discrimination. On behalf of our positive group I request the
panel to help us get treatment with any discrimination.
KA 20
CASE HISTORY OF H
1 am a victim of HIV/AIDS. I am 25 years old and come form Davangere. I have studied till
class 10. My husband Mr.X is an auto driver who hails from the same place. I come from a
large family and my parents thought that I should get married even though I was not interested in
getting married at that time.
After four years of marriage I conceived, but here I was told that I was infected with T.B. It was
routine to do a HIV test for all pregnant women an when it was done it was found that I was
tested positive. My husband was also asked to undergo the test, but he tested negative. Instead
of telling us our results the doctors called my family members and told them that it have AIDS.
This created a commotion in the hospital between both families, thus causing them to disown us
and ill-treat us mentally. Dejected with life we left our hometown Davangere and came to
Bangalore in search of a living. Ismail found it very difficult to get a job and I did not show any
interest in taking a job as I thought that my days were numbered and death was nearing.
I was 2 months pregnant I went to Arogaya Kendra center near my house. After knowing my
status the doctor there did not want to treat me and referred me to Vani Vilas hospital. My
husband Ismail was tested and was found to be positive, by then. Thinking that my child would
be orphaned we decided to terminate the pregnancy. When we requested them to terminate my
pregnancy they refused and asked me to go to a private clinic who demanded Rs.5,000/- which I
could not afford. I went through a lot of mental strain not knowing what to do. After sometime
with help of my neighbors contacted a doctor at a NGO, who was willing to help me, but by
now it was too late and I went ahead with the pregnancy and had a normal delivery. However 1
lost my child.
Today our lives have changed and we are now back in our hometown Davangere and it’s all
thanks to MILANA. Here we underwent counselling and this helped us look at life in a positive
way.
My humble request to the panel is to make the hospital authorities treat us with respect and
concern. Infections come through many routes but the attitude of people remains the same that
of ill-treating us. Counseling and confidentially plays a very important role, which has to follow
strictly. All those would help us lead a positive life.
Denial of Health Care :
Stigma and discrimination
Refusal to provide treatment
Demand fro bribe
Violation of confidentiality
62
KA 21
TESTIMONY OF LATE. MR. H
Mr. H, 35 years old, a chronic
ih alcoholic and chain smoker,
---- , was suffering from stomach pain. His
wife was interviewed on 116 August 2004 at 2.00 pm at her residence in Ragigudda slums, in JP
Nagar.
His wife Mrs. took him to Jayanagar General Hospital six months ago; she does not remember
the exact date. Since she showed her yellow colour ration card they had taken only 50 Rupees for
registration. She said otherwise one has to pay for everything.
He was taken to the hospital at about 9 am. The doctor examined him and said he has ulcers in
stomach and told her to admit him. When she complained to the sisters that he suffers from pain
they would come and give an injection. They gave six injections, which she bought, from a
private medical store by paying Rs. 100. He was also prescribed tonic, which he bought for
Rs.55. With all these his pain never subsided. X-Ray and blood test were done. She said she did
not pay anything for the X-Ray but for the blood test the lab technician took 500 rupees and told
her, not to tell any body that he had taken 500 rupees. He told her to tell if anyone asks that she
had paid Rs. 100 only. The patient was given 3-4 bottles of glucose every day for five days She9
wife of the patient) said she decided to bring the patient home, as he was feeling better.
She again took him to the hospital as he started complaining of pain after two days. This time
also they admitted him and administered glucose. He was suffering from pain, many times he
himself would go to the sisters to call them to come and attend. To this the sisters would respond,
"you are a headache, if we have four patients like you, our lives would be gone. " She ( wife of
the patient) said many times when she went to call them (the nurses) to come and attend to her
husband when he was suffering from pain, they had scolded her and said why did she come to
disturb their sleep? The doctor was not available when needed. The sisters (nurses) demanded 20
or 30 rupees every time they came to give him injections or came to attend, "if you don’t pay
they will not attend to you ”
This time he was there for 5 days. The doctor sent them away by saying he would get better if
she buys the medicines and tonic they had prescribed. She bought half of them from inside the
medical store and half from outside the hospital by spending Rs. 200.
He was brought back home in a bad condition. She immediately took him to Bowring hospital.
She paid Rs. 65 for the auto. They admitted him and put a tube through his nose and removed 45 bottles of fluids every day. She spent here about 1000 rupees for medicines. They did not have
pain killer injection when he was suffering from pain; she had to buy from outside. After a week
she decided to bring him back home as it was too far. She had four little children to care for. She
was also afraid of seeing patients dying in front of her. The doctors told her that he still needs
treatment and investigations had to be done on him.
She kept him at home for four days and took him to Shekar hospital in Jayanagar as he became
very serious. They admitted him after taking Rs. 3000 as deposit. They immediately operated on
him by telling her that he had appendicitis. After surgery they told her that had ulcers in his
63
intestine and it is not appendicitis. They brought and showed her pieces of his intestines. One
month they kept him there. She spent about 5000 rupees for medicines. The doctor there by
seeing her condition of poverty gave her 3,000 rupees. When the final bill came it was about
28,000 rupees. Since she did not have the money, they discussed and told her that she need not
pay. They arranged an ambulance and sent them back home by saying it is difficult for them to
manage. He died the next day at home. She had spent about 10,000 rupees for medicines. She
has borrowed about 5000 rupees and 5000 rupees was give to her by known people.
Denial of health care : Bribery, corruption and poor response to patient’s need, mismanagement,
and incompetence.
Consequences:
Death (avoidable) if proper treatment had been given in time.
Loss of money: becoming indebted, dissatisfaction with public health
care services
Recommendation:
Greater vigilance and supervision by senior staff of the Health Services
and Medical Education Departments.
KA 22
TESTIMONY OF MR. K
Name of the patient: Mr K.
Wife: Lakshmi 32 years, 5 children
Age: 35 years
Sex: Male
Address: Vivekanagar Post, Kormangala, Bangalore 560047
Maritial status: Married
Origin, Duration and progress:
We have a Charitable Health Centre in Viveknanagar slum for last 2 /2 yrs. The patient first
visited our clinic in or around September 200.3.
He was a chronic alcoholic with recently diagnosed Diabetes.
Episode I
On 14.11.03 at around 8.00 pm Mr. K came to our clinic with h/o vomiting blood
(haematemesis) and passing black stools (malena). Immediately after attending 2 patients I
^ised *nd ^companied them for hospitalization. We reached Bowring Hospital Casualty
v At Bowring Hospital after issuing his card he was examined by the doctor in the casualty. As
he was a known case of Diabetes before starting any treatment his blood sugar level
examination was a must.
64
Ironically there was no Glucometer in this Tertiary Care Government Teaching Hospital’!
Approximately an hour was ’wasted' without
’ '
any single treatment.
couldn’t understood the severity of the situation.
Poor, ignorant relatives
1 hen doctor on duty asked the relative to go and get the blood sugar level done from another
private hospital (that too at 10.00 pm)
As I was accompanying the patient I asked the doctor on duty if they can suggest any private
laboratory from which we can get the investigation done.
Above all not a single sister/nurse was ready to take the blood sample so that we could go
and give the blood sample for the test promptly.
They were also not having bulbs for the blood sample collection (for Random blood sugar
test).
None of the doctors were having information about the private laboratory which would be
open at 10.00 pm.
They suggested two laboratories where we went but they were closed and by that time it was
11.00 pm.
Then I decided to go to Wockhardt Hospital. We went there and got the bulb and syringe for
patients blood collection.
Reached Bowring Hospital at 11.30 pm
Ultimately a patient who was admitted with hemetemesis and malena with Diabetes Mellitus
at 9 pm was tested for blood sugar at 2.00 am. All the cost of the investigation +
Commutation was borne by the poor patient, adding one more expense to the already
worried family.
Patient was diagnosed as having — Type I Diabetes Mellitus + Pseudo pancreatic Cyst +
alcoholic liver disease Total Hospital stay was from 14.1 1.03 to 19.11.03.
Episode: 2 In next episode of illness in the same patient because of severe poverty, grave
illness and inadequate treatment he developed diarrhoea and vomiting on 8.6.04. This time
he also had severe jaundice. He was examined by me at his home and I referred them to get
immediately admitted to Bowring Hospital. He was admitted there on 10th June 2004 with
history of severe weakness, severe jaundice, dehydration and pedal edema.
Within last few months patient had lost almost 6-7 kgs of weight.
When he was admitted this time they really had quite a painful and horrifying experience at
Bowring Hospital
In 4 days of stay the patient was given only 2-3 pints of intravenous fluid. That too was
purchased by relatives. The Doctor on duty also suggested more 25% Dextrose; the relatives
65
purchased them, but they were not given to the patient neither was any other IV solution
suggested.
In a patient with severe dehydration jaundice and Diabetes Mellitus careful intravenous
treatment is a must. But except 2-3 pints of IV solution, no other IV infusion was given in
those 4 days of hospitalization. Because of negligence the patient’s condition worsened in
the hospital. I he jaundice got worsened and probably he might have developed hepatic
encophalopathy as he started rowdy behavior from the 3rd day of admission.
And this is not all. In a general ward, with continuation of diarrhoea (black stool) and
jaundice because of negligence and irresponsibility he was worsening day by day. All
through his admission his 12 year old son was there with his ailing father mother could not
stay in the hospital as she had a small child and other 3 children to take care of.
No other relatives were there when they readily needed them. On 4,h day of admission,
because of the rowdy behaviour of the patient one of the ward boy gave a strong punch on
the chest of the patient. Poor 12-year-old boy could not tolerate this. He was shocked as his
father immediately after that punch the patient had a blood vomit. The small, tender boy was
airaid that the ward boy may kill his father. He was so much afraid and shocked that he did
not inform anybody (not to nurse/doctor) he did not even take any of the case papers and
took his father home and explained to his mother with his continuous cry, about what had
happened in the hospital.
This is not only a denial; it is case of great negligence on 1the part of the public health system.
For this illness the patients’ wife spent Rs.600.00. Their• son went for begging and wife for
extra work. Story is not yet over. 3? days
’
"
after
they came from hospital, which is on 16th June
2004, the patient died at his home. Now
his
wife and
- — 53 children are living in immense
poverty with no hope.
Issues:
1. No Glucometer to test for blood sugar is a tertiary care
teaching hospital.
2. No special tubes to collect blood sample for blood sugar
test is a tertiary care hospital
3. Referred to a private hospital from a public hospital for
blood collection and sugar test at extra cost for patient.
} Denial
}
}
}
4. Inadequate intravenous hydration of the severely ill
and inadequate communication of severity and require
5
6.
ments to patients relatives.
Violence on a patient with mental health complications
due to worsening diabetes.
Inadequate response/supervision of case and behavior
of case and behaviour of health staff by senior health
staff.
}
} Negligence
}
}
}
}
66
KA 23
Testimony of Ms. L
Ms. L 37, years old, lives in Ragigudda slums. She is a widow and she works as a housemaid
She was admitted I '/2 years ago at (Sanjay Gandhi Hospital) Jayanagar General Hospital for
hysterectomy. The admission was free. They gave her all the medicines and told her that she
needs blood.
They are doing operation like business. " They asked for AB negative blood
which Ms. L s family could not find any where. They had agreed to do the surgery by taking the
signature of his children a 20 years old daughter and 18 years old son. She was in the hospital
she stayed 11 days after the surgery. The anesthetist came and told her before the surgery that
she must give him Rs. 200. The helpers demanded Rs. 50 to shift her to the ward from the
operation theater, otherwise he tells the patient to walk and go. " How could we walk? So we had
lo pay . The X ray technician and the lab technician took money from her. The nurse who eave
her injection demanded Rs. 5 be paid to her every time she gave an injection. “ They do
surgeries and throw away the patients like animals.
^hi,lecndJS^h,aJ-?ing they demanded Rs- 2500, she did not have that much money. She paid only
<s, 1500. While taking the money they said, " we have saved your life, is (his much worth only "
She said the doctor who does the surgery earns through bribe every week 7-8 thousand rupees
How much they would be earning in a month? She asked.
She was told to stay in the hospital till her scar was healed and go away. The sutures came of the
next day when she came back home. She was profusely bleeding. She immediately went to a
private hospital because she did not want to go to that hospital again after experiencing the ill
treatment and improper care from the staff at the Jayanagar General Hospital. T do not want to
go to a Govt. Hospitals they ill treat the patients. ”
She said at Jayanagar General Hospital they do suturing without giving anesthesia. “ I have seen
patient reeling under pain while they did the suturing. " She said she spent about 20000 rupees
lor treatment both at Jayanagar General Hospital and Private hospital where she went twice She
is still repaying the debts.
Denial of health care:: bribery, corruption, and ill treatment of patients.
Negligence: suturing coming off
Conseqiicnees; dissatisfaction with the service in the Government hospital, loss of money, debt
KA 24
Testimony of Mr. I)
Mr. D, aged 10 years is suffering from epilepsy. He lives in Wahab Garden in Benson town He
went to NIMHANS for treatment on 29,h February 2002. He had to wait for a long time and the
end was simply sent away without prescribing or giving any medicines.
67
he ™ldC“d 0"
for the tablets. The famdvfinZ
’J0'5' EaCh Week he has t0 sPend Rs-100
The family finds it difficult to buy the tablets
Denial of access:
Not given free medicines even though he produced the yellow card
Delay
ueiay in care (not attended iin the first instance)
Consequences:
Huge, unaffordable expenses for the purchase of medicines.
Recommendation:
M“„,"x!;1,t7amed and ms,ruc,‘d “prov,de""
‘h‘
- Institutions must supervise and ensure that the rights of patients are
respected.
KA 25
Testimony of Mrs. Da
Mrs. Da aged 45 years was admitted in
Jain Hospital after a wall near Iher house collapsed and
fell on her. She had undergone tubectomy fe
, :w months ago in a Govt, hospital. When the wall fell
on her, the suturing gave way. She was bleeding and her uterus
------ j came out. Treatment was given
Y
pm. About 12 doctors at Rowr
h
spent almost R 15000 in’the ho
' ) 7
Type of denial:
Y
B°Wring hosPital il was aboul 3-00
? Pr'Vate mediCal St°rCS Spending Rs-5000- She
Bribery at the government Hospital to get the services
Demand for huge payment at the private hospital.
68
Delay in investigation in the private hospital;
Delay in admission at the government hospital.
Consequences:
I luge expenditure.
Recommendation:
Institutions must supervise and ensure that the rights of patients are
respected.
Greater vigilance and supervision by senior staff of the Health Services to
check bribery.
KA 26
Testimony of Mrs. A
Mrs. A w/o Mr. N, 24 years residing at Sriramanahalli, Sasalu Block, and post, Doddabalapura
taluk, Bangalore Rural district went to prenatal care at Saslu Primary Health Center (PHC) three
times. The last visit was on 25th February 2004. Medical officer was not available at the PHC.
The patient was made wait 2-3 hours at the PHC. During the prenatal care no weight was taken.
She did not get any drugs from the PHC, she was given a prescription and she had to buy them
from a private medical stores. The medicines bought were tonics, antibiotics, tablets and Vit.A
syrup. No documents available were available at the PHC, no registration was made during the
visit only patient's> name was entered into a register. If money is not paid the patients are referred
to the taluk hospital under some pretext. The patient was not given any transport facility when
referred.
The doctor comes at 1 1. 00 am to the PHC and leaves at 1.00 pm. There are neither ANM nor
any other staff available at the PHC. The PHC lacks good building, equipments and drugs. There
is no privacy for the patient while being examined. There are no furniture in the center. There
are no drugs available at the PHC. Dr. Ramraj Urs is not available during emergencies.
Denial of health care:
Consequence:
Prenatal care unavailable.
The foetus died during 8Ihe month of pregnancy in the
Recommendation;
Make the medical officer available at the PHC.
Make all the drugs available at the PHC
Stop the practice of bribery from the PHC.
KA 27
Testimony of Smt. T
A lady by name Smt.
f
T aged 38 years of Sriramanahalli died after undergoing abortion. She had
gone to the PHC to get her fore pregnancy aborted. The doctor was not available and the ANM
who was not well versed in conducting the abortion. During abortion the lady died. The ANM
had dragged the dead body and made it to squat in the bathroom and locked the PHC and
absconded.
69
KA 28
User Fee & Denial of Health Care
Mr.. V aa 28
zo years
years old
oio young
young married
married man
man currently
currently resides
resides in a registered slum at Sudhamanagar
near Hindustan Aeronautical Limited (HAL), Bangalore. As the result of many years of
excessive drinking from the age of 13 years onwards, he has severe physical, social and
economic problems. Mr. V is a coolie worker at a scrap collection centre. He earns Rs 100 per
day and spends all the money for alcohol consumption. If he has no money gets it from his wife
who is the breadwinner of the family. She earns money by doing domestic work. He has 6 years
old son and 9 years old daughter. His wife and children are psychologically affected.
Mr V went to N1MHANS on 23r August 2003 to get treatment for alcoholism. Since Mr V was
a chronic alcoholic with severe withdrawal symptoms. Mr. V needed admission for treatment of
his physical and psychological dependency. He was asked to deposit Rs. 2000 for the treatment
as per the policy of NIMHANS. For patients submitting Below Poverty Line (BPL) ration card
the deposit was Rs. 250, and for all others without the BPL card, including urban poor and
migrant people the deposit was Rs. 2000. Since Mr. V did not have a BPL (yellow coloured)
ration card and could not deposit Rs. 2000, he was NOT admitted and treatment was denied to
Now Mr. Viis miserable and sick, not being able to receive the treatment due to the ‘user fee’
Policy at government hospitals. He again visited NIMHANS g,
> on 03/05/04 with very severe
condition and this time too he was denied treatment because of not having a BPL card and
because he was not able to deposit Rs. 2000.
Consequence:
Continued dependence on alcohol
Loss of money
Psychological trauma of the patient and family
Recommendation: The insistence of‘user fee’ and ‘deposits’ should be waived in such cases
The availability of BPL cards should be improved, so that people like Mr. V and migrant labour
have access to them and through them to the needed healthcare.
70
Annexure 5
DETAILS OF CASES FROM KERALA
KL01
ELOOR CASE STUDY: GREENPEACE HEALTH STUDY REPORT IN AUG 2003
Testimonies:
Name: P
Address: Eloor South.
As told by herself. It was in 1961 that her parents returned to their ancestral home in Eloor from
Bombay. She was a student of class! then. The only factory in the area was FACT. She had no
health problems whatsoever when she came here. It was their father’s death that had brought
them to Eloor where they had an own house and some property to call their own. When she was
in class 8 there was a chlorine leak from the TCC factory. Recollecting memories of that day, she
says she remembers running to school and falling faint in the school corridors. The school
authorities admitted her in JNM hospital and she regained consciousness three days later. Her
health woes have started ever since then. She gets breathing difficulty and bouts of
unconsciousness whenever the fumes are very strong. Chronic Cough has been with her ever
since then. She spends around 400 rupees every month on barely keeping away from the major
bouts of breathlessness and cough. None of the doctors have conclusively told her that her health
will see a fine day Her husband too suffers from breathlessness.
