Bharati Sahu : National Rural Health Mission
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- Bharati Sahu : National Rural Health Mission
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2014-2015
2015
Community Health Learning Programme
A Report on the Community Health Learning
Experience
Dr. Bharti Sahu
Sah
COMPANY
555-543-5432
5432
www.yourwebsitehere.com
SOPHEA
2015
Community Health Learning
Program
Dr. Bharti Sahu
SOCHARA
Index
1. Acknowledgement
2. About me
3. Sessions reflection
4. Presentations
5. Field visits
6. Conferences and meets
7. Research
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-: Acknowledgement:-
I would like to convey my heartiest thanks to The Director of SOCHARA, Dr. Thelma
Narayan for introducing this life changing fellowship for people who actually
want to dedicate their work for community welfare
Dr. Ravi Narayan is a wonderful story teller which actually inspires people to
think differently and do differently which mean a lot to someone who needs
your help to make changes in their life.
Special thanks to Mr. Prasanna sir who mentored me for my research topic. I
would like to pay my sincere thanks to Dr. Mohammad and Mr. Kumar who
always guided us in spite for being so busy in their work.
Thanks to Rahul, Janelle and Sabu for so much of support and guidance.
Tons of thanks to Mr. Chander who always motivated me and opened my
eyes to see this world from another prospective when I was almost lost.
My fellows :- Jyoti lakshmi, Krishna, Amrendra, Tosif, Pawan, Rahul,
Phoolsingh, Afsana, Ashma, Yashoda, Huntiful, Regina, Saraswati, Asma,
Vishan, Anusha , Juliet who are now my family far away from home. All our
enjoyment, laugh, secrets and all good times together we shared will be always
into my basket.
Lastly Hari and joshep Bhaiya for the rejuvenating lemon Tea.
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Me :-I originally belong to Raipur Chhattishgarh. I am born in a service(middle) class
family. Blessed to have such a caring parents and loving younger sister. I have
a big joint family.
I am a dentist by profession. I have 1 year experience working “Healthcare
magic” as a medical consultant and 1 year with “Mediassist” as a medical
officer. I opted the paradigm shift from medical model to social model of
Health Care.
This has been a significant turning point in my life, after this I started reflecting
about health of common people and their struggle in life to reach equity and
quality treatment. I have a passion to learn about many things which would
help me to widen my knowledge on any issues especially the struggle of the
people who are marginalized.
This Fellowship had widened my lens from the prospective of community. I
have also learned how to relate with the root aetiology of any disease relating
it directly to the social cause rather than just medical cause of it.
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For community work, remember “Chinese Proverb”.
I.
Go to the people
II.
Live with them
III.
Learn from them
IV.
Plan with them
V.
Work with them
VI.
Start with what they know
VII.
Build on what they have
VIII. Teach by showing, learn by doing
IX.
Not piecemeal, but a system
X.
Not a showcase, but a pattern
XI.
Not odds 7 ends, but a system
XII.
Not to conform, but to transform
XIII.
Not relief, but release
-
Yen Tangchu
Boarded:During CHLP orientation reflection time gave enough opportunity for personal
learning while activities like role – play made me part of the system and helped
in realizing the situation. As I started learning the concept “Health as a Human
Right”, I found that it requires enough resources from the society to reach
individual potential in a dignified way. In this situation “Availability” of the
resources is not enough, another important factor is the “Accessibility” and
“Capability” to utilize these resources.
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“Monsoon game” helped in understanding the web of causation through
social, economic, political, and cultural (SEPC) analysis and the hard realities of
farmers’ life, the caste system, difficulties in loan repayment and other socio
economic factors affecting their life. We understood the abstractness of the
“society”, where it is a stratified group of people, who have power dynamics
(intellectual, financial, natural and physical), Determining use of resources
(ownership, access and control).
While finding the reasons how gender affects women’s health, I found that so
many factors work simultaneously and every factor is interlinked with each
other. Following are the identified factors:
Poverty
Last priority in terms of health
Social Control
Empowerment factor of Women
Discrimination of Women within
their families
Religious and cultural factors
Restrictions in mobility
Violence, overwork and stress
I observed that there are certain factors that make women more exposed to
few diseases i.e. Sex/biology, gender norms and values, Government
activities, access and control of basic amenities and resources. I figured out
that getting same proportion and values of resources as compared to male
gender is important but right to access these resources are essential part
of community setting. How to cope up with the negative feelings and using
them as change agents in society with proper integration with the policies and
systems motivated me to work in this direction. The role play on “Alternative
Paradigm in Community Health – a CHP perspective” helped in realizing how
“individual specific care’ works on social model and recognizes patient as
people (more humane) and enable them at every step to move from disease to
health.