Talking of her surroundings, she still can remember the number of domestic animals that were
seen in and around Eloor in those days. She does not believe that the local community has
benefited from all the factories. A few that got jobs carried on in their jobs and hence traditional
livelihoods have totally been wiped out. The factories and the pollution have also led to a serious
water shortage. The ground well in their house no longer can be used for the quality of water it
has. But she cannot use the water supplied by the authorities for its chlorine content. So she
manages with the well water available.
Factories have led to varied problems not to mention the spate of health complaints it has caused
to the people living here. She wonders how she can inch forward her difficult life.
Testimony of Parent about affected Children:
Name of Child: IJT
Age: 2 years
Address: Eloor
As told by the father: It was in 1965 that the family settled down in Eloor. The wife’s maternal
home is in Ithe district of Allcppcy. They had a baby boy by tubular pregnancy the delivery of
which was by caesarean section. The baby, IJT was diagnosedI as 40% mentally retarded. Two
71
years old now, he still has difficulty in walking. There are occasional attacks of fits in between.
Doctors in Amrita Hospital, Cochin are treating the baby. He has speech difficulties as well. The
medicines being administered are Norma Brain and Digital?.5mg.
Others in the family do complain of severe headaches and bouts of breathing difficulty. They
have already spent around 2 lakhs on the child’s treatment. Though Physiotherapy was also
advised they have discontinued the same due to its high costs.
The child’s aunty , S has been in Eloor for the past six months. She is pregnant now and ever
since she has been here she has acute headaches and breathing problems. Previously a resident of
Cherthallai locality, S admits that she has never ever had such health complaints. Living in the
vicinity of the Leather factory and inhaling the ammonia fumes has led to a major deterioration
of their health, the family avers.
Response of the health care system in Eloor:
There is routine pollution in Eloor due to release of smokes by chemical and pesticides industry'.
The response of the health care services has been very poor. The people have been going
through the brunt of callous attitude of the system. There is one PHC with poor infrastructure in
the area according to Jose, resident of Eloor. The PHC doesn’t have sufficient medicine. The
Pl C sends the patients to the DHC as there is no facility for admitting the patient. There is no
regular surveillance system. People mostly get medicines from private medical shop.
Since Eloor is an industrial belt , known for chemical contamination in the area the non
availability of essential drugs is cause of concern for 30,000 people living in the area.
Response in the emergency situation like gas leaks and accidents is even worse.
r
EXECUTIVE SUMMAR Y
An Introduction to Eloor:
hloor is a river island on the river Periyar around 17 kms from its mouth at the Arabian Sea
icar the city of Cochin. It occupies an area of 11.21 square kilometres. Eloor supports the
largest industrial belt in Kerala with over 247 chemical industries. The industries make a
range ofchemicals- petrochemical products, pesticides, rare-earth elements, rubber
processing chemicals, fertilizers, zinc/chrome products and leather products. Most of these
industries are over 50 years old and employ the most polluting of technologies. The
industries take large amounts offresh-water from the River Periyar and in turn discharge
concentrated effluent with very little treatment. This leads to the large-scale devastation of
aquatic life in (he river and the farmlands in the region. There are 35 illegal pipes spewing
effluent into the river directly from the industry.y Air emissions range from acid mist to
sulphur dioxide, Hydrogen Sulphide, Ammonia and Chlorine gas.6 There are close to 40,000
people living and working on the island, 29,064 of whom are part of the village community
From a joint assessment done by the Periyar Malmeekarana Virudha Samilhi and the Kerala State Pollution Control Board
1 here are many unidentified chemicals that are in the plumes of the industries of the area. The Pollution Control Board has
comprehensively monitored these.
not
72
not employed by the industries. The rest are employees and stay in the company quarters.
The Woman to Man ratio is 1000:1054.7
The Background to the Community Health Assessment:
Despite the fact that the pollution of the River Periyar and the land has been established
unequivocally there has been little action by regulatory authorities.8 It seemed to us at the
beginning of the research like there needs to be stronger arguments and actions from the
community that backs up the new research. We decided to back our existing research on
contamination by the local pesticide industry, Hindustan Insecticides Ltd and Merchem
Ltd. Meanwhile a resident of Eloor was appointed by Greenpeace as the Riverkeeper for
the Periyar to monitor water quality of the river and alert local government, regulatory
authorities and the pollution control boards of the need to take immediate action to stop
pollution.
.
The fact that the Community Health Problems, of Eloor were quite apparent and that a
- similar reality was observed across the country along the 24 hotspots identified by
Greenpeace India prompted us to go for a health assessment that shall establish prima facea
the problem. Greenpeace initiated an alliance with Occupational Health and Safety CellMumbai, which has prior experience in the matter of Epidemiological Research. The broad
framework of OHSC taking the lead with Medical Verifications of the primary data
collected using a questionnaire research was arrived at jointly, with Greenpeace taking the
primary role in the field based research and the survey. The Ethical Guidelines developed
by ^e National Committee for Ethics in Social Science Research in Health (NCESSRH/2
The Proposed Research Question in the first round of discussions was: “What is the prevalence
of Chronic Respiratory Illness and Cancer in the affected community around Eloor Industrial
Estate? This evolved into the more broad and exploratory research question later as we
7
14,144 women and 14,920 men Most people are employed in the services industry-serving the government or private industry Many run
ocal businesses. Traditional occupations including fishing and farming have been entirely wiped out by polluting industry. There is a section of
people that are migrant and are involved in illegal sand-mining from the bed of the river. A small population on the island is unemployed.
g
The local pollution control board has been entirely ineffective in ‘controlling pollution' if not preventing it Therefore the local community
agnations have more often focused on the pollution control board to initiate immediate action against polluting bodies Refer the Kerala Pollution
Control Board Website for developments: http:/-vvww kspcb nic in
9
After the Greenpeace Sampling mission of 1999 when it was established that a large amount of polluting chemicals have been released by
certain specific industries (Hindustan Insecticides ltd, Merchem Ltd), the local community took direct action against the polluting agencies by
damming the polluting stream-Kuzhikkandam Thodu. The companies have ever since been forced to enter into a dialogue with the panchayat and
local people to come up with a plan to clean up the mess along the stream. They have failed to come up with a safe protocol for doing so. Their
current plan involves dredging the sludge and dumping it in a nearby wetland permanently destroying the water table. There is currently a court
injunction on any such action.
10
He has also addressed the people of Cochin city with the dangers of using the polluted river water for drinking purposes.
The local people have been complaining of large-scale health problems on the island These include respiratory disorders, cancers, congenital
problems like mentally/ physically challenged children, chronic depression and reproductive problems
Ethical Guidelines tor Social Science Research in Health By National Committee for Ethics in Social Science Research in Health
(NCESSRH).
www.cchal.org/Dublications/cthical I html
r II Aln° ree ’ N?I,CS °n Quall,a,lve Research and Ethics of Research On Disaster and Complex Political Emergencies by Fatima AlvarezCastillo, Professor.Umversily ol the Philippines Manila, Email fatima caslillofoup edu ph
73
interacted with the advisory board: “What are the Health Problems faced by the resident
community of Eloor Industrial Estate, due to increased pollution of the air and water by chemical
industries? The meetings with the advisory board also discussed and thrashed out issues like
scientific biases, sampling sizes/ratios, training module for interviewers, ethics and statistical
analysis.
The Findings. The one simple and basic finding is that we observed is that without exception, all
body systems are adversely affected in Eloor as opposed to Pindimana. This shows that the
cocktail of poisons in the air and water of Eloor as opposed to Pindimana is exerting synergistic
effects on the local population and these effects seem to be unpredictable especially across
particular age groups.
The Conclusion; Immediate punitive action need to be initiated by the Government on the
companies that are criminally violating the right to Life of Communities and workers in the
Industrial Estate and around. Remedial action which includes, life-long medical rehabilitation,
compensation and clean-up of contaminated sites must be taken up by the polluting companies
Zero Discharge on the Periyar must ensure that the people of Cochin are not poisoned
II.
MAIN RESEARCH AND POLICY FINDINGS:
Contrary to the expectations based on the initial literature <survey on increases in particular
types of diseases due to air and water pollution; this health assessment has discovered that
there is a general increase in all types of systemic diseases across Eloor (target village) when
compared to Pindimana (reference village). Broadly one can say that the cocktail of poisons
in the air and water of Eloor affects all body-systems adversely. Potentially the immune
system seems to be affected too.13 Increased prevalence and incidence of diseases and
symptoms at Eloor have been observed from the database of health information of the
community and workers at Eloor and Pindimana generated by the Field Investigation based
on an exploratory format questionnaire.14
A Stratified^ Random Sample of the Eloor15 (target) population when compared with those at
Pindimana (reference) shows a significant increased disease incidence in many body
systems. The key systems that are affected are the Neoplasm17 (2.5 times odds). Blood &
blood forming organs18 (2.1 times odds), Endocrine, nutritional and metabolic system19 (1.17
times odds), Mental and behavioural20 (3.03 times odds). The Nervous system21 (1.59 times
odds), 1 he eye & adnexa^ (1.21 times odds). The Ear & mastoid process23 (1.49 times odds),
Despite the fact that Pmdimana, the reference village, was going through an epidemic of Leptospirosis and Dengue Fever the rate of
occurrence of infectious diseases under Category-1 of the ICDflnternational Classification of Diseases) in Floor Section A and Floor Sect.on B.
wo target areas within Eloorfwhich was not facing an epidemic) was slightly more than the rate at the reference! This clearly shows that there is
an ongorng live epidemic in Floor which is not being perceived as one that requires attention as it is on all the time.
Please see Appendix I for details
s Sampling Ratio was I 4
16 Sampling Ratio was I 7
"Schakel3he 'n,Crna"Onal Class,ficalion °r Diseases, the ICD. Version-10. hltn:,.www wellcool.demon co nk/ltmhi/PBarkerlCDIO hint
19 ibid Chapter-4
2(1 ibid Chapter-5
21 ibid Chapter-6
22 ibid Chapter-7
2’ ibid Chapter- 8
74
The Circulatory system24 (1.59 times odds), The Respiratory system25 (1.29 times odds), The
Digestive systerrT6 (1.69 times odds). Skin & subcutaneous tissue27 (1.69 times odds), the
Musculo-skeletal system & connective tissue28( 1.17 times odds), the Genitourinary system29
1.09 times odds), Congenital malformations, deformations & chromosomal30 (2.63 times
odds), Injury, poisoning & certain other consequences of external causes31 (2.65 times odds),
External causes of morbidity & mortality32 (1.36 times odds). All systemic classification was
based on the International Classification of Diseases-10 (ICD-10).
One of the body systems worst hit seemed to be the nervous system when combined with the
mental and behavioral effects (odds- 1.59:1 & 3.03:1). Congenital malformations,
deformations and chromosomal aberrations follow (odds- 2.63:1). Accidental injury and
poisonings are leading causes of mortality (Odds- 2.65:1). Diseases affecting the Neoplasms
(2.5:1) and Blood and blood forming organs (2.1:1) are significantly greater in Eloor.
Clinically confirmed33 Cancer Incidence is greater in Eloor in a statistically significant rate.
When 13 cases of incidence were reported in the Eloor set, only one was reported in the
sampling set at Pindimana. The combined odds ratio across Eloor and Pindimana is (2.85:1).
This is alarming to say the least.
Medical Verifications were performed using the lung function tests (Spirometry) on a
random sample of the reference and target populations. These confirmed high rates of actual
incidence.34
It is clear that the nature of illness spreads across practically all body systems in an almost
unpredictable manner. This is clearly due to the fact that it is a cocktail of chemicals (a few
score heavy metals, a few hundred organic chemicals) and that are in the air and water of
Eloor. There is very little medical research globally that accounts for synergistic effects of
synthetic chemicals in human beings. The evidence that one finds at Eloor clearly shows that
the synergistic effects of these chemicals are more devastating than expected.35
24 ibid Chapter-9
25 ibid Chapter-10
26 ibid Chapter-11
27 ibid Chapter-12
M/AW Chapter-13
29 ibid Chapter-14
30 ibid Chapter-17
” ibid Chapter-19
12 ibid Chapter-20
” Clinical Confirmations were obtained by follow-up house visits with a team of doctors from the Occupational Health and Safety CentreMumbai using Spirometry for Respiratory Illness (Chapter-10, ICD-IO)and examinations of medical records (Chapter-10, ICD-10) for
ascertaining Cancer Incidence
34 For Eloor the figure was 10- severely affected under FEVI or FVC or both below 60% of the predicted values, the expected values in healthy
persons. 7 are moderately affected and 9 showed that their values for lung function are just below the 80% of predicted values. Totally 26 out of
45 tested tor lung function are affected ie 57.8% confirmed respiratory illness rates. Lung function test could be administered to 43 persons.
Three persons were obviously affected and could not perform the test. Eight had reported respiratory problems but did not want to go through the
lung function test. Four persons were in good health with no problems so tests were not administered Totally 28 persons interviewed (and tested
or only checked) have respiratory system affected.
35 See www.ourstolenfuture.orq/NewScience/synerqY/sYnerqy.htm
Also http://www.heallh.state.mn.us/ciivs/eh/qroundwater/hrlmix.html for some new action on groundwater contamination and
synergistic effects.
Also http://www nmenv.state.nm.us/aqb/proiects/Corrales/ DOH Synergistic Effects.pdf
75
Annexure 5
KL 02
HOW PREPARED ARE THE PUBLIC HEALTH SERVICES TO RESPOND TO
CHEMICAL EXPOSURE AND DISASTERS/ ACCIDENTS.
Observations from the HIL Endosulfan plant fire Eloor, Kochi, Kerala.
The HIL fire raises as many questions about the negligence of the company as it does about the
complicity, complacency and, ultimately, the total failure of regulatory authorities such as the
District Administration, the Pollution Control Board, the Factories Inspectorate and the
Controller of Explosives. In enquiring into this incident, investigation into the failures of these
departments would be critical to preventing such disasters from recurring. T he response of the
District Administration and regulatory authorities in dealing with medical emergency caused by
the fire was ad hoc and uninformed. I his indicates that the administration is totally unprepared in
terms of medical response in the event of such emergencies. It is also clear that the medical
professionals who led the health camp on 6th July had little or no understanding of the special
needs of victims of chemical poisoning.
Reconimen dations
1. Hindustan Insecticides Ltd and its senior executives should be criminally charged with
negligence for having failed to take adequate steps to prevent the fire that injured a yet-to-be
determined number of people and polluted the environment.
2. Criminal action must be taken against the Occupier and Manager under Section 92 of the
Factories Act for violating the provisions of the Factories Act.
3. The Central Government should conduct a formal enquiry into the “causes of the accident”
and should coopt one or more persons possessing legal or special knowledge as assessors in such
enquiry. The Centre can order such enquiries under Section 9 A of the Explosives Act, or section
41 -A of the Factories Act.
4. The District Administration, along with relevant authorities and community groups, should
establish a system for long-term health monitoring, disease surveillance and treatment of people
in the impact zone of the HIL smoke plume. Firefighters, police personnel and HIL staff exposed
to the fire should undergo a complete medical examination, monitored on a long-term basis and
provided with specialised health care. The company should be directed to compensate at those
affected, whether directly or indirectly, by the fire.
5. 1 he Kerala Pollution Control Board should submit a report prepared at HIL’s cost, on
pollution containment measures, and short-term and long-term environmental monitoring plans
deployed by it in response to the HIL fire. (See footnote for more details)6
6. The Factories Inspectorate must be asked to submit a report on steps taken by it to assess the
adequacy of safety systems
7. The District Administration should explain why it failed in preparing people for an appropriate
response in the event of such emergencies, and what steps it is taking to avoid a repeat of such
haphazard response in the event of future emergencies.
8. Companies that do not have or do not disclose onsite and offsite emergency plans to workers
and members of public should be ordered to do so within a set time frame or shut down after
presenting a plan for rehabilitating its workers.
76
9. Infrastructure for mass evacuation from Eloor Island to the mainland at crucial points in Eloor
should be set up for use in the very LIKELY event of an industrial disaster.
10. The District Administration should prepare a comprehensive disaster response plan to react
to such disasters. The plan should include components dealing with mass evacuation, disaster
containment, emergency environmental response, emergency medical response, and shortand
long-term medical and environmental monitoring and rehabilitation. Suitable experts should be
consulted for the development of each of these components, and the plan should involve
significant participation from workers, community residents and community groups.
11. Given the high levels of existing pollution in Eloor, and the incremental burden added by
ongoing pollution and incidents such as the HIL fire, the KPCB should develop a comprehensive
environmental remediation plan for Eloor and the River Periyar. The development and execution
of the plan should be led by workers and residents and be paid for by all Eloor industries each
contributing in proportion to their pollution output.
KL 03
TESTIMONY ON IMPROPER MANAGEMENT OF TRAUMA VICTIMS
Trauma mainly Road Traffic Accidents have become a major public health problem in India too.
The early management of trauma victims consists of maintaining Airway, Breathing and
Circulation (Primary Surveyj.This is essential to maintain the chain of survival. This does not
require any sophisticated gadget and can be carried out by a trained paramedic even. No referral
shall be made without maintaining Airway, Breathing and Circulation. The H'ble Supreme Court
has also made it mandatory for every medical practitioner to bring a patient out of the zone of
risk.
We had made a study of the early management of trauma and found that there is a gross
deficiency in this. Many a death can be avoided if this simple protocol can be followed.Our study
was published in The Hindu and Indian Express.
Denial of Health Care: Improper management of trauma cases.
Consequences: Avoidable death, complications and disabilities.
Recommendations: - Training of all doctors in management of trauma.
- Instructions of all doctors to follow the protocol.
KL 04
ENDOSULFAN POISONING DUE TO COMMUNITY EXPOSURE - FAILURES IN
RESPONDING TO THE HEALTH PROBLEMS AND PROVIDING PUBLIC
HEALTH CARE AND SERVICE.
The incidence of the endosulfan poisoning at the Kasargod villages in Kerala is exposing many
77
limitations, negligence, failures, lack of accountability, responsibility, casual and careless
attitude of officials, lack of information and knowledge, system failure, lack of systems, buy
outs, etc.
The attempt in this presentation is to look at the failure in the public health sector.
KL 05
TESTIMONY ON USE OF IRRATIONAL DRUGS
At present, many drugs which do not find a place in any standard text book of medicine or
pharmacology are prescribed to patients under considerations other than scientific indications.
This increases the cost and many a time prove to be hazardous to health. Anti oxidants, tonics,
irrational combinations of drugs are prescribed and used. The recent controversy where
gynaecologists prescribed Letrozole for infertility is another, eg. Letrozole is an anti cancer drug
and its label carries the warning : To be prescribed only by an oncologist. The MIMS also
carries a list ol drugs prescribed in India which are either irrational or not recognized by the
Drugs Controller General Of India. A study conducted by SCTIMST, Trivandrum has found
66 of prescriptions to be irrational. Since SCTIMST is a national institute of repute, this has to
be given due importance. Another study recently released by Dr. Indira of Medical College,
Trivandrum Clinical Epidemiology Unit has brought out the irrational use of antibiotics in
respiratory infection in children.
Indian Medical Council Regulations 2002(N’otified On 11-3-2002 Published In Gazette Of India
Dated 6 April 2002 1.5 Says
Every physician should as far as possible prescribe drugs with generic names and ensure that
there is a rational prescription and use of drugs.
Denial of Health Care: Irrational use of drugs
Consequences: Impairment of health
Recommendations:
The Medical Council India (MCI) must be directed to implement this statutory regulation in
letter and spirit and institute a Prescription Audit..
The Drugs Controller General India must publish the list of drugs approved by him for use in
India with indications.
The MCI shall direct all doctors to prescribe only those drugs which are given in standard text
books and approved by DCG till a National Formulary is accepted..
78
MCI must publish a National Drug Formulary or accept the already available ones Eg: IMA
Drug formulary,CHAI-CMAI Formulary.
All prescriptions should be from within this Formulary. This must be made mandatory'
KL 06
NEGLIGENCE IN PESTICIDE USE AND ABUSE - RESULTING EXPOSURE TO
COMMUNITY & ENVIRONMENT
Need for preparedness to avert disasters and provide relief for victims.
I here were several cases of poisoning in cashew factories in Trivandrum last year; 1500 women
workers were hospitalized. The response was limited to just First aid and acute poisoning
mitigation.
Over 100 students were hospitalized in Wynad resulting from the pesticide use by a farmer in
the compound next to the school. The timely intervention of the District Collector saved the lives
of 8 serious exposure cases.
Exposure and access to pesticides in the plantation areas of Idukki makes it the district with
highest suicide rates in the state. The district also reported the rise in cancer patients resulting
from pesticide use.
Denial of health care : Absence of regulation in the purchase and use of pesticides
Consequences: Ill health of the people.
Recommendations: Regulations of the production, sale and use of pesticides
KL 07
LACK OF A FORUM WHERE PATIENTS CAN LODGE COMPLAINTS
REGARDING TREATMENT
There is no effective forum where patients can 1lodge
' complaints regarding treatment (consumer
forum is only for compensation) eg: unnecessary drugs, unindicated drugs or other treatment,
unnecessary costly investigations deviations from accepted treatment protocols etc. eg;
Caesarean Sections are in the range of about 30% though the accepted range is only 10%.
As patients arc not capable of assessing the scientific validity of the treatment meted out to them,
expert panels need to be constituted under each medical council to address this issue.
79
Demal of Health Care: Absence of forum to lodge complaints of mismanagement and
i alpractice, other than the courts of law or the consumer redressal forums. &
cCarenofqUCnCCS: ,SSUeS °f general nature of mismanagement in health care are not heard or taken
“'X”'
<*■»>.
»i.> hs,e„ these
80
Annexurc 6
DETAILS OF CASES FROM PONDICHERRY
PY01
Name: Mrs. M
Age : 60, female
Address : Karaikal
Mrs M. received treatment at Karaikal Government Hospital for her eye defect. She visited the
hospital six times for checkup and treatment, and every time she did not have to wait more than
15 minutes to get the treatment. Both her eyes were operated on one after another, and on both
occasions the operation was done the day after admitting her as inpatient. Good care was given
at the Centre, and staff of the Centre rendered good service whenever required. They were
available in their duty time.
According to the patient, all equipments were kept ready in working conditions for diagnosis and
treatment. Except eye ointment, all medicines were supplied from the hospital. The expenditure
was only on their own transport, food.and for purchasing spectacles. They did not pay any bribe
to the doctors or any other hospital staff. Mrs. M was satisfied about her treatment and
experience at the Karaikal Government Hospital.
Result: Patient satisfaction, when there is quality of care
PY02
Name: Mrs. IM
Age : 49, Female
Address : Sonampalayam, Pondicherry
Mrs. IM visited the Pondicherry Government Hospital twice at Chenchsalai, Pondicherry twice,
to get treatment for excess bleeding (uterus related).
Without any delay her check up was done with scanning etc. She was happy with the care she
received and have no complaints about the hospital. Care and attention was given when she was
at the hospital, the equipment were in usable condition, and she received all the medicines at the
hospital. She mentioned that she did not spend any money for this treatment. She is happy about
the treatment received by her.
Result : Patient satisfaction with the services provided in the public health facility.
81
r
PY 03
Name:
Age :
Sex:
Date of interview:
Problem:
Mr. N
29 years
Female
3rd July 2004
chest pain and stomach pain
She visited the Othiyansalai Primary Health Center in Pondycherry to get the treatment. She said
there was delay of about 30 minutes in attending to her after she reached the PHC but she
received the necessary treatment. The doctor checked her Blood Pressure and did an ECG. She
received good care and treatment from all the staff in the health center. She was given free all
the medicines necessary. All the equipment at the center is functioning condition and kept ready
for use. Regarding expenses she said, she did not spend any money for her treatment, she spent
only for transportation. She is happy with the treatment provided to her at this PHC.
Result: Patient satisfaction
PY 04
Name:
Age:
Sex:
Problem:
Ms. AK
44 years
Female
fracture of the hand
She received the treatment for fracture of her hands at the Karaikal Govt. General Hospital. She
said proper treatment was given to her at the general hospital. She said she unnecessarily spent
money for buying oil from the traditional healer before she went to the general hospital.
Result : Patient satisfaction
PY 05
Name:
Age:
Sex:
Problem:
Mr. DA
30 years
Female,
throat pain
He received the treatment for his throat pain. He said, though the doctors attended to him but
they were not very attentive, as there is ego problem among the doctors. Otherwise everything at
the General hospital was good.
82
PY 06
Name:
Age:
Sex:
Problem:
Mrs.K
36 years
Female,
abscess
She visited five times the Primary Health Centre at Censalai in Pondicherry for treatment. She
says that proper treatment is given to her.
PY 07
Name:
Age:
Sex:
Problem:
Mrs.L
35 years
female
Chronic headache
She visited Thuppurayapatti Primary Health Center to get treatment for her headache. She also
said proper treatment was given to her.
PY 08
Name:
Age:
Sex:
Problem:
Mrs. R
38 years
Female
chest pain
Radhika says that she received good treatment from the oliyansalai Primary Health Centre in
Pondycherrry.
PY 09
Name:
Age:
Sex:
Problem:
Ms. S
24 years
Female
not mentioned
She did not mention for what she received treatment at Karaikal General Hospital. But she said
she received proper treatment.
83
PY 10
Name;
Age:
Sex:
Date of documentation:
Problem:
Comment:
Ms. T
40 years
Female
30th June 2004
Not mentioned
The staffs at the Nedunagar Primary Health Center do not
give proper care and treatment with concern.
PY 11
Name:
Age:
Sex:
Problem:
Ms. ER
45 years
Female
Diabetes
She says that she is receiving proper treatment from Karaikal General Hospital.
PY 12
Name:
Age:
Sex:
Problem:
Mr. S
38 years
Male
Tuberculosis
He says he received proper treatment for tuberculosis.
PY 13
Name:
Age:
Sex:
Problem:
Ms. GS
38 years
female
ulcer of the stomach
Comment:
She says she has received proper treatment from
Mummombakkam Primary Health Center.
84
PY 14
Name:
Age:
Sex:
Problem:
Ms.S
40 years
Female
White patches
She says she has received treatment for white patches from Villianur Primary Health Center. She
went there four times. As she was not cured, she went to J1PMER in Pondicherry. She says,
though she did not get cured at the Primary Health Center she was treated well by the staff there
85
T
Annexure 7
DETAILS OF CASES FROM TAMIL NADU
TN 02
SIPCOT, Cuddalore: Special Needs of Pollution Impacted Communities Ignored
The SIPCOT chemical industrial estate in Cuddalore is one among many such clusters of
polluting industries in India. The needs of communities and workers in such areas is remarkably
different from those of communities not living in polluted places. In unpolluted places, the health
of communities would be the responsibility of the municipality and/or the health department. In
pollution-impacted communities, the causes and sources of pollution are often within the
jurisdiction of agencies such as the Pollution Control Board and the Factories Inspectorate,
whereas the health of the workers outside the factory and residents comes under the purview of
the District Administration and the public health system. Given the peculiarities of this situation,
it is important that any approach to addressing health issues in such areas is done in coordination
among these bodies.
The pollution-related health problems in SIPCOT, Cuddalore have been mentioned by
community residents since at least 1984. However, till date no official study has been
commissioned to enquire into the reported health problems in the area.
In her submission to the Indian People’s Tribunal on Environment & Human Rights, Dr. R.
Sukanya, a public health specialist notes of the SIPCOT environment:
"Health problems among people due to exposure to environmental toxins is an important
public health problem. Threat ofemerging antibiotic resistance, eye problems, chronic
compromise oflungfunctions, high morbidity among children, lack ofproper medical care and
rehabilitation, medical apathy are all highlighted in the case studies from Eachangadu." In
conclusion, Dr. Sukanya notes the need for a comprehensive health assessment of the villagers
and SIPCOT workers, and "active measures to stop the contamination from the nearby factories
and to restore the quality of the water to prevent further damage to health of all."
While the kinds of industries and the number of people living within the impact range of
pollution may differ from place to place, the problems faced by and the demands of workers and
communities living along or near the fenceline of polluting factories is identical throughout the
country.
The following issues inevitably arise with regard to health in pollution-impacted communities:
•
•
High rates of morbidity among exposed people, especially women and children.
Because women, children stay at home and, hence, in a polluted atmosphere all day
long, they (along with factory workers living within the pollution-impacted
community) arc worse affected than men or others who may leave the pollution area
to work elsewhere.
Children are routinely identified as one of the most affected groups in SIPCOT,
Cuddalore.
86
•
•
•
•
•
•
•
Symptomatic treatment for chronic illnesses caused by exposure to pollution
No specialized treatment for cases of industrial poisoning
Medical expense disproportionately higher than income
Loss of income due to lost work days
Standing the Precautionary Principle on its Head: Anecdotal evidence, testimonies of
pollution-impacted people, complaints and even simple studies seem to be inadequate
to move district authorities, the health department and the Pollution Control Board
into action. Rather than act on this evidence, they demand conclusive proof of harm
from complainants or belittle their claims as exaggerated.
No preventive action: Ongoing exposure - Many officials at regulatory authorites
believe that pollution is inevitable. They also recommend “reason” and “patience”
saying that the pollution has to be reduced gradually keeping in mind the need to
balance the interests of the industry and the community. In a sense, this attitude
condones pollution and authorizes the ongoing exposure of communities to pollution.
Alarmingly, the Health Department is noticeably absent from the discussion around
the issue of health in pollution-impacted communities. In the absence of any steps to
stop exposure to pollution, there is little that can be done to improve the health status
of pollution-impacted communities.
Lack of specialized infrastructure in the event of a disaster or emergency.
This case will be a presentation by Nityanand Jayaraman based on documented and referenced
interviews with representatives of the District, Health and Environmental administration, and
testimonies gathered from residents of SIPCOT.
Recommendations:
•
•
•
•
•
•
Operationalise the Precautionary Principle, and use the Precautionary Principle rather
than a cost-benefit analysis to guide decision-making on the matter of environmental
health.
Notify areas around polluting industries as “Zones of Environmental Health
Concern.”
In the health administration infrastructure (ESI, PHC, GH etc) covering “Zones of
Environmental Health Concern,” deploy specialised environmental health cells or
retrain existing health department staff to deal with a) long-term monitoring health
among pollution-impacted communities; b) providing long-term specialised health
care to people living, working within such Zones; c) cases of acute poisoning by
industrial chemicals.
Deploy an emergency plan to contain the damage already done to children's health,
and initiate measures for the rehabilitation of children’s health.
Operationalise the Polluter Pays Principle: Polluting industries maximize their profits
by externalizing the costs of pollution to the community in the form of transferred
health care costs to repair pollution-related health damage. These industries should be
made to pay for the health care of pollution-impacted communities and for the
specialized health care infrastructure required in such communities.
Take steps to eliminate exposure by stopping pollution
87
•
Involve representatives (particularly women) from the pollution-impacted
communities and local public interest organizations in monitoring health and
reporting pollution incidents.
TN 03
Industrial Accident Leading to Death
On 9 April, 2004, Mr. R - a contract worker from Periyapillaiyarmedu, SIPCOT, Cuddalore began work as a daily-wage labourer hired by a contractor at Tanfac Industries Ltd.
On 1 1 April, 2004, Mr. R was exposed to concentrated sulphuric acid fumes while cleaning an
acid tank at TANFAC Industries Ltd. Immediately upon exposure, he climbed out of the acid
tank and fainted. After he recovered, he was given something to drink and sent back to clean the
acid tank where he was exposed further.
Upon returning home, his wife reports that he was coughing and complained of heaviness in the
head, and difficulty in breathing. The problem worsened, and he.was taken to the Government
Hospital in the early hours of 12 April, 2004.
On the same day, the doctors at the GH recommended his relocation to a private hospital. He was
moved to Kannan Hospital, Cuddalore. No ambulance or hospital vehicle was provided to
convey him to the Private Hospital.
On 22 April, 2004, Mr. R was transferred to JIPMER, Pondicherry, after his complications failed
to subside. He succumbed to his exposure on 30 April 2004.
His post-mortem report identifies the cause of death as “chemical pneumonitis.” A chemical
analysis report prepared by the chemical examiner of the Public Health Laboratory, Pondicherry,
confirms the “presence of corrosive acid such as sulphuric acid.”
This case demonstrates a prevalent problem — failure of regulatory authorities such as the
Factories Inspectorate to sincerely implement the rules relating to industrial safety, health and
hygiene. Victims of such failures are almost always workers, particularly contract workers.
Mr. R, an untrained contract worker, was sent to do a highly specialized and hazardous job. The
acid tank was not certified free of toxic fumes as required by law. There was no first aid
available, and the worker was sent back to the toxic work atmosphere.
DENIAL OF HEALTH CARE :
•
Lack of preventive care: Ensuring health practices within industries is the mandate of
the Factories Inspectorate. In practice, this department serves as the Government’s
arm on onsite industrial health and hygiene. The Factories Inspectorate failed to
ensure the rules in TANFAC, thereby eliminating any possibility of preventing harm
from happening. 1 he absence of substantial punitive measures against violators is
tantamount to condoning violations and represents a failure to prevent injury or health
damage.
•
Lack of emergency response: Again, the failure of the Factories Inspectorate to
rigorously implement the rules has led to a situation where Mr. R had no access to
first-aid and sensible advice after the accident.
•
Lack of adequate and appropriate facilities in Government I lospital: Despite its
proximity to an industrial area notorious for its pollution- and accident-related
injuries and deaths, the Government Hospital in Cuddalore seems ill-equipped to deal
88
•
with cases of chemical poisoning. This is clear from the fact that Mr. R had to
relocate to a better hospital within hours of getting himself admitted at the GH.
Challenges in Accessing Redressal: If accessing health care for Mr. R was difficult,
the task of accessing compensation and assistance from the District Authorities and
the ESI is proving to be even more complicated. The widow has received no interim
relief. No case has been filed against the violator - Tanfac. Pension under ESI is still
several files away. These complications are very much related to the failure in
regulating industrial safety and health, and in maintaining appropriate health systems.
CONSEQUENCES: Death (avoidable if proper first aid and treatment facilities were available
and used)
RECOMMENDATIONS:
I. 1 he Health Department should play a proactive role in ensuring that practices to
prevent harm are followed within industries. 1 hey should do this by coordinating
with the Factories Inspectorate.
2. The Health Department should facilitate the routine monitoring of workers health
data required to be collected under the Factories Rules to identify problems (if
any) of occupational diseases among them.
3. J he Factories Inspector should be directed to diligently perform his/her functions,
particularly in regard to maintaining industrial safety and ensuring emergency
response by industry. The Inspector should also ensure that only trained workers
are deployed on hazardous jobs and contract workers are not used for such
activities.
4. Hospital infrastructure in the areas near polluting industries should have trained
personnel and equipment to deal with cases of industrial injury and poisoning.
5. The District Administration should be instructed to assist the victim or his/her
survivors in accessing compensation and/or pension.
TN 04
Injury to Fishermen as a Result of Water Pollution
In September-October 2002, fisherfolk working in the river Uppanar, that runs behind SIPCOT,
Cuddalore, stopped fishing after all active fishermen began developing serious skin problems.
They attributed the problems to an illegal discharge of acidic effluents from Pioneer Miyagi
Chemicals -- a routine occurrence, according to them.
The company uses large quantities of hydrochloric acid to dissolve bones (and manufacture
Ossein). The New Jersey Department of Health warns: "Contact [with hydrochloric acid] can
cause severe skin burns and severe burns of the eyes, leading to permanent damage with loss of
sight. Exposure to dilute solutions may cause a skin rash or irritation."
A submission by the Joint Director of Health Services, Cuddalore, corroborates the charges by
the fisherfolk against Pioneer Miyagi for discharge of untreated acidic effluent into the river. "On
20.9.02, 13 persons (fishermen) suffered chemical burns due to the effluents/discharge from
SIPCOT industries into Uppanar River," the statement read.
89
The fisherfolk said medicines from the Government hospitals and private hospitals did little to
ease their problem. No systematic treatment was provided for the victims of acid burns.
When the fisherfolk approached the District Collector for assistance, the Collector is reported to
have dismissed their concerns and advised them to look for an alternative livelihood. This
attitudinal malady that afflicts many bureaucrats and people in regulatory agencies is the most
serious obstacle to implementing the Precautionary Principle, or taking any sensible steps in the
matter of health.
In October 2002, NGOs FEDCOT and CorpWatch requested public health specialist Dr.
R. Sukanya (M.D) to look into reports of the September 2002 occupational injuries among
fisherfolk, and the general state of health in SIPCOT. In her report submitted to the Indian
People’s Tribunal on Environment and Human Rights, Dr. R. Sukanya states:
"In the fishing village of Sonnanchavadi, chemical contamination of the river poses a serious
and ongoing occupational health threat. The fact that the villagers have been forced to stop
fishing - and suffer wage losses - is a violation of their fundamental and constitutional
guaranteed right to livelihood. ”
DENIAL OF HEALTH CARE :
1. Lack of preventive care: Adequate efforts have not been made to eliminate
pollution-related health injury.
2. Absence of appropriate treatment: Fisherfolk received no effective treatment for
their ailments.
CONSEQUENCES:
1. Prolonged skin problems
2. Difficulties in accessing redressal (including compensation)
3. Lost wages and added expenses due to health care costs
RECOMMENDATIONS:
1. Action to be taken as suggested in Case/ and as applicable to this type of chemical
pollution.
2. Primitive action against the industry as deterrant to future violations.
TN 07
Testimony of S.J.
Name:SJ
Age : 45, male
Address : N.Punjampatti, P.O Dindigual-644503, Tamil Nadu
Date : 30.6.2004
90
SJ met with an accident and went to Dindigul Government Hosptial for treatment at 10.30 p.m.
with head injury. I hey did the first aid but did not take CT Scan to diagnose head injury' even
though the patient had severe pain and swelling of face. There was delay for attending the
patient. Consequence of the delay caused blood clots in the eye and reduced eyesight, severe
pain and his condition become serious.