During my learning phase, I had many questions hovering in my mind about
how to move ahead and how to handle the multidimensionality and
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complexity of the health issues. My outcome to these thoughts was that when
someone has focus on Research and learning, for finding a solution to a
particular question, It is inevitable that one will encounter another set of
intriguing question in the problem solving process. This helped me to
understand the importance of “feedbacks” and “Reviews” in my problem
solving methods, by this I understood that learning is a continuous
phenomenon which reflects in to our future course of action. Blow flow chart
shows the importance of learning which reflects the changes in work.
Reflection on
work
Actoins due
to learnings
Learning
I learnt that committed leaders can provide the direction, inspiration, and will
to bring together needed Partnerships and resources to ensure success.
Leaders also can ensure that there is an active plan to sustain a community’s
ongoing ability and commitment to work together to establish, advance, and
maintain effective strategies that continuously improve health and quality of
life for all.
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Paradigm Shift:
Journey:
The session on globalization helped me understand following concepts:
Globalization in its current phase has been described as an
unprecedented compression of time and space reflected in the
tremendous intensifi
intensification
cation of social, political, economic, and cultural
interconnections and interdependencies on a global scale.
Recent years have witnessed the emergence of new forms of global
health care mobility, and increased popularity of existing forms due to
processes such as the development of a globalized economy,
establishment of international and bi-lateral
bi lateral trade agreements.
Nongovernmental organizations (NGOs) have become increasingly
important players in the realm of global health and development. They
operate projects
ojects in low and middle-income
middle income countries (LMICs)
throughout the world
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Commonly cited factor related to NGO distribution is the health and
development needs of a population. Social and economic indicators of
these needs include literacy rates, infant mortality rates, or life
expectancy. Organizations whose objectives are oriented towards
improving the well-being of neglected populations logically would target
populations with serious needs according to health and well-being
indicators.
The session on “Whatever happened to health for all by 2000 AD?” explained
following key points:
Primary health care was adopted as the policy model for global health.
The outcome document, the Alma Ata Declaration, adopted this holistic
approach, which emphasizes human rights and social and economic
dimensions of health and well-being. It shifted the focus from cure to
the prevention of ill health.
The Alma Ata Conference took place in the political context of the New
International Economic Order (NIEO), formally adopted by the 6th
Special session of the General Assembly in April 1974. NIEO was a set of
proposals developed during the 1970s by formerly colonized countries in
the developing world. The main aim was to revise the existing
international economic system to make it more favourable to the Third
World countries, as they were then called.
By 2005, implementation of the Global Strategy was still slow; the
funding base decreasing rather than increasing.
In the late 1990s, as the trend to public-private partnerships was
becoming established, IBFAN-GIFA observed their formation and the
development of the WHO Guidelines on Interaction with Commercial
Enterprises.
April 2008, GAIN introduced in India its Infant and Young Child Feeding
(IYCF) program and proposed to launch officially an IYCF Alliance, which
had been under discussion for some time. This effort met with strong
protest from 19 national public interest organizations working in the
areas of health, development, gender, education and nutrition, including
Breastfeeding Promotion Network of India, Jan Swasthhya Abhiyan and
All India Drug Action Network.
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The demonstrators protested against the increasing interference from
manufacturers to influence policies on infant and young child feeding
and nutrition.