1 inally operation was done after paying the bribery amount. The medicine was bought outside
for the operation and it costs Rs.750.00. CT scan also taken outside. The patient paid money to
all level of people at the hospital. They borrowed money for high rate of interest and spent
Rs.5,500/- for getting treatment. Proper care was not given when he was getting the treatment
and whenever medical attention was needed the hospital staff ignored him.
DENIAL OF HEALTH CARE:
Negligence
Bribery
Delay in health care
Unnecessary expenditure: purchase of medicines and taking
of CT scan outside.
TN 08
Testimony of Ms. G
Name : Ms. G
Age : 35, Female
Address : Dindigal Dist. Tamil Nadu
Hospital Visited : PHC, Alamaruthupatti
Ms. G was admitted in the Alamarathubatti, PHC for her delivery. Delivery conducted by staff
nurse Ms.Rajalakshmi, and she delivered a stillborn baby. Due to her anemic condition she
needed blood, for this she was referred to nearest referral hospital. She went by the Government
bus though the ambulance was in PHC at that time.
DENIAL OF HEALTH CARE
•
•
•
Non-availability of blood at the Primary Health Centre
The ambulance service was not provided even though available. She had to go by the
ordinary transport even though she had just delivered and still born baby and needed
blood transfusion
Failure of antenatal care, leading anemia and still births.
TN 09
Testimony of S.G.
Name : S.G
Age : 45, Female
91
Address : Pullampadi P.O, Lalgudi, T.K. Trichy Dt. Tamil Nadu.
S. G was suffering from TB. First she went to PHC of Pullampadi and after the check up her
disease was found to be pulmonary. Then she was sent to Government Rajaji TB Prevent
Centre, 1 richy for continuous treatment. Last one year she was going to Trichy from her village
for getting treatment. Important medicines were bought from outside medical shop. 8 times
scanning were taken from outside.
She did not get any improvement now she is getting
treatment at private clinic called Madha Clinic, Pullampadi. For the treatment she borrowed
Rs. 15,000/- and sold 24 gram gold jewellary, 10 goats and one milch animal
DENIAL OF HEALTH CARE :
Ineffective treatment
Asked to get medicines and tests done outside.
CONSEQUENCES :
Delay in improvement of health
Heavy indebtedness, borrowing money and selling assets.
TN 10
Testimony of H.S.
Patient’s Name: H.S.
Adddress : Lalkudi Taluk, Trichy (Dist), Tamil Nadu
For more than 2 years, H.S. suffered from cold and Asthama. He used to go to Pullambadi
Government Hospital.
But he could not overcome his disease through the medicines and
services, given by the Government Hospital. So, he went to private hospital in Lalkudi. He
spent nearly Rs.30,000/- for his complaints. In order to raise the amount he sold his cattle, land
and jewels.
DENIAL OF CARE
1.
2.
No proper services available in Government Hospital
Unnecessary expenditure of Rs.30, 000/-, making the patient sell his assets.
TN 11
Treatment without Examination
Case 1. P, aged 50 years, went to Government General Hospital at Manaparai in Trichy district.
She is suffering from high blood pressure. Earlier she was taking treatment with a private clinic.
At present due to economic crisis in the family she is going to Government Hospital. She said the
doctors at the governmental hospital are without checking her blood pressure, giving her
medicines. She takes the tablets and goes to the private clinic to check her blood pressure and
takes the tablets according to the doctor’s advice there.
92
Case 2: M, aged 38 years, is going to the Government General Hospital for diabetes. They give
her the tablets without examining her urine and blood. She goes to a private clinic to get her
urine and blood examined and take the tablets according to the doctors’ advice there.
DENIAL OF HEALTHCARE:
Negligence
Absence of simple diagnostic aid (B.P. apparatus)
not performing; the needed tests, before the
administration of drug
CONSEQUENCES :
- Unnecessary expenditure to get the tests done at
the private clinic.
- Delay in administration of drugs.
TN 12
Testimony of M
M, aged 20 years, went to Government General Hospital at Manaparai in Trichy district for first
delivery. The baby was delivered through caesarean. The day when delivery was conducted she
suffered from more pain but they did not give her any medicine. She had to wait till the doctor
came the next day to give her the injection.
DENIAL OF HEALTH CARE: Delay in health care and relief of suffering.
TN 13
Testimony of NS
Name : NS
Address : Manaparai, Tamilnadu
He was admitted in Manaparai Government Hospital. The staff did not give him proper food.
They are selling the food and other things. Due to this patients are not getting proper services
from hospital.
DENIAL OF CARE: Negligence and corruption
TN 14
Testimony of N
Name : N
Age : 45, male
Address : Pungawadi, Manapparai, Tamil Nadu
Hospital visited : Manapparai Govt. Hospital, Manapparai, Tamil Nadu
93
He got bad damage’ in the spinal cord due to hit by the bullock. He was admitted in the
TZnParai Govrernment HosPilal for 4 days . Hospital staff told him that, ‘ he need Rs
10,000/- to rectify his complaint, but he could not pay that amount, so he was discharged from
the hospital. Now h.s two hmbs are not useful to him. He is living without the usage of his legs.
?F HEALTH CARE : Medical attention denied because the patient could not give
the bribe demanded’ by the staff of the Government Hospital.
CONSEQUENCE : Disability; unable to use the legs
TN 15
Testimony of G.P.
Patient’s Name : G.P.
Address : Sangralingapuram, Tamilnadu
For the heart complaints she used to go to Aruppukottai Government Hospital. On 8 8 03 she
was admitted m the above hospital for treatment. There she had an X-ray taken. Due to the non
availability of doctor and the deficiency of the medicines, she didn’t get timely treatment As a
consequence she died.
For the treatment of her complaint she spent almost Rs.20,000/-. She raised this money through
selling her land and borrowings.
DENIAL OF CARE
-
Non availability of doctor and medicines in the Government Hospital
Free health care if not given; so, she had to spend more than Rs.20,000/-
CONSEQUENCES : Death
TN 16
Bribery in Govt. Hospital
Patients’ Names :
1. A.S
2.
3.
4.
A.L
V. M
KG
Hospital Visited : Cuddalorc , Government Hospital
Among
Minong the
uic four,
iour, two
two of
oi them
them went
went for
for delivery
delivery and
and other
other two
two went for Family Planning
operation. The Cuddalorc Government Hospital is the District Hospital. All of them gave
94
Rs.700 to Rs.500 rupees as bribe to avail the services. They received good treatment and other
services from the hospital.
DENIAL OF CARE : Bribery
TN 17
Case Study of Theni, Tamil Nadu
The situation in Theni, the largest cotton producing district of Tamil Nadu is very unique since
pesticide use in cotton growing areas is higher than in any other crop in India. Such high
pesticide use which goes up to 25 sprays in one season brings with it a large number of health
related issues ranging from cases of acute poisoning to a high rate of fainting due to inhalation of
pesticide fumes and chronic disorders like impaired mental developmental abilities in children.
The health care scenario in Theni District:
Three to six villages have a representation of the Village Health Nurse (VHN) who are provided
with living quarters next to their small dispensary. They have the capacity only on issues like
vaccination, vitamin and mineral deficiencies and maternity advice. The villagers too do not
depend on them for any serious health problems. Even for common illnesses like fever, they
might either go directly to the PHC (Public Health Centre) or to the nearby private doctor.
Approximately three or four of these VHN’s come under a PHC. They have a few beds and a
doctor is assigned to each PHC, who hardly comes on time and leaves by lunch. By and large,
they do not admit patients and send them to the district General Hospital. Even first aid is mostly
not administered on the pretext that they are anyway going to the GH. Most of the cases who
have been admitted in the PHC’s seem to have got some political pressure exerted by the local
party men.
As observed by the Greenpeace study “Arrested Development” in Theni, in three villages, the
effects of pesticides are highly pronounced on the mental abilities of children. An issue, which
needs to be taken up seriously, is the faulty system of health care, which consists of callous
professionals who have been risking the life and health of the future generations.
DENIAL OF HEALTH CARE
Exposure to toxic and hazardous chemicals (pesticides) without adequate preventive and
precautionary steps.
Inadequate health care to tackle the adverse effects of the chemicals.
CONSEQUENCES
Arrested development of children.
Impaired mental abilities.
RECOMMENDATIONS
95
Apply the precautionary principle at all stages for the pesticides.
ARRESTED DEVELOPMENT - An Executive Summary
In the cotton-growing season between April and December 2003, Greenpeace India studied the
chronic effects of pesticides on the development of children growing up in cotton cultivating
areas of six states of India. The results of this study, published in April 2004 as Arrested
Development, reveal that exposure to small doses of pesticide during childhood years has
severely impaired the analytical abilities, motor skills and the concentration and memory of
children from farming communities - the 1648 children who participated in this study are
representative of the population of India.
Most studies in the past have focused on pesticide residues in food and water, instead of which
this study attempts to correlate the indiscriminate use of pesticides with the health of
unsuspecting little children (4-5 years) and older ones (9-1'3 years); children who appear normal
and happy but whose mental development lags far behind their counterparts in pesticide-free
environments. The study focuses on children, as they are particularly vulnerable, given their
physiology and behaviour patterns
A total of 899 children from six locations in the cotton-growing belts of the country, (which
implies the intensive and high use of dangerous pesticides cocktails) were compared with 749
children of the same age, economic background and ethnicity in a different location (within the
same state) where the pesticides usage was far less.
The researchers arrived at the data for this study through using a Rapid Assessment Tool.
Through this tool, the children were asked to participate in a wide range of tests using a play
approach, where the tools were individually and verbally administered to each child.
Widespread documentation on neurological effects of pesticides including effects on memory,
judgment and intelligence as well as personality, moods and behaviour determined the kinds of
tests administered.
The tests included the use of wooden blocks and jigsaw puzzles to measure mental abilities, ball
catching and balance tests to test motor abilities and memory games to asses the level of
concentration and memory.
The study found a remarkable difference between the abilities of the two groups of children, with
more or less consistent trends across different locations in both the age groups. With all other
possible confounders controlled for, the only significantly accountable reason for these
disturbing findings is the children’s exposure to pesticides.
The findings of Arrested Development make a strong case for the application of the
Precautionary Principle. In the case of hazardous and toxic substances like pesticides,
Precautionary Principle needs to be applied in their manufacture, distribution, marketing, storage
and use. The current legislations, policies and practices in India do not adhere to this
precautionary principle.
96
The report strengthens the evidence against pesticides and calls for a ban on all pesticides,
starting with those banned in other countries. As cleaner, safer alternatives for farming have been
well demonstrated by farmers in the country, the study is a wake up call to the government and a
demand for them to provide greater support to organic farming in terms of resources,
mechanisms for more research, extension and crop loan support and infrastructure.
Notes:
The six locations were chosen from states and districts where cotton cultivation and pesticide use
are high, and from where earlier reports of pesticide-related problems have emerged. The
problems here could have been environmental, human health or agronomic. These locations are:
•
•
•
•
•
•
Bharuch in Gujarat (Halder, Kavitha and Samlod villages)
Bhatinda in Punjab (Bangi Nihal Singh, Jajjal and Mahi Nangal villages)
Raichur in Karnataka (Khanapur, Manjerla and Poorthipli villages)
Theni in Tamil Nadu (Rassingapuram, Silamalai and Visuvaspuram villages)
Yavatmal in Maharashtra (Dahelitanda, Kopamandvi and Sunna villages)
Warangal in Andhra Pradesh (Atmakur, Oglapur and Peddapur villages)
TN 19
Testimony of Mrs. P
Mrs. P aged 20 native of Rosalpatti village Virudhunagar block -studied upto 12th
standard -doing agricultural collie work. She was admitted to Municipal maternity hospital
Virudhunagar in July 2003.,for delivery of baby and there was no doctor in the night.
Only health nurses attended in a rough manner. After 3 hours doctor came and did
caesarean operation and the still born baby was taken out. Unusual delay caused the death
of the baby. Later Mrs. P had to district general hospital, Virudhunagar to remove the
fluids in the stomach. After one month she recovered and now is pregnant again with 5
months baby.Since the fluid came out from the uterus, the baby had to die after a
few hours. The timely treatment was denied.
TN 20
Testimony of R
Raged 22 was admitted to Government Hospital Virudhunagar due to labour pain, in
August 2003. The doctor was not available. Relatives were waiting right from 7 a.m.
the morning, (more details awaited)
in
TN 21
Primary Health Center Study
Location of Primary Health Center : Kaniyambadi in Vellore district,Tamil Nadu.
Name of the interviewer
: Sri.Syed kalcem Ahmed
Date of documentation
: 4th August 2004
97
In frastructure
This primary health center has all the staff except the lady doctor. All the staff are staying within
the campus of the PHC. The condition of the building is good with water and electricity
condition. The road to this PHC is good and is well accessed by public transport facility. This
center has an ambulance. The vehicle number is ITI 09G1537
No information is given regarding the ownership of the building and water problem. The center
is clean. The center has toilet facility with water supply and the people who visit the center are
allowed to use it. It is reported that the beds and the labour room is in good condition. The
Operation Theater and the operation table also are in good condition. The refrigerator is in
working condition. The center has facility for autoclave. The microscope is in good working
condition. The ambulance is working condition and it is made available for patients free of cost.
Part II
The center has always anti snake venom for snakebites and anti rabies vaccine for dog bites.
There is no information regarding anti malarial medicines. TB medicines are available. There is
no information given if all the medicines are given free of cost and prescription is given for any
specific medicine.
Part III
The center conducts cataract surgeries. No information is given if the center provides first aid,
does sutures and facility for putting the cast for fractures. The interviewer does say that the
center treats fractures cases. He also says that first aid is given for burn cases and snakebites.
Part IV
Health camps are regularly held for pregnant women and children. The center has facility for
conducting normal delivery round the clock. There is facility for conducting both vasectomy and
Tubectomy.
Treatment is given for women's health problems such as white discharge and problems related
menstruation and if women attend the center for these problems. The report says that the center
has facility for medical termination of pregnancy (MTP) but it does not give any information
regarding about the conditions for MTP, such as that the patient must accept planning after MTP,
need the permission of the husband, family. It is reported that no fee is charged for MTP.
The center provides childhood immunization, and provides treatment for pneumonia and
diarrhoea and dehydration. The center has facility for treating childhood disease.
Laboratory facilities
The center has facility for diagnosing anemia, malaria, and tuberculosis. It also has facility for
doing urine examination for pregnant women.
During the past three years, there is no report of any epidemic of the following diseases; malaria,
measles, cholera, jaundice. The report says that that the staffs of the PHC are kind and polite
with the patients. None of the doctors from this center do private practice either during office
hours or after office hours. There is no report of this center ill treating dalits, traiblas, and other
marginalised people. People affected by TB, Leprosy and HIV/AIDS are not discriminated. The
98
center has private place for examining women with their attendants and they are treated with
respect. The center has facility for treating in-patients. The centers provide complete treatment
for chronic illnesses. The center refers immediately the patients to the nearest hospital at times of
emergencies and when they feel they cannot manage. The center has complaints register. No
information regarding if there are any complaints written.
In the any other information column the interviewer recommends this center and Dr. Palani
Bhushneshwai for conferring any award.
NB- further clarification have been sought from Sri.Syed Kaleem Ahmed, to fill in some aspects
that are incomplete.
Testimonies:
I belong to a minority community. I have admitted my grand daughter S at the PHC for family
planning surgery. They do not discriminate because we belong to Islam. I vouch that there is no
human right violation in this center. 1 thank Dr. Mrs. Bhuvaneswhari, Mrs. Subbalakshmi and
Mrs. Vijayakumari for whole-heartedly giving us the treatment lovingly.
Signed
Mrs. S
Saidapet
Vellore- 12
V.Subbalakshmi ANM
Kaniyambadi PHC
Dr.Bhuvaneshwari
Civil surgeon.
Govt. Primary Health Centre
I am R related to Mrs. B who was admitted at the Kaniyambadi PHC for family planning
surgery. Dr. Bhuvaneshwari and her colleagues ANM Mrs. Subbalakshmi and Mrs.
Vijayakumari treated us lovingly. They did not discriminate me because I belong to a tribal
community. I vouch that in this PHC there is no violation of human right for people belong to
dalit and tribal communities.
Signed
Mrs. B
Karugamputhur Village
Vellore Taluk
Dr. Bhuvaneshwari
Civil Surgeon
Govt. Primary Health Centre
Kaniyambadi.
V.Subbalakshmi
ANM, PHC Kaniyambadi.
99
Annexure 8
BRIEF NOTE ON JUSTICE V. M. TARKUNDE
JUSTICE V.M. TARKUNDE was bom in Saswad near Pune on July 3, 1909. He graduated from
Fergusson College, Pune. He went to the UK and joined the renowned London School of
Economics and subsequently passed the Bar-at-law. Returning home, he started his legal practice
in Pune. He was a member of the Congress Socialist Party. But meeting M.N.Roy radically
changed the political outlook of Shri. Tarkunde. Roy founded the radical Democratic Party and
Tarkunde gave up his legal practise to work with him. Neither of them had faith in party politics and they believed in conscientising people at the grass root level to promote democratic
ethos. Shri Tarkunde resumed his legal practice in 1948 and became a judge of the Bombay
High Court. He resigned in 1969 and set up practice in the Supreme Court of India.
In 1974, Shri Tarkunde with Shri. Jai Prakash Narayan (JP) founded Citizens for Democracy
with the latter as President and Shri Tarkunde as General Secretary in 1976. During the
Emergency, People’s Union for Civil Liberties and Democratic Rights (PUCL & DR) was set up
with JP as President and Shri Tarkunde as Working President. As a legal luminary', he was
committed to civil liberties. He retired from legal practice in 1997.
Shri. Tarkunde was a man of vision rooted in idealism. He believed that humanism was the
fountainhead of democratic ethos. He wanted this to be the basis of civil society. He symbolise
a spirit of humanism and human rights. Being a rationalist, he had little patience for religion. In
its stead he upheld values that transcended all faiths.
Shri. Tarkunde upheld the rights of labour and never appeared for the management. He was
among the few who recognised early the genocidal nature of communalism and was
uncompromising in his opposition to it. His sympathies lay with the rights of the people of
Kashmir and North East. Shri. Tarkunde was one of those who kept alive ‘the hope of a new day
dawning’ with the ‘recognition of the inherent dignity of the equal and unalterable right of all the
members of the human family in the foundation of freedomjustice and peace in the world’.
Justice V.M.Tarkunde passed away on 23rd March 2004 in New Delhi. It is a fitting tribute to the
indomitable spirit of V.M.Tarkunde to keep green his memory and sustain his vision.
100
Annexure 9
BRIEF NOTE ON ANANDI BAI
ANANDIBAI JOSHI was India's first woman doctor to be educated in the US. Anandibai
Joshi's life spans just about twenty-two years, from 1865-1887. She was educated at the
Women's Medical College of Philadelphia, USA.
Life in the late nineteenth century in Maharashtra was preoccupied with the ancient rituals and
traditions with no hope for independent thought or action, thus preventing all progress. Outside
Pune there was a poor postal clerk, and a widower named Gopalrao Joshi who was possessed by
the thoughts of widow-remarriages and education of women.
Having failed in finding a widow for remarriage, Gopalrao was forced to marry a 9-year- old
pockmarked girl named Yamu. This is the story of that young girl Yamu who was renamed
ANANDI after her marriage.
It was a struggle to get Anandi to share a room with her husband during the day for her lessons.
Meetings between a husband and wife during the day were unheard of in those days. But once
she learned to read Anandi discovered for herself the joy of reading and knowledge. They moved
from Kalyan to Alibaag to Calcutta, any place where they would be left alone to learn together.
The story of Anandi is the story of a woman’s transformation from a reluctant pupil and obedient
and scared wife to self-assured and independent woman.
On one level, Gopalrao and Anandi were facing oppressive society, but for Anandibai the
struggle was much more complex. She soon realized the superficiality of traditional rituals and
learned to probe deeper for the meanings in them.
By remembering Anandibai today, we are not only celebrating her achievement of becoming a
doctor, but her insurgence as an intelligent, and independent woman that makes her an
inspiration to the world, even today.
RH P- -/ So
09711
101
)- I
7
Annexure 10
SOME VISUALS OF THE SOUTHERN REGION PUBLIC HEARING ON RIGHT TO
HEALTH CARE, HELD AT CHENNAI ON 29th AUGUST 2004
'v.;> .
V-
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\'^4
■ I
CT
Ii
If
f; ■
■1 ■
■
’
w11
. ~ .
^3SS
' vl' ■' •' I
J
Fig 1: A man from Tamil Nadu presents his testimony before the Panel at the Southern Region
Public Hearing on Right to Health care.
MW
C,
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■ ■ . ^^2?*'“? :- 4 S'
1^20
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jj^sp^
.-■- Jggl
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Fig 2: A section of the crowd at the Public Hearing, including senior health government officials
from the southern region.
102
J. Js
' 5W ’ 5w
W,
.k
lb
^rU| . '■
■•
r
L - \ >r«‘'
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i
Fig 3: Case presentation underway at Parallel Session I (Andhra Pradesh, Karnataka)
w’»i
’
■
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■V ■
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Fig 4: Case presentation underway at Parallel Session II (Kerala, Pondicherry, Tamil Nadu)
103
SDH
Fig 5: A woman presenting her testimony at the Public Hearing
104
SOUTHERN REGION PUBLIC HEARING ON THE
RIGHT TO HEALTH CARE
Co-organized by
Jan Swasthya Abhiyan (Peoples’ Health Movement, India) and
The National Human Rights Commission (NHRC)
on 29th August 2004 at Chennai
STATUS OF HEALTH AND HEALTH SERVICES
OF
THE PEOPLE OF KARNATAKA
Submitted on OHM*behalf of the
JAN SWASTHYA ABHIYAN
C/o Commanity Health Cell
# 359, Jakkasandra 1“ MainJ“ Block, Koramangala, Bangalore - 560 034
Tel. . (080) 25531518 Telefax : (080) 25525372 Email: chc(g)sochara.org Website : www^ochara.org
H
I OS'
-Li
IL
4T..,
-
n
Status of Health and Health Services of the
People of Karnataka
Karnataka is considered to be just above the national average as regards the overall
health status of the people and just below the average among the states in the southern
region. There has been improvement, as in other states, in the health status of the
people over time, as shown by indicators such as life expectancy at birth, crude birth
rate, crude death rate, infant mortality rate and under - five mortality rate. There has
been control, to some extent, of vaccine preventable diseases, through widespread
immunization. In family welfare, the couple protection rate has increased to a large
extent. There is a wide network of health care institutions in the public and private
sectors, functioning at the primary, secondary and tertiary levels. There are also a
large number of professional educational institutions, affiliated to the Rajiv Gandhi
University of Health Sciences, training doctors, nurses and other health personnel.
1. Issues of Concern that impact on the Right to Health Care
There are many issues of concern requiring urgent action.
These have been
brought out by the Karnataka Task Force on Health and Family Welfare in its
report of April 2001. Among them are:
•
neglect of public health and distortions in primary health care
•
widespread corruption; inequity in» «ccess to health care that widen
the
existing disparities in health and health care; implementation gaps between
policies and practice
•
inadequate emphasis on quality of health care
•
absence of attention to ethics
•
improper development of human resources for health, and
•
inadequate allocation and utilisation of funds and resources.
Other important problems in the health sector include:
•
inadequacy of the health budget
IQ6
1
•
unacceptable quality of health care services
•
inadequacy of certain categories of health personnel, both in numbers and
quality
•
poor nutritional levels, particularly among infants, children, adolescents and
pregnant women
•
inequitable access to health care and
•
non-involvement ot the community in planning, monitoring and evaluation of
the health sendees.
2. Health Services Facilities (Governmental)
Primary Health Care
The following facilities and infrastructure have been established by the State, are
expected to provide primary health care:
Subcentres: 8143
<4>
Primary Health Centres (PHC): 1676 + 9 (urban)
<4>
Community Health Centres (CHC): 249
Primary Health Units (PHU): 583
(Source: Annual Report,
Department of Health and Family Welfare, 1999-2000)
Of these health centers, the first three follow generally the norms of the
Government of India as regards staffing pattern and infrastructure, even though
there are many vacant posts and lack of buildings to house them. The availability
of essential drugs has been a perennial problem. This affects the poor, who do not
have the means to purchase the drugs from outside, with the prices of drugs rising
constantly.
This leads to avoidable deaths, permanent damage to health and
indebtedness.
Lack of buildings; or geographically inaccessible locations of
PHCs; poor construction and maintenance, and the non
availability' of drugs are major structural obstacles to fulfilling the
Right to Health Care.
Primary Health Units are peculiar to Karnataka (from Mysore State before the
formation of Karnataka)
3. Vacancies of Health Workers
There are numerous vacancies in all cadres of health workers.
An important
group of professionals providing health care are the Junior Health Assistants -
female (auxiliary nurse midwife. ANM) and their supervisors, the senior Health
Assistants, (the Lady Health Visitors-LHV).
Vacancies of Female Health Workers (ANMs and LHVs)
Gulbarga District: Talukwise
ANMs
Taluk
Sanctioned Vacant
LHVs
%
Vacant
Sanctioned
Vacancies
5
vacant
Gulbarga Taluk
58
0
0
6
0
0
Jeevargi
39
12
30.8
10
2
20.0
Aland
57
18
31.6
6
4
66.7
Afzaipur
40
11
27.5
9
7
77.8
Chincholi
41
10
24.4
8
1
12.5
Chitapur
57
15
26.3
10
5
50.0
Sedam
35
13
37.1
7
2
28.6
Shahpur
48
17
35.4
7
5
71.5
Surpur '—-
56
18
32.1
10
7
70.0
Yadagiri
53
20
37.7
10
7
70.0
Gulbarga Dist
484
134
27.7
83
40
48.2
Source: Ibid
Shortages of Male Health Workers, Lab technicians and other field staff are also
significant. Mismatch between qualifications and postings / job responsibilities
causes frustration and wastage of resources.
Absence of trained and motivated Health Workers is the single most
significant systemic obstacle to Right to Health Care, putting great
additional strain on available health workers and leading to referrals
to private health care.
4.
Regional Disparities
There is wide disparity in the provision of services between the various districts.
A sample from 3 selected districts is shown below
a) RCH Survey : Selected districts; selected indicators in percentage
Family
District
Full A> C
Institutional
Children not
planning
Deliveries
immunized
knowledge of
methods
Udupi
78.9
76.6
0.5
70.7
Tumkur
68.7
48.4
0.5
40.8
Gulbarga
21.2
27.9
31.1
27.2
52.4
8.3
46.1
Karnataka State
(Source: Rapid House hold survey, RCH, 1998, Kanbangi, et al.,)
ANC : Antenatal care
b) RCH Survey, 1998 : Selected districts; selected indicators
District
CBR
CDR
Women using
Safe
contraceptives
Deliveries
Children 12-36
months fully
immunized
Udupi
19.7
7.0
63.7%
91.5%
86.0%
Tumkur
24.1
8.2
61.3%
63.5%
88.0%
Gulbarga
30.1
10.7
39.2%
47.7%
25.3%
Karnataka
22.5
8.5
58.1%
68.2%
70.5%
State
(Source : Human Development in Karnataka, 1999)
CBR-Crude Birth Rate, CDE-Crude Death Rate
Regional disparities that are not effectively and adequately addressed by
proactive, regional, need based planning, but continue to be driven by
normative planning focused on the whole state, is a policy obstacle to the
Right to Health Care
Public and Private health care institutions in Karnataka
Institutions
Beds
Public
2624
43,868
Private
1769
40,900
(Source : Health Care facilities in the Non-Govemment Sector, STEM 1996)
There has been a gradual increase in private sector health care facilities in the
state. There is a need for regulation, incentives and other means to ensure
quality of care in the public and private sector, and access to health care for
the poor and vulnerable.
a
5. Some Indicators related to Basic Determinants of Health
a) Nutrition, Karnataka
There is considerable amount of undemutrition in Karnataka, leading to or
contributing to death and disease. According to the National Family Health
Survey, Karnataka, 1992-93, babies with low birth weight constituted 22% of
all live births.
Children under 4 years
Under weight for age
54%
Under height for age
48%
Wasted
17%
140
Status
Percentage
Normal (>90%)
94
Mild malnutrition (75-90%)
39.0
Moderate malnutrition (60-75%)
45.4
Severe malnutrition (<60%)
6.2
Total
100
Source: NNMB Rural, 1999 (Gomez classification)
Inadequate food and nutrition security in the state due to agricultural
policies that promote cash crops over basic staple-foods (eg : ragi. oil seeds
and dhal production in the state are inadequate, while production of silk,
tobacco, and horticulture, for export are increasing); an inadequate public
distribution system; and inadequate nutrition supplementation to
vulnerable groups among under 5 populations result in a major denial of
the Right to Health, since a low cost balanced diet is a minimum
requirement and basic determinant of health.
b) Health Revenue Expenditure, Karnataka, 1995-96
As percentage of state budget: 5%
As percentage state GDP : 1.48%
Distribution of health expenditure based on level of health care
Percentage
Primary Health Care
37.94
Secondary and tertiary case
31.08
Family Welfare
19.65
Medical Education and Training
9.26
Administration
2.08
(Source : Human Development in Kamaraka, 1999)
121
While this may be slightly higher than in some states, it is very inadequate.
Though costs of health care are rising, over the years the health budget and
health expenditure per capita are declining, with most of it going for salaries,
leaving \ ery little for programmes and services reaching people.
Public sector financing which is much below the norms is the main policy
obstacle to operationalising the Right to Health Care in the state. Low
health budgets and expenditure are directly correlated to structural and
systemic inadequacies, resulting in poor quality’ of health services, and
impacting negatively on the Right to Health Care.
6. Water Supply and Sanitation
There is inadequacy of water, both in quantity and quality. 71.68% of the
households had access to potable water : 81% urban and 67% rural (1991).
Improvement in some regions have taken place in the last decade through
government programmes. The situation however is likely to become worse with
drought and climate change resulting in further reduction in water availability.
There is increasing chemical and microbial contamination, which require urgent
steps to be taken.
Inadequate access to
water has also important social
dimensions, with women, the rural poor, scheduled castes and scheduled tribes
being more adversely affected.
Only 34% of the households have access to toilets: rural 6.85% and urban 62.5%
(Human Development in Karnataka, 1999).
Others use open spaces for
defaecation. Poor access of households to sanitation facilities (toilets) and lack of
environmental sanitation (sanitary waste disposal, drainage) are closely associated
with microbial contamination of water. This is a major cause for diseases such as
worm infestations, diarrhoea, typhoid, etc. Many of the slums in the urban areas
have common toilets but they are poorly maintained and , hence, not used.
Sanitary latrines were constructed under the Nirmala Grama Yojana, starting in
October, 1995.
Ui
112.
It is essential to link water supply and sanitation. Often measures for better
sanitation fail because of lack of water. And, efforts at better water supply and
absence of sanitation lead to faeco-oral spread of infection.
Inadequate attention to universal water supply, availability of
potable water and sanitation rank next to inadequate
food/nutrition security as a major policy / structural / systemic
obstacle to the Right to Health Care. Without adequate food and
water, a healthy environment and a minimum wage — all basic
determinants of health, the Right to Health remains a dream.
7. Health Services
The present structure of Karnataka Health Services has evolved over the years.
The importance given to preventive and curative services has varied at various
times. Earlier, there was an emphasis on and promotion of public health. But it
disappeared in more recent times. The present structure of health services has the
Ministers for Health and Family Welfare, Medical Education and Indian Systems
of Medicine and Homeopathy.
Next to the ministers, there is the Principal
Secretary, Health, the Secretary, Medical Education and the Commissioner,
Health. There are the Director of Health and Family Welfare, Director of Medical
Education and Director of Indian Systems of Medicine and Homeopathy. There
are Additional, Joint, Deputy and Assistant Directors. At the districts, there are
the District Health and Family Welfare officers, the District Surgeons and
Programme Officers.
The following deficiencies have been observed in the organization of the Health
Services.
❖ Not enough importance to public health, with steep decline in the number of
trained and experienced public health professionals in government service.
Neglect of the North Karnataka Region in relation to health needs
❖ Not enough accountability to the public.
If3
<♦ Too wide a span of control for the Director of Health Services and the
Commissioner, making the controls ineffective.
The many challenges identified by the Karnataka Task Force
on Health and Family Welfare include the gross neglect of
public health orientation to health teams; neglect of public
health human power development,; gross regional disparities;
and an all pervading corruption. Though these are deep rooted
policy and structural obstacles, they need to be addressed at the
highest level to fulfill the Right to Health Care.
The Karnataka Task Force on Health and Family Welfare (KTFH 2001) has
suggested changes in the organizational structure, keeping the following principles
in view:
❖ The emphasis on public health should be revived.
❖ Separate cadres would be constituted for public health and medical (clinical)
responsibilities of the Department.
❖ All health personnel up to the district level will form the District Cadres.
❖ The higher posts would constitute State cadres; selection based on competence
and not only on seniority will be the mode for filling these posts. The state
cadres will constitute the Karnataka Health Sendees.
❖ National Health Programmes would be integrated into the health system,
ensuring better supervision, management, and health outcomes.
❖ The expertise and morale of the staff will be built up, enhancing skills and
through a transparent transfer policy.
❖ Northern districts will get special attention, with an additional Director under
the Commissioner.
(Not surprisingly the KTFH report was entitled ‘Towards Equity, Quality and
Integrity’)
1^
-if
8. Karnataka Panchayat Raj Act, 1993
An important step in decentralization of health care sendees was taken with the
enactment of the Karnataka Panchayat Act, 1993. The Panchayat’s promote local
initiatives to meet the local needs, vesting power with the people.
According to the Act, the Zilla Panchayats are to look after hospitals and
dispensaries, excluding district hospitals and hospitals under direct government
management (those with more than 50 beds) and the implementation of schemes
for maternity and child health, mainly family welfare and immunization. They
are expected to deal with the district sector budget and other state sector schemes,
entrusted to them by the State Govemmenu The Zilla Panchayats have a standing
committee for education and health. Taluk Panchayats are to look after health and
family welfare programmes and promote immunization; supervise health and
sanitation at village fairs and festivals.
The Taluk Panchayats look after the
maintenance of the health subcentres and anganwadi centers. Gram Panchavats
deal with family welfare programmes, preventive measures against epidemics,
participation in immunization programmes, regulation of sale of food articles,
licensing of eating establishments and the regulations of offensive and dangerous
The Panchayat also deals with rural drinking water and sanirarion
trades.
schemes.
Strong commitment to Panchayiti Raj Institutions and their
orientation and involvement in basic health care can be one of the
most significant policy commitments to establishing the Right to
Health Care in the state.
9. Health situation in the Southern States
It is useful to compare the health situation in the four major southern sates
(selected indicators)
State
IMR
CBR
CDR
(1996)
(1996)
(1996)
MMR*
Sex
Ratio
(1995)
(1991)
Andhra Pradesh
73
22.8
8.4
436
972
Karnataka
53
23.0
7.6
450
960
Kerala
14
18.0
6.2
87
1036 “i
Tamil Nadu
53
19.5
8.0
376
974
I
(Source : Family Welfare Programme in India, GOI, 1996-97; The progress of
Indian States, UNICEF, New Delhi, 1995)
Life
State
expectancy
at birth
Human Development index
1993
1
2
3
Andhra Pradesh
61.5
0.400
0.392
0.413
Karnataka
62.5
0.448
0.442
0.468
Kerala
72.9
0.603
0.597
Tamil Nadu
63.3
0.438
0.432
.
0.628
0.511
Source : Human Dvelopment in Karnataka, 1999. l.Shivkumar( 19981-92);
2. HDR of South Asia ( 1992-93); 3. UNFPA( 1992-93))
116
-a
Underweight children below 4 years
Andhra Pradesh
49%
Karnataka
54%
Kerala
29%
Tamil Nadu
48%
While Karnataka, Tamil Nadu and Andhra Pradesh differ from each
other marginally in different indicators, they are all still significantly
behind the health indicators of Kerala — the fourth southern state which
continues to demonstrate good health at low cost with focus on land
distribution, female literacy, a functioning Public Distribution System
and a network on rural libraries that provide community information.
This should be studied, reviewed and emulated
10. Health Policy
The Karnataka Cabinet approved the Karnataka Integrated Health Policy in
February 2004. The focus is on strengthening comprehensive primary health care
and public health. The state government has initiated several measures over the
past years to implement recommendations of the Task Force and other
governmental programmes. Several linkages with NGOs and the private sector
have been initiated.
These have been positive initiatives, which need to be
followed up with implementation of the state health policy and the integrated
health, nutrition and family welfare project.
U?
4
SUMMARY OF RECOMMENDATIONS TO STRENGTHEN THE
PUBLIC HEALTH SYSTEM
1. Implement the Karnataka Integrated Health Policy, focussing on primary
health care and public health.
2. Incrementally increase public sector expenditure on health care, bringing it up
to the norms of the National Health Policy, 2002.
3. Focus on the basic determinants of health - food, water supply and sanitation,
environmental pollution.
4. Ensure quality of health care by regulation of the public and private sector
services and improving the quality’ of training and medical education.
5. Improve governance and social accountability of the health sector, reducing
corruption and improving utilization and impact.
6. Reduce disparities in access to health care by increasing sensitivity to needs of
women, children, elderly, disabled, scheduled caste and scheduled tribe
groups.
* * *
* *
*
n
1*8
MDHRPi
PRRDESH
/ASSESSMENT OF INFRASTRUCTURE IN PUBLIC HEALTH INSTITUTIONS
Infrastructure creates the basis for growth. It will play a critical role in
achieving the vision for Andhra Pradesh.