The session on National Rural Health Mission – A nation’s effort to
strengthening of health systems and improve people’s health” described the
following points:
Major objectives of NRHM include the following :
o to raise public spending on health,
o with improvements in community financing and risk pooling
o to provide access to primary healthcare services for the rural
poor, with universal access for women and children
o Child health, Water, Sanitation and Hygiene
o to see a concomitant reduction in IMR / MMR / TFR; to prevent
and control
o communicable and non-communicable diseases
o to revitalize local health traditions
What is actually under new NRHM :
o Creation and upgradation (on infrastructure / human resource /
managerial fronts using untied funding) of SCs, PHCs,
o CHCs; Revitalising and mainstreaming AYUSH; Mission Flexible
Pool untied funding; Janani Suraksha Yojana (JSY);
o Accredited Social Health Activists (ASHAs); Involvement of
community at decentralised levels through Hospital
o Development Societies (HDS) or Rogi Kalyan Samitis (RKS) / Village
Health and Sanitation Committees (VHSCs);
o Converging health, nutrition, water, sanitation and hygiene
activities through District Health Plans; Integration of vertical
health and family welfare programmes at national, state, district
and block levels; Fostering public-private partnerships while
regulating the private sector; Instituting Indian Public Health
Standards.
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Issues and challenges for NRHM :
o LACK OF TRAINED PERSONNEL: Lack of trained personnel and
infrastructure is a major concern for proper implementation of
NRHM.
o ORGANIZATION OF SOCIETIES: Implementation of NRHM in many
states like Jharkhand is very challenging .These states lacks the
basic infrastructures for implementation of national health
programs and state health societies were not constituted here for
long.
o PARTICIPATION OF LOCAL SELF-GOVERNING BODIES: At present,
the NRHM is being seen as a package of schemes but in reality it is
a participative program of different stakeholders like Community,
PRIs, government and non-governmental organizations in a wellcoordinated manner.
o CORRUPTION IN IMPLEMENTATION: There is possibility of
corruption in the implementation of these programs.
o UTILIZATION OF UNTIED FUNDS: Civil society engagement has not
yet taken place at the state level.
o PUBLIC-PRIVATE PARTNERSHIP: Public-private partnership
processes should not encourage the privatization of health
services. Financing should be from public funds so that universal
access to services is ensured.
The overall health status of the poor and socially excluded population is
meagre in some states. The reasons for the poor health status of millions
of people are not hard to find. Major factor hindering access to quality
health services are lack of or non-existing inter-sectoral linkages
between different stakes holders. This phenomenon is also found
between different Government Departments. Here the role of
panchayati raj institutions and civil society organizations becomes
pertinent as one of the important stakeholder. There is also need of
forging alliances with wider determinants of health. Existence of services
in terms of structure will never ensure its utilization to fullest unless and
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until there is proper channel between different stake-holders which can
link people to these services.
Essential concepts: ---Health
WHO says “Health is a state of complete physical, mental and social well-being
and not merely the absence of disease or infirmity”.
But as scholar activists the word health can be Health is a Fundamental right
and all need health. It is not only the responsibility of the medical people but
also the responsibility of people who are involved in the well-being of the
population. Even a health worker can also take health in to his hands through
scientific knowledge and transmit this knowledge to others.
Community
A group of people having same identity living in a locality having a common
interest looking for common goal.
Community Health
It is related with health of the community. A well-developed community should
have proper drinking water, sanitation, nutrition, good environment,
education, accessible to primary health care and so on.
Determinants of health:
Economical
Cultural
Social
Political
Environmental
Community health Axioms:
Rights and responsibility
Autonomy over health
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Integration of health and developmental activities
Building decentralized democracy at community and team level
Building equity and empowering community beyond social conflicts
Promoting and enhancing the sense to community
Confronting the biomedical model with new attitude skills and approach
Confronting the existing super structure model of medical/health care to
be more people and community oriented
A new vision of health and healthcare not a professional package for
illness
An effort to build a system in which health for all can become a reality.
4 pillars of primary health:
Appropriate technology
Equity
Community participation
Inter structural collaboration
Four A’s in health stream:
Accessibility
Affordability
Availability
Acceptability
Health Policy in India
According WHO “a national health policy is an expression of goals for
improving the health situation, the priorities among those goals and the main
directions for attaining them.”
In India we have two national policies: National Health Policy (NHP) 1983 & 2002
National Population Policy (NPP) 2000
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It means that the people should have the opportunity to participate and to
access health care freely.
Challenges and Barriers:-Social inclusion/exclusion; ability to pay, Political
choice, negotiation, contestations, Peoples’ participation, perceptions, beliefs
and experiences, War, violence, conflict, natural disasters.
Health system
According to WHO “a health system comprises all organizations, institutions
and resources devoted to producing actions whose primary intent is to
improve health.
Most national health systems include public, private, traditional and informal
sectors. The four essential functions of a health system have been defined as
service provision, resource generation, financing and stewardship.”
Health system in India is in the hands of the rich and the poor has known
approachability to get any health facilities unless one needs to corrupt. The
idea of health system is to enable any person in India to get health where ever
he/she is, what kind of job he/she does and so on. If people have the
possibility of health insurance then a great worry of the people well is
removed.
The main components of health systems are the following:• Financing- public, private, out of pocket
• Organization of health care systems
• Governance & accountability mechanisms
• Implementation issues
• Quality of care
• Outcomes and impacts, including equity
• CPHC approach to health system development
• Health systems as a health determinant.
Health as a Right
When we talk about health as a right all those social, cultural, environmental,
political, economic factors should be dealt at first then only the word HEALTH
FOR ALL is achieved.
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The Declaration of Alma-Ata was adopted at the International Conference
on Primary Health Care (PHC), Almaty (formerly AlmaAta), Kazakhstan (formerly Kazakh Soviet Socialist Republic), 6-12 September
1978. It expressed the need for urgent action by all governments, all health
and development workers, and the world community to protect and promote
the health of all people. It was the first international declaration underlining
the importance of primary health care. The primary health care approach has
since then been accepted by member countries of the World Health
Organization (WHO) as the key to achieving the goal of "Health For All" but
only in third world countries at first. This applied to all other countries five
years later.
Useful parameters:Total fertility rate (TFR):
TRF of a population is the average number of children that would be born to a
woman over her lifetime if:
She were to experience the exact current age-specific fertility rates
(ASFRs) through her lifetime, and
She was to survive from birth through the end of her reproductive life.
Incidence: Occurrence of new cases of a specified disease in a specified
community during a specified period of time
Prevalence: A measure of the total number of existing cases (episodes or
events) of a disease or condition at a specified point in time. (If a period of
time is specified, then the resulting disease measure is period prevalence.)
Morbidity: Any departure, subjective or objective, from a state of physiological
or mental well-being, whether due to disease, injury or impairment.
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Methods and formulae:
Incidence: [Number of new cases in a given time period] X100/population at
risk in given time period]
Prevalence: [total number of new and old casesX100]/Population
Incidence rate: [Number of new cases in the given time period*1000]/Total
person-time of exposure
For infectious diseases, it can also be expressed as:
Incidence: Number of episodes in a given time periodX100/Population at risk
during the time period.
Proportion: Defined as the fraction a/ (a + b) for mutually exclusive groups
with elements a and b.
(The b elements may belong to more than one group, each mutually exclusive
of the group with the a elements.)
Rate: A measure of the "speed" at which events are occurring (for example
rate of incidence of a specified disease is a measure of the "speed" with which
new cases occur in the community).
Ratio: Defined as the fraction a/ b for two mutually exclusive groups with
elements a and b (conventionally expressed as 1: b/a).
Crude death rate (CDR): [Total number of deaths occurring in a year x
1000]/Mid-year population. The adjective "crude“ refers to the overall death
rate with no compensation for the effect of any associated factor, such as age,
sex or race.
Perinatal mortality rate: [(Number of stillbirths) + (number of infant deaths in
the first week after birth) in a year X 1000]/Total number of births in the same
year.
Perinatal mortality ratio: [(Number of stillbirths) + (number of infant deaths in
the first week after birth) in a year X 1000] /Total number of live births in the
same year.
Infant mortality rate: [Number of deaths under one year of age in a year X
1000] /Total number of live births in the same year.
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Maternal mortality rate: [Number of female deaths due to complications of
pregnancy, or during child birth in a year X 1000] /Total number of live births in
the same year.
Definitions of new terms and concepts in the context of health indicators:
(Health) status indicator:
An indicator of the level of the health phenomena of interest.
Example: Average annual number of cases (episodes) of diarrhea per child
under five years of age
Feasibility:
The ability to obtain the data needed to compute the indicator.
Example: An indicator of fetal loss may not be feasible, since not all data on
fetal losses are routinely collected.
Goal (of a health programme):
The ultimate aim of a health program.
Example: polio eradication.
Indicator:
A variable that helps to measure changes directly or indirectly and is used to
assess the extent to which objectives and targets are being attained.
Example: see Handout 16.3.