Every objective, whether it is
developing the growth engines, improving the education and health services or
augmenting the services in villages and cities can be achieved only if the
necessary infrastructure is created (Vision 2020). Given this mandate, all the
development related efforts should contribute in translating the vision into a
reality. This is pertinent to health sector because it occupies a pivotal position in
the
developmental
process.
recognised as significant
Hence,
Health
System
Reforms
should
be
“processes” in which structural and organisational
changes would be taking place with the expressed intention of achieving health
care objectives.
In India, the establishment of Primary Health Centres (PHCs) in each
Community Development Block was launched on October 2, 1952. Since then
health service organization and infrastructure have undergone extreme changes.
As per the population norm, a subcentre health facility should be provided for
every 5000 population in plain area and 3000 population in hilly/tribal areas. The
' corresponding population for PHC is 30,000 & 20,000 respectively.
Similar
population norm for CHC indicates a total of 120,000 & 80,000 for plain and
hilty/tribal' areas in that order.
sanitation, hospitals
Providing service in the area of public health
& dispensaries are the responsibilities of the state
governments as per constitution,
However, population control and family
planning are concurrent subjects.
Further, the quality and quantity of health
personnel and infrastructure facilities are furnished by state governments. Thus
the success of this programme depends on many factors. Currently the Ministry
of Health and Family Welfare (MoHFW), Govt, of India is implementing the RCH
programme in the country.
The current RCH programme is implemented mainly through primary
health care approach. Infrastructure assessment and its utilisation provides an
opportunity to understand the supply and demand dimensions of the programme
in the state.
Status: At present, the state has a large health care infrastructure in the form of
public health institutions mostly created in the post-independence era. There are
I
about 11,000 Subcentres and 1400 PHCs at the primary level. About 230 health
facilities are functioning at the secondary tier to support the primary level. Atleast
40 hospitals are providing tertiary care.
Table -1:
Existing Infrastructure in A.P.
Number
i)
ii)
Under
Commissionerate
Welfare
Subcentre
of
Family
Under Directorate of Health:
PHCs_______________________________
CHCs_______________________________
Govt. Hospitals_______________________
Govt. Dispensaries____________________
Mobile Medical Unit___________________
Prnject Hospitals/Dispensaries•
iii)
District Hospitals______________________
2.1
Area Hospitals________________________
56
MCH Hospitals_______________________
"7
Paediatric and CD________________
3
117
24
Civil Dispensaries
Under Directorate of Medical Education
Teaching HospitaIs____________________
Rural Health Centres
v)
31
6
Under University of Health Sciences
Medical Institutions
vi)
1,386
47
67
104
45
24
Under APVVP
CHCs_____________________________ _
iv)
10,568
5
Autonomous Institutions
NIMS, SVIMS, Cancer Hospital
3
(DFID, Impact & Expenditure review; Health sector; draft final report;
March 2001; p18)
The existing infrastructure can be compared with the planned activities of
Government of India, in this aspect. Government of India has envisaged the
I'i-O
I
requirement of Health Infrastructure in A.P. for the year 2002 in the following
pattern:
Table - 2:
Requirement of Infrastructure as per GOI
Subcentre
CKOs
PHCs
R*
P
S
R
P
S
R
P
S
AP
11207
10568
639
1868
1636
232
467
238
229
India
155455
137271
22927
25907
22975
4323
6479
2935
3553
($) Infrastructure required in 2002 as per projected population and in
position as on 30-06-1999. (Bulletin on Rural Health Statistics in India, Issued by
Rural Health Division, Directorate of Health Services, Dept, of Family Welfare,
MOHFW, GOI, June, 2000; table 18,p 40).
*R: Required: P: Position; S: Shortfall
In a similar way, Health Systems Resource Centre of DFID, has estimated
a shortfall of about 1300 Subcentres, 500 PHCs and 250 CHCs in the state.
Further; it has highlighted that only 85 PHCs and 15 CHCs were established
during ninth plan period out of proposed 300 New PHCs and 60 CHCs.
I Table - 3: Current Infrastructure and Norms - DFID
Norms
Current
Required
Shortfall*
1/5000 (PI)
10568 ?
11885
1317
1386**
1889
503
218
472
254
Facility
Subcentres
1/3000 (Trb)
1/30000 (pl)
PHCs
1/20000
(Trb)
Govt.Hosp. No norms
144
Proj. Hosp. No norms
6
CHCs
1/100000
* as per norms and 1991 population figures
** includes
Upgraded PHCs
Old PHCs
MPHCs
I
53
397
439
I
I
NewPHCs
380
Subsidiary HCs
55
Govt. Disp.PHCs
20
LF Disp.PHCs
48
However, with a rural population of 55,223,944 (72.92%) in A.P. as per
Census 2001 and calculating the requirement with the set norms for health care
institutions, it can be estimated that approximately 11044 subcentres; 1840
PHCs and 552 CHCs may be required.
Thus, a shortfall of atleast 476.
subcentres, 472 PHCs and 332 CHCs may be worked out.
Access to health facility is crucial in terms of health seeking behaviour.
National Family Health Survey (NFHS -2; 1998-99) reported that median
distance from a nearest PHC in the state is 5.4 Kms. while about three-fourths of •the rural population have access to a subcentre within a distance of 5 Kms. The
survey also reported that 48 percent of rural women live in a village with either a
PHC or a sub-centre. ?
Table - 4: Distance from Nearest Health Facility
Distance
Within
Village
l\l I I
5-9Km
10+Km
Median
Distance
SC
PHC
Either SC or
PHC
Hosp.
Disp/
Any Health
facility
46.3
29.6 1
14.5 ,
9.6
14.1
32 4
324
31.1
48.3
31.8
12.8
7.1
15.4
28.9
23.6
32.0
45.4
21.6
15.4
17.6
64.2
23.9
7.8
4.1
I
I 5.4
5.8
1.3
(NHFS-2;t 2.13;p31)
Table - 5: Percentage of rural residents living in villages that have
selected facilities and services, A.P.
Primary Health Centre
Sub-centre___________
Hospital______________
Dispensary/clinic______
Private doctor_________
Visiting doctor_________
Village health guide
TBA_______________ __
Mobile health unit
14.6
45.7
15.7
47.1 Z
60.8 V
STD__________________
Medical shop/Pharmacy
Cable connection
(NFHS-2;t2.14,p32)
57.3 1/
43.7 Z
72.7 Z
31.2
16.6
39.7 ,
88.4 7
122.
/
laboratory facilities; about one-third are having a labour room; and less than 10
percent are having a telephone.
Table - 8: Percent of PHC having following infrastructure
Facility
Percent
Water (continuous supply)
52.3
Electricity
96.3
Labour Room
40.6
Laboratory
55.8
Telephone
8.6
Vehicle (functional)
30.5
(Facility Survey 1999, under RCH;ASCI, April 2000, Vol 1 & 2)
A study in AP, conducted by Institute of Health System (Structure and
Dynamics of the Primary Health Sector) identified that auxilliary services like
telephone facilities and Ambulance services are available in 6 and 26 percent of
PHCs respectively. However, under APERP and local area programmes, the
situation must have improved in the last 2 years. For example 1200 external
telephone lines are expected to be made available under APERP (Action plan
document for 2001-2002, item No. 32, Rs. 3,600 million, procurement through
direct contracting); and Generators to 315 PHCs (item 29, 5 KVA Generators).
Similar facilities at CHCs and FRUs show a better status. But, one in 4-5
of these institutions are not having continuous water supply and less than onethird of them are having functional vehicle. About two-thirds of FRUs and one-
half of CHCs are having separate aseptic labour room and an adequately
equipped laboratory facility.
12.3
I
IHS study, 2000 noted that Mean floor space in PHC is 2,198 square feet
while the mean land area is 3,543 square yards. These figures indicate by and
large adquacy of the health institutions in term of space and floor area for the
present and near future requirements.
In order to strengthen the secondary level health care system, the
Government of Andhra Pradesh, has developed infrastructure facilities through
AP First Referral Health System (APFRSH) project.
Table - 6: Position after upgradation of hospitals
Before project
Category
After project
No. of His.
No.of beds
No. of His.
No.of beds
District H
17
11
23
51
5800
Area H
4354
1085
4980
CHCs
3981
540
120
5130
Speciality H
113
06
10
Civil dispens
25
00
24
824
00
Total
172
9960
228
16734
(APVVP; Departmental manual, VVP 115;DRMCRHRDIAP,p 76)
The year 2002 being the end of the project period, it is encouraging to
observe that very high proportion of hospitals have already been commissioned
under APWP.
i)
Construction of 627 PHCs with compound walls: Out of 627 PHCs
601 are completed.
ii)
No. of compound wall to old PHCs 561 Nos.: Out of 561 PHCs 553
are completed.
Facility Survey (1999) under RCH project, evaluated the infrastructure
facilities available in the state. A total of 622 PHCs spread in 12 districts were
surveyed. About one-half of the PHCs are having continuous water supply and
iiq
/
Information available regarding RCH related supplies and equipment kits both at
PHC and secondary tier reveals that there are apparent gaps even at these
levels.
Table -12: Percent of PHCs having supplies and equipment.
Percent (N=622)
Supplies
I.
31.6
44.9
6.2
9.26
62.1
84.3
25.3
63.8
Kit G (IUD insertion)________________
Kit I (Labour room)__________________
Em O C drug kit____________________
Mounted lamp 200w bulb____________
Oral pills___________________________
Measles vaccine___________________
IFA tablets (large)__________________
ORS packets
II.
Equipment (at least one functioning)
89.0
97.0
84.3
78.8
14.7
73.4
Deep freezer_______________________
Vaccine carrier_____________________
BP apparatus______________________
Autoclave__________________________
MTP suction aspirator_______________
Labour room equipment
(Facility Survey 1999 under RCH; ASCI, April 2000, Vol 1 & 2)
Table -13: Supply and equipment at Secondary level institutions
I. Supply
Tubal rings________________
Std. surgical kit (all 6 kits)
Em O C Drug kit
RTI/STI Lab kit____________
New born care equipment kit
Labour room kit
(Per cent)
FRU
CMC
DH
2.1
27.1
11.9
2.1
15.2
35.8
4.5
37.2
37.2
12.4
19.1
37.6
0.0
25.0
16.6
16.6
16.6
33.3
36.9
43.4
46J
47.2
100
100
II. Operation Theatre equipment
Boyles apparatus_______
Oxygen cyIinder________________
tV X I
US'
Shadowless lamp
88.0
91.6
77.5
(Facility survey 1999 under RCH; ASCI April 2000, Vol 1 & 2)
IHS study 2000, revealed that family planning, AN care and Immunization
services are available in atleast 85% of Primary Health Centre in the state. But,
availability of intramural diagnostic services are observed in only 10 percent of
PHCs.
Information on the availability of supplies of medicines, contraceptives
and equipment at subcentre also indicate shortages. The shortages are mostly •
for antibiotics or cotrimoxazole and equipment like weighing scales. Stock outs
for one month or more are frequent in tribal areas.
Table - 14: Percent of Sub center reporting supplies and equipment
Percent (N=58)
1
2
3
Medicines
I FA tablets (iarge)
72.2
QRS packets
81.0
Vitamin A syrup
-<-----------
Antibiotics or cotrimoxazole
I 41.1
75.4
Antimalaria drugs
41.6
Paracetamol
72.9
Deworming medicine
68.4
DDK
28.7
Contraceptives
OCP
73.9
Condoms
11.4
IUD
48.7
Working equipment
Infant Weighing scale
62.4
Adult weighing scales
66.2
12C
/
Syringes
98.5
Steam sterilizer
90.2
BP apparatus
59.9
(CARE, INHP, Final Evaluation, AP, 2001, IIHFW)
Table - 15: Subcentres Reporting Stock Outs on Medicines/Contraceptives
Medicines/Contraceptives
IFA Large________________
IFA Small_______________________
ORS packets___________
Vitamin A solution________________
Antibiotics (Cotrimoxazole)________
Anti Malaria drugs (Chloroquine)
Paracetamol
Deworming Medicine (Mebendazole)
Oral Contraceptives_______________
Condoms
IUDs
DD Kits
UIP
Available
72.2
80.6
81.0
75.4
41,1
41.6
72.9
68.4
73.9
11.4
48.7
28.7
76.6.
Stock out 1 month or
______ more
Rural
Tribal
52,8
52,8
50.0
50.0
72.7
75.0
63.6.
47.7
43.2
71,8
52.3
75.0
90.9
81.8
100.0
b2.8
63.6 '
90.9
81.8
100.0
90.9
90.9
63.6
90.1
63.6
72.7
T67 (8.2.3) CARE INHP QS. AP 2001
Drug and equipment procurement for public health institutions in A.P.:
Centralised Drug procurement and supply: In September 1998, a centralised
drug procurement was formed in APHMIDC. The drug wing operates its own
warehouses in 22 districts of the state with Executive Engineer as administrative
head supported by pharmacists. The budgets to the individual hospitals are allo
cated by their respective Heads of Department i.e., DME, Director of Health and
Commissioner of APWP. The hospitals heads in turn utilise the budget to
purchase drugs, surgical items and medical consumable. This budget is
distributed between APHMIDC, individuals hospitals and DMHOs on the lines of
general procurement, emergency procurement and procurement as per
requirement changes. Out of 100 percent budget 2 percent is given to APHMIDC
towards supervision charges. From the balance, APWP keeps 90 percent with
corporation for procurement of drugs and allots 10 percent to individual hospitals.
DME keeps 80 percent with APHMIDC and the balance 20 per cent is allotted to
I2-7
/
the hospitals under control. Director of Health keeps 80 percent with corporation
but the remaining 20 percent is equally allotted between individual hospitals and
DMHO i.e., 10 percent each. Drugs are distributed to user institutions as per the
allocations made by the Heads of the respective departments. Institutions draw
drugs on a quarterly basis budget through a passbook system. The user and the
warehouse maintain identical copies of the passbook.
PHCs are permitted to obtain drugs from the approved list of 33 drugs;
while secondary level hospitals from 103 drug-list and for tertiary care institutions
from 171 drug list. At PHC level the drug are grouped under antibiotics, IV fluids
and general drugs.
Drugs under national health programmes are not supplied through the
Central Drug Stores. By and large PHCs are eligible for drugs worth Rs.1.2 lakh
annually. Lifting of drugs from District Drug Stores is done once in a quarter.
Drugs are provided to APWP hospitals from three different sources.
Fiist, Rs.2000 is allocatted per bed per quarter under centralized drug
procurement system. The second source of drugs is from the emergency
provision of Rs.100 per bed provided every month directly to the hospital. The
third source is from the DCHS store where drugs are procured under project are
stored and supplied. In addition to the above, separate allocation are made for
procurement of ARV and ASV.
Only recently, the corporation is involved in procurement of equipment and
consumables also. From February 2002, this organisation is procuring MCI
identified deficiency equipment.
In A.P. under Sukha Parivaram scheme of Social Marketing programme
12,000 condom vending machines are obtained.
Urban Health Centres also obtain drugs once in 6 months from the 33
drug list after centralised procurement. But the drugs are supplied through the
office of DMHO. In addition, “Emergency funds” to a maximum of Rs. 10,000 per
year will be released to each UHC for providing treatment and drugs for
emergency cases of maternal an infant care at FRU/private clinic. A maximum of
RS. 750 can be incurred for each beneficiary. For each UHC 34 items of drugs
and 13 items of furniture are supplied.
Equipment and Drugs for PHCs from APERP:
IT? ..
/
16 items of furniture and equipment like microscopes, centrifuge Hb
metre, Haemocytometre, ESR stand etc. for 668 PHCs are part of the goods
procurement for the year 2001-2002.
135 items for 315 Round-The-Clock PHCs consisting mainly clinical
equipment and consumables like syringes, face masks, bed linen sets etc. are in
the process of finalisation. For 1336 PHCs mechanical needle cutters (3 per each
PHC) and white cotton bedsheets (10 each for PHC) are also figured in the
goods to be procured in the action plan. Epidemic drugs valued Rs. 6,775
millions (as when required) are ear marked by APERP.
I
I
I
12.7
I.
I
B.
UTILISATION OF INFRASTRUCTURE:
In A.P., only one out of five persons who fall sick utilise the health facilities
in the public sector, while majority of them seek services from the private sector.
NGOs and others play a very insignificant role.
Table -16: Percentage distribution of households by main source of health
care, when household members get sick, according to residence
Residence
Source
Urban
Rural
Total
Public Medical Sector
15.3
14.6
14.8
NGO or Trust
0.8
0.6
0.6
Private Medical Sector
81.2
81.9
81.7
Other Source
2.7
2.9
2.8
(NFHS-2, table9.1;p 200) >
However, the assessment of services by the users' in public sector seems
to encouraging. Other factors may be dominating in expressing such a
favourable opinion.
Table -17: Quality of care during the most recent visit to Health Facility
(Public sector)
Urban
Rural
Total
1. % who received the service they went for
98.4
98.0
98.1
2. Median waiting time
29.7
29.5
29.6
3. % who rated facility not clean
6.7
2.6
3.6
Indicator
(NFHS-2,t9.51, p 206)
However, Public sector health facilities play a major role in providing
immunization
and family planning services. It is alarming to observe that in
I3o
I
conditions like reproductive health problems, more than two-thirds of women do
not approach either the public and private sector.
I
I
2J
13.J
/
Table -18: Source of childhood vaccinations by residence (per cent)
Urban
Rural
Total
Public Medical Sector
59
80
74.4
NGO or Trust
1
1
0.9
Private Medical Sector
38
18
22.9
Other Sources
2
2
1.8
Source
(NFHS -2; f 6.5;p 134)
Table -19: Sources of family planning among current users of modern
contraceptive methods - Percent distribution
Urban
Rural
Total
Public medical sector
64.9
83.4
78.5
NGO or Trust
1.1
0.6
0.7
Private medical sector
29.8
15.4
19.2
Other source
3.6
0.7
1.5
Don’t know
0.7
0.0
0.2
Source
(NFHS-2;f5.2, p97)
Table - 20: Treatment of Reproductive Health Problems
(Among women with RH problem, the percentage who sought advice or
treatment from specific providers by residence.)
Urban
Rural
Total
Public medical sector
6.1
7.1
6.8
NGO worker
0.2
0.2
0.2
Private medical sector
36.0
30.1
31.5
Other
0.4
0.7
0.6
Provider
13 i.
/
58.3
NONE
62.6
64.0
(NFHS-2,t8.13,p 186)
ROH programme encourages deliveries under proper hygienic conditions
under the supervision of trained health professionals. Every second birth takes
place in health facilities. But utilisation of public health facilities is one-quarter of
the private sector in institutional deliveries.
Table - 21: Per cent of Place of delivery
Public institutions
13
NGO/Trust hospital
2
Private Institutions
35
Own home
25
Parents’ home
24
Other
1
(NFHS-2; figure 8.4; p 185)
i
Even out of institutional deliveries, urban women utilise this type of service
two times than of rural women.