Objective (of a health program):
A measurable state a health program is expected to be in, at a given time, as a
result of the application of program activities, procedures and resources.
Example: An objective of an expanded program of immunization could be
effectively to immunize at least 90% of the eligible children by the end of the
current 5-year national health program.
Process indicator:
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A measure of the extent, efficiency or quality of service performance.
Example: Proportion of pneumonia cases seen who receive standard case
management at health facilities.
Proxy indicator:
An indicator used in place of a direct indicator which may be more difficult to
measure or compute.
Example: School absenteeism may be used as a proxy indicator for general
morbidity in school-age children.
Relevance:
The extent to which an indicator contributes to the understanding of the
phenomena of interest.
Example: The proportion of preschool children (under 5 years of age) more
than 2 SD below the median height-for-age of the WHO/National Center for
Health Statistics reference population contributes to the understanding of
childhood moderate and severe stunting.
Reliability:
The indicator should be reproducible if measured by different people under
similar circumstances.
Example: Infant mortality is a reliable indicator of early childhood mortality in
countries with comprehensive birth and death registration.
Sensitivity:
The degree to which an indicator reflects changes in the phenomena of
interest.
Examples: The quantity of non-expired drugs by category at a health facility is a
sensitive indicator of drug supply at the facility. In many developing countries,
outpatient attendance rates at public health facilities are a sensitive (proxy)
indicator of the supply of drugs at those facilities.
Specificity:
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The ability of an indicator to reflect changes in only the specific phenomena of
interest. Example: The amount of drugs dispensed daily at a health facility is
not a specific indicator of drug supply at the facility.
Some of the indicators for monitoring the goals and targets of the World
Summit for Children
Indicators of mortality
Infant mortality rate: the annual number of deaths of infants under one year of
age per 1000 live births.
Indicators of childhood nutrition
Underweight prevalence:
Proportion of preschool children (under 5 years of age) more than 2 SD
(moderate and severe) or more than 3 SD (severe) below the median weightfor-age of the WHO/National Center for Health Statistics reference population.
Indicators of water and sanitation
Proportion of the population with access to an adequate amount of safe
drinking-water in a dwelling or located within a convenient distance from the
user's dwelling.
Proportion of the population with access to a sanitary facility for human
excreta disposal in a dwelling or located within a convenient distance from the
user's dwelling.
Indicators of disability
Disability type-specific prevalence:
The total number of persons with disability, specifying the number having
serious difficulty in seeing, hearing or speaking, moving, learning or
comprehending, or having strange or unusual behavior, or other disability of
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duration of at least six months or of an irreversible nature, in the following age
groups: 0-4, 5-14, 15-19 and 20 and over.
Indicators of health and nutrition of the female child, and of pregnant and
lactating women
Antenatal care:
Proportion of women attended at least once during pregnancy by trained
health personnel.
Indicators of child spacing
Contraception: proportion of women of childbearing age (15-49) currently
using contraceptive methods (either modern or traditional).
Fertility: fertility rate of women 15-49 years of age.
Indicators of immunization coverage
Proportion of children immunized against diphtheria, pertussis, and
tetanus (DPT, 3 doses) before their first birthday.
Proportion of children immunized against measles before their first
birthday.
Proportion of children immunized against poliomyelitis (OPV, 3 doses)
before their first birthday.
Proportion of children immunized against tuberculosis before their first
birthday.
Disease:
A disease is a particular abnormal, pathological condition that affects part or all
of an organism. It is often construed as a medical condition associated with
specific symptoms and signs.[1] It may be caused by factors originally from an
external source, such as infectious disease, or it may be caused by internal
dysfunctions, such as autoimmune diseases. In humans, "disease" is often used
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more broadly to refer to any condition that causes pain, dysfunction, distress,
social problems, or death to the person afflicted, or similar problems for those
in contact with the person. In this broader sense, it sometimes includes
injuries, disabilities, disorders, syndromes, infections, isolated symptoms,
deviant behaviours, and atypical variations of structure and function, while in
other contexts and for other purposes these may be considered
distinguishable categories. Diseases usually affect people not only physically,
but also emotionally, as contracting and living with a disease can alter one's
perspective on life, and one's personality.
it can be broadly classified in two ways:
•
Communicable
•
Non communicable
Communicable d/s: A communicable disease such as a cold is a disease that
spreads from person to person. Communicable diseases are diseases that you
can "catch" from someone or something else. Some people may use the words
contagious or infectious when talking about communicable diseases.