Table - 22: Per cent distribution of Institutional deliveries by residence
Urban
Rural
Public health facility
18.6
10.5
NGO/Trust
3.6
1.7
Private
56.4
29.8
12.4
8.7
0.3
29.8
29T)
1.1
Institutional :
Home deliveries:
Own home
Parent’s home
Other
l3>3
/
During
the
last
two
years,
GOAP
launched
has
an
innovative
“8UKHIBHAVA”, improvement of institutional delivery services scheme to assist
the rural pregnant women who are below the poverty line.
This scheme will
enable them to access the service of hospitals for conducting of deliveries which
helps in reducing the maternal mortality in the state and also in long run helps in
positive attitudinal shift in health seeking behaviour of the poor, rural women.
Similarly “AAROGYA RAKSHA”, a health insurance scheme aiming at
strengthening the confidence of poor and illiterate in their ability to get health
care for their children. It also seeks to remove any fears in their minds about any
risk to survival of their children.
Like wise, JANANI programme was initiated to ensure micro-level
planning and implementation with the participation of local resources towards ■
universal immunization of eligible in the state. The impact of these schemes is
yet to be documented.
Diarrhoea! disease contribute for-almost oneTourth of under five mortality
in the state. Usage of ORT including ORS remains to be the main stay in
preventing deaths due dehydration and electrolyte imbalance. Inspite of limited
ORS usage, public sector is the major source of ORS packets in such situations.
Table-23: Source of ORS packets among children under age 3 who were
treated with a solution from ORS packets for diarrhoea
Source
Per cent
Public Medical Sector
43.3
Private Medical Sector
30.9
Other Source
25.7
(NFHS-2;t 6.14; pagel42)
Terminal method of contraception is the most popular family planning
method in the state. About 95 % of acceptors are women. However, the role of
public and private sectors in motivating
the users of contraceptives is very
limited.
/
Table - 24: Motivator of current users of modern contraceptive methods
Urban
Rural
Total
Public health sector
_______________ 12,2
22.2
Private sector_____
NGO_____________
Other
_______________ 4.3
_______________ 0.0
______________ 29.1
54,4
25.8
2.4
0.1
0.1
25.2
26.3
46.4
48.5
NO ONE
2.9
(NFHS-2;t9.7,p208)
Facility survey 1999, also provides useful information on the utilisation of
RCH services in the public health care institutions.
RCH programme envisages provision of pregnancy related services; first
trimester abortion services; and management of RTI/STI through syndromic
approach in addition to family planning services . At PHC level 97 per cent of
institutions are providing sterilisation services.
In only
42 percent of PHCs
deliveries are conducted. About one-third are utilised for RTI/STI problems. Only
1.5% of PHCs are conducting MTP services.
Table - 25: Utilisation of services at PHCs (during the last three months)
a. Percent conducting
b.
Average
No.
Deliveries
MTP
RTI/STI
ARM
Sterilizations
42.2
1.5
34.2
18.5
97.5
27.0
4.8
70.9
99.2
113.2
conducted
(Facility survey1999 under RCH; ASCI April 2000)
Similar utilisation at secondary level institutions does not reveal any
changes in the pattern. The proportion of deliveries to total admissions (Delivery
Rate) in APWP hospitals remain constant at 0.12% over the last several years.
Table - 26:
Delivery Rate in APVVP Hospitals
T!
•^5"
I
i
Year
No. of Deliveries Conducted
Delivery Rate
1996
59,710
0.12
1997
65,996
0.13
1998
62,578
0.11
1999
68,570
0.12
2000
90,019
0.13
2001
94,690
0.12
(O/o. APVVP-MIS Division)
Infrastructure will be put to optimum utilisation only when supply of drugs and
consumables etc. are regular; adequate and functioning equipment is available
and the staff are in position and trained. Taking into consideration these critical
indicators, assessment of health facilities in the state revealed a situation of
inadequacy. None of the facility shows presence of 100% critical inputs, even
presence of 60% critical inputs is noticed in only one-fourths of the institutions.
Table - 28: Percent of Health Facilities Adequately Equipped
(having >60% Critical Inputs)
PHC
FRU
CMC
Infrastructure
31.6
84.8
63.4
Staff
50.4
24.9
33.3
Supply
16.3
8.7
11.1
Equipment
83.9
55.7
52.3
Training
21.3
All items
24.5
22.8
25.3
(Facility survey1999 under RCH; ASCI April 2000)
-
MAINTENANCE OF INFRASTRUCTURE
C.
Maintenance of the available facilities is critical in enhancing the credibility
of organisations. Data available identifies a need to improve the maintenance of
the infrastructural inputs.
Table - 29: Percent of PHCs with adequacy in maintenance of selected
indicators
Regular building maintenance
14.46
2.
Fumigation done regularly in OT
67.20
3.
Fumigation done regularly in LR
65.54
4.
Dial thermometer is kept in ILR
42.24
5.
ILR with daily temp, is maintained
58.00
6.
Sufficiency of stocks
i
T
Nirodh
40.51
OCR
51.26
IUD
53.85
DDK
37.00
Measles vaccine
52.57
IFA (large) tablet
15.91
ORS packets
33.11
(Facility surveyl999 under RCH;ASCI April 2000)
Equipment maintenance:The
state
has
different
levels
of
equipment
maintenance units with different capacities. There are 7 Health Equipment Repair
Units (HERUs).
under Director of Health.
4 Equipment Maintenance and
Training Centres (EMTCs) are functioning exclusively for APWP hospitals.
In
addition, one district mechanic besides private contractual arrangements are also
made available at this level. Tertiary hospitals have its own maintenance capacity
and contract out to private facilities. The equipment strength at PHC is around
20 items. Maintenance cost of equipment in hospitals is around 2-3 percent of
the total value of the equipment.
/
’
rr-
-.m- ■
APERP while supplying the equipment issued specific guidelines for
acceptance and routine testing of medical electrical equipment. Project inputs are
based on the PHC Needs Assessment Study carried out at the beginning. The
requirements at the PHC level are considered under major, minor equipment;
furniture, instrument kits and others.
13 «
I
Table - 30: Arrangements for the maintenance of equipment
Existing maintenance and repair
Facility
________ arrangements_________
1.
HERU
PHCs
District mechanic
2.
Secondary
Repairs by hospital staff
level
Hospitals
*EMTCs_____________________________
* AMCs and contracting out on need basis
* Warrants
3.
* Repairs by hospital staff_______________
Tertiary level hospitals
* HERU______________________________
* AMCs and contracting out on need basis
* Warranties
At PHC§ and Hospitals under Directorate of Health guidelines are issued
for Drawing and Disbursing Officers regarding responsibility of maintenance of
Stock Registers including medicines, linen, equipment, annual verification of
stocks, quarterly verification of costly articles like surgical instruments etc. (Under
Subsidiary registers and records attached to the cash book Item 8 (c)). PHC
Medical Officer is not empowered for condemnation procedures.
In APWP institutions, as laid down under Art 135 of APEC vol 1, as the
furniture and other equipment will stand distributed in the various wards, theatres
and other departments of the hospitals, entries should be made, attested by the
head of the organisation. Any addition or alteration in the list will be made only by
him under his initials (H.S.O. 494).
For condemnation of equipment, furniture
etc. Further, through Pro. Rc. No. 90/HEM/89 procedures for condemnation are
laid down. Rules for auction of unserviceable articles are laid down, in H.O.S.
402 to 425. These can be implemented through Condemnation committee.
General Maintenance:
Advisory Committee set up in different levels of health
care institutions monitor the general maintenance of the institutions.
/
G.O.Ms. No. 151, dt. 21-050-1998, item (x) provides provision for
utilisation of hospital revenues for toilets maintenance, sanitation of the hospital
wards etc.
In A.P. every third Saturday of the month is observed a clean and green
day for all the government institutions for upkeeping the premises.
Key observations on infrastructure during Field visits in policy review
activities have are as follows:
1.
Some PHCs buildings are located away from the periphery of the villages
which discourages people to utilise the services in late hours. Directions
for the location of PHC and hospitals are not found on the main roads.
2.
Amount paid towards house rent for subcentres will not provide required
accommodation for ANM to function effectively.
3.
Rarely one can find a PHC with plantations in the yard.
4.
Atleast one to two rooms in each PHC are used as store rooms mostly for
unserviceable goods like old sterilisers, broken furniture etc.
5.
Most of the drugs meant for Subcentre from the quarterly budgets are
being utilised at PHC only.
6.
PHC kits have not reached districts in a few places.
7.
At present, most of the PHCs do not have telephone facility.
8.
Continuous water supply though very essential, many a times water for
i
only limited hours is available in number of PHCs.
9.
Drug budgets are strongly felt to be inadequate at both PHC and FRU
level. In one district hospital a detailed assessment done recently on
requirements of drugs from all the consuming units revealed a shortage of
Rs.2 lakhs per quarter in comparison to the existing budgetary allocations.
10.
Though essential drug list also mentions about the availability in adequate
quantities and all the times, stipulated eligible number of drugs as per the
list are not available in the drug stores. The shortages become grave
during summer months.
11.
Though PHC staff take the attestation of district authorities on drug
indents, neither the officials keep a copy nor conversant with issues of
drugs at the district stores.
I Mo
/
12.
District pharmacists at district stores are not exposed to any training
during the last three years.
The reports on drugs lifted by the Drug
Inspector for quality control never reach drug stores.
13.
PHC staff are totally ignorant of the mechanisms for verification when the
quality of drug is suspected.
14.
Significant compromisations are noticed in Safe injection practices of
health staff in the public health institutions. Boiling of disposable needles
and syringes
is not an infrequent site. Syringes and needles are used again and again
without resterilisation.
15.
Minimum Essential items for clinical examination (like a set of
stethoscope, BP apparatus, thermometer, torch, weighing machine, height
measuring scale, examination couch with screen and steps) are hardly
noticed in any of the half-a - dozen PHCs visited.
16.
Special health campaigns like Janmabhoomi etc. drain the meagre drug
allocations from the health institutions because of change of decisions in
reimbursements after the events.
17.
Though government discourages prescription of drugs from outside, very
,
often consumable are made to be purchased by the patients from outside.
At FRU it becomes inevitable in items like urobags, ryle’s tubes, infant
feeding tubes. Sometimes drugs like mannitol and higher group antibiotics
are prescribed outside. Even non-emergency items like hematinics are
i
prescribed because of high demand from users.
18.
At PHC, in addition to the centrally procured drugs, drugs and items are
supplied under the following different subheads:
MCH programme
DIP programme
RCH programme
APER programme
School Health programme
Under Epidemics
JB drugs
FW programme
Emergency drugs/life saving drugs
F4J
General items (Subcentre wise)
Supplies under these heads are erratic. This leaves a room for confusion
about the assessment of drug availability.
19.
Most of the health units staff have expressed difficulties in maintenance of
equipments. There are cases of ultrasonographic scan even if certified
condemned no replacement is done for three years. Sophisticated
instruments like endoscopy remain unutilised because of very high cost
for repair. Boyle’s apparatus being regularly used equipment are also
never serviced during the last
5 years. Generators are another set of
equipment which often need repairs.
20.
Atleast in one CHC, equipment like sterilisers are kept in a corner without
opening for long months.
21.
In very few PHCs/CHC shadowless lamps are made to use as prescribed.
They are simply hanged from a wire.
22.
All the temperature charts of the coldchain equipment show fixed pattern
of recordings over several months.
23.
Diluents and other lab chemicals are also noticed in the cold chain
equipments
24.
Hb 'scale books (Tallquist) are frequently seen for supply to even
subfcentres. Urine exam in some places done with unsticks, otherwise no
attempt is made for such analysis at PHCs.
25.
Delivery tables with bricks and cement plastering are noticed.
26.
In the health centers and hospitals height is measured against the
marking made on the wall rather than with height measurement scale.
Attempts a identify the center where facilities for complete available
antenatal checkups (including Haemoblogin estimation, Urine examination
for Albumin and Sugar, Height and weight measurements are accurately
followed) were not successful.
27.
No village other than subcentre headquarters is having facilities for proper
storage and maintenance of required supplies for rendering RCH services.
SUGGESTED POLICY OPTIONS:
1.
Enhance the budget for renting subcentre accommodation.
2.
Storage
shelves
at every
village with
required
supplies
equipment to enable ANM to conduct outreach services.
/
and
3.
Use the principle of SIGNAGE by display boards on the main roads
indicating the location of FRUs and RTCs. This helps in improving
the visibility of the organisation.
4.
Permit ANMs to give Intramuscular antibiotic injections.
5.
Hiring private services for maintenance of building, water, sanitation,
electricity, security at PHC level by contracting out. Necessary
budgetary allocations
may be
identified
as a
part of regular
expenditure.
6. .
Provide communication and transport facilities at every
particularly
telephones
and
arrangements
for
PHC
in
ambulances
emergency situations.
7.
Prepare and implement standard pattern of layout of usage of space
in PHCs.
8.
Establish a standard norm for equipment to be available at different
levels of institutions and create annual appraisal systems for the
adequacy. Create a cadre of Biomedical engineer for maintenance,
using services on co-terminus basis for primary and secondary level
organisations. Identify the list of essential items at every OP unit in
the state so that thorough physical examination can be conducted.
9.
Increase the essential drugs in the list from the existing number of
34at PHC,103 at FRU and 171 at tertiary care units to 54, 140 and 270
to meet the demands. Even budget should be enhanced by 75 per
cent at all levels to meet the growing demands and costs. Create a
second pass book system to monitor the drugs and other supplies
reaching the health units from other sources through DMHO to
enable streamlining supply and planning for coming years. Drug
education and information activities should be initiated immediately
to
curb
improper prescription
practices
in
resistance because of re-emerging infections.
the
light of drug
These steps will
ensure safe, effective and prudent use of essential drugs.
10.
A practice of noting provisional diagnosis even for O.P. cases at all
health units (Eg. 150 disease list recommended by WHO) will
facilitate
furtherance
of
scientific
prescription
practices
and
appropriate usage of essential drugs and their dosages. Whenever
l^3>
ky
I
necessary standard therepeutic protocols should be developed for
management of cases related to RCH services.
11.
Mandatory safe injection practices should be ensured in all health
units of the state. Awareness campaigns can also create an
environment of demand
in this
regard.
This does
not mean
encouraging disposable needles and syringes but focus on properly
sterilised needles and syringes and injection techniques.
12.
State should take up voluntary blood donation campaigns to the
district and rural areas on priority basis which can save precious
maternal deaths.
Access to blood in rural areas can be strongly
considered for public private mix ventures.
Status in A.P.:
Number of cases referred among high-risk pregnant women, newborns,
APIs, diarrhoeal diseases, VPDs and adverse events following immunization
RTI/STI etc., find a place in the reports and records at SC and PHC under RCH
Programme.
The GOAP through its Lr. No. 11077/Ci/96 and Lr. No. 11593/Ci/96,
issued a referral manual on behalf of Dept, of Health, Medical and Family
Welfare which states that patients may be referred from one level to the next for.
1.
Clinical examination or specific examination
2.
Consultation or expert advice
3.
Intervention or patient care
i
The manual mentioned referral procedures using slips, referral register,
transportation norms, counselling, referral network preference and back referral
slip. Referral manual provides summary of recommended clinical services at
primary/secondary/tertiary health care institutions. It includes
33 medical conditions (from convulsions to STDs)
9 surgical procedures (from l/D to gastrointestinal)
5 newborn/child conditions (LBW to severe diarrhoea)
11 obst/gyn conditions (complicated deliveries to malignancies).
Referral zoning of district hospitals to tertiary hospitals is done in the A.P.
The review of existing literature on referral system in A.P provides the
following relevant information:
Iff *
Evaluation study on First Referral Health Systems in AP(1997) observed that in
referral practices:
Out of 66,937 OP cases treated on an average by each OHO, only 133
(0.20 per cent) cases are referred to District hospitals, while Private hospitals out
of 10,335 cases 91 (0.88 per cent) only are referred to District Hospitals. This is
certainly not an encouraging performance. However, percentage of specific
cases referred to DHs is more. About 5 per cent of ARI cases, 3 per cent of
delivery cases, 100 per cent of cancer cases and 57 per cent of DUB are referred
to DHs by CHCs.
The linkage between PHC and CHC also appears to be weak. There is no
information in the CHCs records as to how many OP cases are referred from the
PHCs. However, informations on how many cases of some specific diseases are
referred from PHCs is available. About 12 per cent of diarrhoea cases, 67 per
cent of infertility cases and 100 per cent of cancer cases are referred from CHCs.
Out of 1,486, illness episodes (Non-hospitalisation cases) 945 (63.6 per
cent) have reported to have consulted another doctor before consulting the
FRUs.
The preference of the people at the first level as well as the secondary
'level consultation is clearly towards the private hospitals. While only 71 per cent
of (he OPs consulted private doctors at the primary level. The percentage
increased to 78 per cent at secondary level. While 69 per cent shifted from one
private hospital to another private hospital. 8 per cent shifted from government to
private ones.
As regards the use of referral systems in the government hospitals, while
25 per cent approached government hospitals in their former visits, only 17 per
cent visited them in the current visits. Only 16 per cent retained the referral status
with the government hospitals.
Turn over of inpatients shows that while 70 per cent visited private
hospitals earlier to the hospitalization. Those who have shifted from government
to private are 15 per cent. In the government hospitals only 6 per cent have
retained the referral status which means that only 6 per cent of the patients
continued to go to government hospitals.
The study concluded that the linkages between sub-centre, PHC, CHC
and DH are very weak or almost nonexistent. Even though the system of issuing
referral slips at PHC level is in vogue, none seems to issue them nor they are
accepted or given preferential treatment at FRU. The study recommended that
14s/
referral ship system should be revived and implemented according to agreed
procedure (6).
Facility Survey (1999) AR observed that
The district hospitals (12) have conducted a total of 4,677 deliveries
averaging 389 per DH in the previous three months of the survey. Out of the total
of 612 complicated deliveries, 532 were direct admissions and only 80 were
referred. Of the total 1063 Caesarean deliveries, directly admitted were 976 and
87 were referred.
At FRUs out of the total number of deliveries conducted 7843
FRUs) spread in 12 districts,
( in 92
out of 616 were complicated deliveries directly
admitted and 91 were referred. The C-section deliveries directly admitted and
referred are 252 and 112 respectively.
At CHCs, 16,176 deliveries are conducted during the three months
preceding the survey in 63 centres spread in 12 districts, complicated deliveries
directly admitted are 2385 (14.74 per cent) and referred are 256 (1.58 per cent).
A total of 4591 C-sections are conducted and 31 are referred.
Table - 31:
Number of women received services for the three months
preceding the date of survey in APVVP hospitals in 12 districts of AP (1998-
99)
Total no. of deliveries
Category
Conducted
Admission
__
Direct
C-Section
Admission
Referred
Direct
Referred
DH(12)
4,677
532
80
976
87
FRU
7,843
523
93
252
112
CHC
16,176
2,385
256
4,591
31
Total
28,696
3,440
429
5,819_____
230
(11.9%)
(1.49%)
(20.27%)
(0.80 %)____
(Facility Survey 1999 under RCH; ASCI, April 2000, Vol. 1 & 2)
/
IHS sutdy, 2000 on Referral linkage has noted that 72 per cent of PHCs
received patients regularly referred by other providers. 98 per cent send patients
to other hospitals. The departmental manual of APWP in its future prospects
and vision identifies improving the referral system by establishing proper linkage
between primary, secondary and tertiary levels of health care system. The
following ultimate benefits are expected:
1.
Improved efficiency and effectiveness of health care services.
2.
Optimum resource use, avoid duplications, reduced waste and over
crowing on tertiary facilities.
3.
Improved health status, specially of the poor by reduction in mortality,
morbidity and disability.
4.
First referral hospitals becoming more client-friendly and patients seeking
timely care resulting in higher cure rates at lower costs.
5.
Regulated patient flow and reduced cost of treatment by reduction in
patients flow to tertiary hospitals where treatment is more expensive.
6.
Improved quality of treatment at a level where sustained linkages with
private health care can be established
;
i
IQ?
A*
/.
Kerala Health Profile
__________ Indicator______________ Kerala
India
Area (Sq. km)______________________ 38863
3166285
Population______________________ 31841374
1026443540
Households__________________
6595206
191963935
Sex Ratio___________________
______ General_______________
1058
933
______ Child (0-6 yrs)_________
960
927
Growth Rate %_______________
Decadal (1991-2001)
9.4
21 .3
______ Natural Growth Rate 2001
17 .0
10 .6
Life expectancy (years)________
______ Total_________________
72 .4
______ Females_______________
75 .8
______ Males________________
69 .3
Effective Literacy rates %______
______ Total_________________
90 .9
64 .8
______ Females_______________
87 .7
53 .6
94 .2
______ Males________________
75 .2
Birth Rate - 2001_____________
17.2
25 .4
Death Rate - 2001_____________
6.6
8 .4
Infant Mortality Rate -2001_____
11 .0
66 .0
Maternal Mortality Rate 1998
.80
4 .07
0-5 Mortality Rate____________
18.8
94 .9
1-4 Mortality Rate____________
2 .6
29 .3
Neonatal Mortality Rate________
13 .8
43 .4
Perinatal Mortality Rate________
24 .2
2.5
Suicides per 1 lakh population per
31 .0
11 .0
year________________________
People above 70 yrs of age %
4 .95
Childhood Malnutrition < 3 yrs %
______ Weight for Age < -3 SD
______ Weight for Age < -2 SD
______ Height for Age < -3 SD
______Height for Age < -2 SD
______ Weight for Height < -3 SD
Weight for Height < -2 SD
4.7
26 .9
7.3
21 .9
0.7
47 .0
23 .0
45 .5
2.8
11 .1
15 .5
18 .0
Source
‘Census 2001
Census 2001
Census 2001
Census 2001
Census 2001
Census 2001
2SRS 2002
3Ker Eco 2003
Ker Eco 2003
Ker Eco 2003
Census 2001
Census 2001
Census 2001
SRS 2002
SRS 2002
SRS 2002
4SRS 2000
5NFHS-2
NFHS-2
NFHS-2
NFHS-2
Econ Rev-03
Econ Rev-03
NFHS-2
NFHS-2
NFHS-2
NFHS-2
NFHS-2
NFHS-2
NFHS-2
1 Census of India 2001, Final Population Totals, India, State and Districts, Directorate of Census
Operations, Kerala (2004)
2 Sample Registration System Bulletin October-2002; Vol 36 no. 2; Registrar General, Govt of India
3 Kerala Economy 2003; Department of Economics and Statistics, Kerala
4 Sample Registration System April 2000; Vol 33, No. 1; Registrar General, Govt of India
5 International Institute for Population Sciences (UPS) and ORC Macro 2001; National Family Health
Survey (NFHS-2), India 1998-99; Kerala, Mumbai UPS.
___________ Indicator
Kerala
Anaemia 6-35 mths g% of Hb
______ Total (< 11)
43 .9
Mild (> 10 < 11)________ 24 .4
Moderate (> 7 < 10)
18 .9
Severe (< 7)
_________
0.5
Married Women %____________
Received ANC (% of mothers)
98 .9
Institutional deliveries
93 .0
Average Height in cm
Height < 145 cm
Nutritional status_____
Average BMI_____
Underweight (BMI - : 18.5)%
Overweight (BMI >' 5<30)%
Obese (BMI >30)%
Anemia (g% of Hb)
Total (<11)
Mild (> 10 < 11)
Moderate (> 7 < 10)
Severe (< 7)
BPL families (%)
Total_______
Rural_______
Urban______
ICDS units 2003
Infrastructure in Govt
Total
Institutions____________
Beds_________________
Inpatients_____________
Outpatients____________
Beds per 1 lakh population
Allopathy_______
______ Institutions
______ Beds_____
______ Inpatients
Outpatients
India
65 .3
34 .0
Source
NFHS-2
NFHS-2
NFHS-2
NFHS-2
NFHS-2
NFHS-2
NFHS-2
NFHS-2
152 .6
8 .8
151 .2
13 .2
NFHS-2
NFHS-2
22_.O
18 .7
20 .6
3 .8
20 .3
35 .8
10.6
2.2
NFHS-2
NFHS-2
NFHS-2
NFHS-2
22 .7
51 .8
35.0
14.8
1 .9
NFHS-2
NFHS-2
NFHS-2
NFHS-2
27 .09
23 .62
5652
6NSSO 55th
NSSO 55th
19 .5
2.7
0.5
9 .38
20 .27
163
74 .3
22 .9
45 .9
5.4
Number
Percentage
Source
2712
50805
1935696
80940260
100
100
100
100
Econ Rev-03
Econ Rev-03
Econ Rev-03
Econ Rev-03
Econ Rev-03
48 .3
91 .0
95 .2
48 .3
Econ Rev-03
Econ Rev-03
Econ Rev-03
Econ Rev-03
160
1310
46224
1842642
39054674
6 National Sample Survey Organisation, 55th round (1999-2000)
Infrastructure in Govt__________ Number
Percentage
______ Beds per 1 lakh population
145
Ayurveda_____________________
Institutions______________
845
31 .2
3411
______ Beds___________________
6.7
______ Inpatients________________
68450
3 .5
______ Outpatients______________ 17976627
22 .2
______ Beds per 1 lakh population
10 .6
Homeopathy___________________
______ Institutions______________
557
20.5
______ Beds___________________
1170
2.3
______ Inpatients________________
24604
1 .3
______ Outpatients______________ 23908959
29.5
______ Beds per 1 lakh population _______ 4
Allopathic Institutions___________
Number
Percentage
Under DHS_________________
1299
______ Beds___________________
37646
31 .7
_________ Primary Health Centres
5060
13 .4
_________ Comm. Health Centre
4726
12.6
_________ Hospitals_____________
22636
60.1
_________ Other institutions______
5224
13 .9
______ Personnel________________
_________ Total Doctors_________
3032
__________ Administrative position
1 .7
__________ PHC doctors_________
29 .0
__________ Secondary healthcare
69 .3
_____________ Specialists_______
58 .0
__________ Dentists____________
60
______ Senior Nurses____________
1416
______ Junior Nurses____________
6165
______ Lady Health Inspectors_____
872
______ Pharmacists______________
1589
jphnZ2I222Z22ZZZ2Z
JHI_____________________
HI
5272
3017
811
Primary Health Centres
Community Health Centres
Hospitals______________
Dispensaries and others
933
115
130
121
Subcentres
5094
Medical colleges institutions
Beds
11
8578
72 .0
9.0
10.0
9.0
Source
Econ Rev-03
Econ Rev-03
Econ Rev-03
Econ Rev-03
Econ Rev-03
Econ Rev-03
Econ Rev-03
Econ Rev-03
Econ Rev-03
Econ Rev-03
Econ Rev-03
Econ Rev-03
Econ Rev-03
Econ Rev-03
Econ Rev-03
Econ Rev-03
Econ Rev-03
Econ Rev-03
Econ Rev-03
Econ Rev-03
Econ Rev-03
Econ Rev-03
Econ Rev-03
Econ Rev-03
Econ Rev-03
Econ Rev-03
Econ Rev-03
Econ Rev-03
Econ Rev-03
Econ Rev-03
Econ Rev-03
Econ Rev-03
Econ Rev-03
Econ Rev-03
Econ Rev-03
7.2
Econ Rev-03
Econ Rev-03
J $70
Infrastructure in Govt_________
Co-operative Hospitals_______
______ Beds__________________
E.S.I Hospitals_____________
______ Beds__________________
Regional Cancer Centre______
______ Beds__________________
Sree Chitra Institute of Medical
Science and Technology_____
______ Beds__________________
Private Sector______________
______Beds__________________
Total_____________________
Beds
Number
_____ 69
3306
_____ 12
1113
Percentage
2 .8
0.9
______ 1_
320
0.3
1
217
4288
67517
5681
118697
0 .2
56 .9
100 .0
Health Personnel (Jan 2001)
Registered Doctors
______ Allopathy________
29656
______Ayurveda_________
7356
______ Homeopathy______
6704
Siddha___________ 135
______ Unani____________
____ 5
______ Dental___________
3776
Nurses______________
60760
ANM/ JPHN_________
12907
Dental Mechanics_____
245
Dental Hygienists
242
Immunization coverage %
BCG______________
Measles___________
DPT______________
Polio______________
TT of Preg. Women
TT for 5 year olds
TT for 10 year olds
TT for 16 year olds
2001-02
Public spending (% of GDP)
Health________
Education____________
Development Index
1980-81
2 .02
5.22
1981
103 .8
86 .2
93 .1
92.8
89 .9
93 .9
97 .6
96 .5
____ Source
Econ Rev-03
Econ Rev-03
Econ Rev-03
Econ Rev-03
Econ Rev-03
Econ Rev-03
Econ Rev-03
Econ Rev-03
Econ Rev-03
Econ Rev-03
Econ Rev-03
Econ Rev-03
7Cyber journal
Cyber journal
Cyber journal
Cyber journal
Cyber journal
Cyber journal
Cyber journal
Cyber journal
Cyber journal
Cyber journal
2002-03
103 .0
90 .6
95 .8
95 .3
86.1
89 .2
98 .1
95 .0
1998-99
0.95
3 .25
1991
Econ Rev-03
Econ Rev-03
Econ Rev-03
Econ Rev-03
Econ Rev-03
Econ Rev-03
Econ Rev-03
Econ Rev-03
8NHDR-2001
NHDR-2001
7 www.cyberjournal.org.in
National Human Development Report 2001; Planning Commission, Government of India, March 2002
*
Public spending (% of GDP)
Human Development Index
Human Poverty Index
Gender Disparity Index
1980-81
0.50
32.1
0.87
Prevalence of Diseases of Public
2002
Health Importance (per 1000)
Leprosy_____________
0 .71
Filaria______________
1 .02
Tuberculosis_________
1 .2
Acute Diarrheal
17.63
diseases_____________
Pneumonia__________
____________ 0.66
____________ 0 .23
Enteric fever_________
Measles_____________ ____________ 0.10
Respiratory Infection
216 .62
Outbreaks in 2003_______
Number affected
Dengue_____________
__________ 3332
Leptospirosis________
__________ 1343
Diarrhoea including
463094
39 cholera cases______
HIV / AIDS (total till 2003)
1219
1998-99
0.59
19.93
0.82
_____ Source
NHDR-2001
NHDR-2001
NHDR-2001
2003
0.66
1 .28
0 .70
16.96
Econ Rev-03
Econ Rev-03
Econ Rev-03
Econ Rev-03
0.60
Econ Rev-03
Econ Rev-03
Econ Rev-03
Econ Rev-03
_026
0.07
221 .42
Deaths
66
96
13
Econ Rev-03
Econ Rev-03
Econ Rev-03
411
Econ Rev-03
09711
I5Z
n
TAMIL NADU HEALTH REPORT
Health Profile of Tamil Nadu
As on 1st March 2001, the population of Tamil Nadu stood at 62110839,
according to provisional results of the census of India 2001. In population it holds
the sixth position among the states in the country. The Density of population was
478. As against all India decadal growth rate of population 21.34% during 1991 —
2001, in Tamil Nadu this has further slipped to 11.19% from 15.39% during 1981
-91. The sex ratio (ie, the number of females per thousand males) of population in
the State has improved from 974 in the previous census to 986 in the present
census. During 2000 - 2001 the Birth Rate (per 1000 population) was 19.2; the
Death Rate was 7.9; Infant Mortality Rate was 51. Expectation of life at Birth :
64.85 for male and 65.20 for female. Still Birth Rate : 16.1. Fertility Rate : 2.0.
Couple Protection Rate : 58.7. Tamil Nadu State reveals morbidity incidence rate
per 1000 in rural area as 52 and in urban area as 58.
The Literacy rate in the State has shown remarkable improvement. This has
increased to 73.47%, when compared to 62.66% ten years back during 1991
census. The per capita income at current price is Rs.20975, in 2002.
Health Budget
The provision under the Medical(792.96 Crores) and Public Health
demands (541.76Crores) in Budget Estimate 2001-2002 was Rs.1334.72 Crores,
which worked out to 5.44% of the total expenditure on the Revenue account of
Rs.24522 Crores in Tamil Nadu State budget. The provision for Health and Family
welfare for 2003-2004 is Rs. 1380.29 Crores.
IS^
Primary Health Care
In Tamil Nadu 1411 Primary Health Centres and 8682 Health Sub-Centres
are functioning. These Institutions provide preventive, promotive, curative and
rehabilitative health care services. Between April 2002 and February 2003, 498
lakhs outpatients were provided treatment in the Primary Health Centres. All
Block Primary Health Centres have been provided with telephone facilities. To
involve the community in the maintenance of Primary Health Centres,
Participatory Community Health Committees have been formed in all the Primary
Health Centres.
Upgradation of Primary Health Centers
This Government has decided to provide at least one 30 bedded Health
Institution in each block. These Institutions will have specialist doctors and
modern equipments like Ultra Sonograph, Portable ECG, and X-Ray, along with
improved laboratory facilities and ambulance. During the year 2002-2003, 58
Primary Health Centres have been taken up for upgradation.
Improving Quality of Primary Health Care
To improve the quality of Health Care at Primary Health Centres, each
Block is provided with a Portable ECG machine to diagnose cardiac problems. A
Glucometer is also provided to each Block Primary Health Centre to enable early
detection of diabetic patients. The Operation Theatres attached to the Primary
Health Centres have been provided with Anasthesia apparatus, operating table and
surgical instruments to enable them to perform minor surgeries.
The Village Health Nurses at Sub-Centres have been trained to take Blood
Pressure and each Health Sub Centre is provided with BP Apparatus and
ISXf
Stethoscope. The Sub-Centres are also supplied with a Medical Equipment Kit
consisting of basic instruments and weighing scales.
The Health Sector is equipped to maximize the use of Information
Technology. All the District Offices are provided with Computer and E-Mail
connectivity. Computers have been provided to Primary Health Centres in
Madurai, Theni, Salem and Namakkal Districts.
To meet the manpower needs of the Primary Health Centres, Government
has proposed to recruit 500 more doctors to fill the existing vacancies.
Speciality Medical Camps
Specialised Treatment is not easily available to rural people for illnesses
like cancer, and diabetes. Specialty Medical Camps to detect diseases like cancer,
diabetes, heart ailments, hypertension and geriatric problems are conducted at the
rate of one per Block. During 2002-2003, 385 Speciality Camps have been
conducted and 7.98 lakhs people were screened. 5.24% were found to be affected
with diabetes, 5.02% with heart ailments and hypertension, 0.54% with cancer and
22.4% with geriatric problems.
Mobile Health Services
In order to ensure that people living in tribal, remote and inaccessible areas
get medical facilities, 25 Mobile Health Units have already been launched and 20
more Mobile Health Units are being established in the current year. So far
1,79,571 patients have been provided with treatment by the Mobile Health Units.
1
Maternity and Child Health Care Services
Maternal and Child Health Services are the most important of the services
provided by the department. The services provided are Antenatal registration and
check up, administering vaccination against Tetanus, immunization against
vaccine preventable diseases, delivery care and post-natal care. At present the
institutional deliveries account for 89.9% of the total deliveries in the State.
Immunization against vaccine preventable diseases are sustained at 100%
every year. Apart from routine immunization, Pulse Polio Immunization is
conducted every year and two additional doses of oral polio vaccine are given to
all children below 5 years of age. In the current year the first round of Pulse Polio
Immunization was conducted during 5th January and 9th February covering 73
lakhs of children under 5 years of age. The successful implementation of Pulse
Polio Immunization added with sustained coverage in routine immunization has
made the State free from polio for the past three years. Other vaccine preventable
diseases are also under control.
Hepatitis B Vaccination has already been started in the city of Chennai
from February,2003. This will be extended to 4 more Districts viz. Virudhunagar,
Ramanathpuram, Madurai and Nilgiris during 2003-2004.
Malaria
Malaria is prevalent mainly in urban, coastal and riverine areas in the State.
In Tamil Nadu more than 70% of the total malaria cases occur in urban areas.
Chennai is the major problem area.
I'
The cases in Chennai city are mostly confined to North Chennai. To
eliminate the Malaria parasite so as to make Chennai free from Malaria, the
Directorate of Public Health and Preventive Medicine and Chennai Corporation
jointly organized a “‘Malaria Free Chennai Campaign” from September 15 to
December 15 last year. A total number of 1228 Malaria cases were detected and
treated during the campaign. People were advised to adopt measures for the
reduction of Vector breeding sources.
Filaria
The National Filaria Control Programme is implemented in Tamil Nadu
since 1957. The recent advances in the field of Filariasis Control have indicated
that annual single dose Mass DEC administration for at least 5 years is one of the
most cost effective methods of eliminating this disease. Mass DEC administration
has been carried out to 2.3 crores of people in March 2003 to eliminate lymphatic
filariasis in 13 filaria endemic Districts.
National Leprosy Eradication Programme
The National Leprosy Eradication Programme was launched in 1954-55.
The programme is marching towards achievement of the target of less than 1 per
10,000 population and ultimately total elimination of leprosy. Towards this MLEC
IV was launched to detect hidden cases in the community, with a specific focus on
tackling urban leprosy with the help of Non-Governmental Organisations as
facilitators.
Diarrhoea
Acute Diarrhoeal diseases and suspected Cholera are common among the
water borne diseases in Tamil Nadu. 2232 Anti Cholera inoculations were given
n ■
and 60,507 water sources were chlorinated in 2002 as preventive measures.
Administration of Oral Rehydration Salt during epidemic outbreaks of Acute
Diarrhoeal diseases has been popularized through Intensive Health Education.
Conchision
Inspite all these health care arrangements by the government, people are
affected by the structural deficiency in public health care services. Public hearings
are organized by National Human Rights Commission in association with ISA to
streamline the public health care systems on one hand and to increase awareness
about health rights in the community on the other. The Public hearings will also
facilitate dialogue between the public and the government health officers.
Source
1. Census of India,2001 (Provisional)
2. Ministry of Health and Family welfare Reports, 2000, NewDelhi.
3. Health and Family welfare Department, Government of Tamil Nadu.
4. Statistical Hand book of Tamil Nadu 2002.
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