There are four major types of germs:
•
Bacteria
•
Viruses
•
Fungi
•
Protozoa
Hepatitis: Viral hepatitis is a major global health challenge. Viral hepatitis,
which affects the liver, is a group of infections referred to as hepatitis A, B, C,
D, and E. It is responsible for more than 1.4 million deaths annually, mostly in
low- and middle- income countries. This public health threat rivals the number
of deaths from HIV/AIDS (1.7 million), tuberculosis (1.4 million) and malaria
(700,000).
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One in three people worldwide have been infected with the hepatitis B virus at
some point in their lives, and 400 million people live with chronic hepatitis B or
C infection. Hepatitis B and C causes roughly 80 per cent of liver cancers, and
are an important cause of cirrhosis (scarring) of the liver. A key concern about
viral hepatitis is hepatitis virus co-infection among people living with HIV,
which can increase the risk of both serious liver disease and more rapidly
progressive HIV infection.
Close attention should therefore be paid to viral hepatitis as we implement
global programs on HIV/AIDS such as the Presidents Emergency Plan for AIDS
Relief (PEPFAR) and the Global Fund to fight AIDS, Tuberculosis, and Malaria.
Influenza: Seasonal Influenza (the flu) is a contagious respiratory illness caused
by influenza viruses. It can cause mild to severe illness, and at times can lead to
death. Some people, such as older people, young children, and people with
certain health conditions, are at high risk for serious flu complications. The
best way to prevent the flu is by getting vaccinated each year.
Polio: Polio, short for Poliomyelitis, is an infectious disease. It is caused by a
virus that invades the nervous system. Less than 1 per cent of polio cases get
to the paralysis stage, which is fatal when it reaches the muscles humans need
to breath. Still, fewer than 10 per cent of polio cases that reach paralysis result
in death. Polio is a horrific disease because it tends to infect children under
five, causing lifelong crippling conditions. There is no cure for polio, but there
are two vaccines, meaning the strategy to eradicate the disease is focused on
prevention.
AIDS/HIV: Human immunodeficiency virus (HIV) destroys or impairs the
immune system of the people it infects. As the immune system weakens
individuals become more at risk to infections. As condition progresses, the
immune system becomes weaker and the individual becomes more at risk to
acquired immunodeficiency syndrome (AIDS), the most advanced stage of HIV.
Because of advances in medicines called antiretroviral drugs, many people with
HIV live for 15 years or more before symptoms of AIDS appear.
Malaria: Malaria is a preventable parasitic disease transmitted by mosquitoes.
It is prevalent especially in sub-Saharan Africa and Southeast Asia.
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According to WHO’s World Malaria Report 2012:
•
There were roughly 219 million cases of malaria in 2010
•
There were an estimated 660,000 deaths from malaria in 2010
•
Ninety per cent of all malaria deaths occur in Africa; many victims are
children under five years old
•
Between 2000 and 2010, more than 1.1 million malaria deaths were
averted globally as a result of scale-up interventions
Because malaria is a global emergency that affects mostly poor women and
children, malaria perpetuates a vicious cycle of poverty in the developing
world.
Tuberculosis: Tuberculosis, also known as TB, is a disease caused by bacteria
spread through the air from one person to another. Commonly, it attacks the
lungs, but also other parts of the body. It is estimated that one third of the
world's population is infected with TB, but it can lay latent, meaning not
everyone develops the active disease. Persons with latent TB do not spread the
disease unless it is active in the body. Of all TB cases in the world, 85 % occur in
22 countries. Of these 22 countries, 9 are in sub-Saharan Africa and over 1.5
million cases of TB occur in Africa each year. In Africa TB/HIV co-infection is
one of the main causes of morbidity and mortality in Africa. A 3-5 drug regimen
using Directly Observed Therapy – Short course (DOTS) over a 6-8 month
period is the standard of treatment for TB. Treatment failures result in drug
resistance including multi-drug.
Non communicable d/s:
A non-communicable disease, or NCD, is a medical condition or disease that
can be defined as non-infectious and non-transmissible among people. NCDs
can refer to chronic diseases which last for long periods of time and progress
slowly. Sometimes, NCDs result in rapid deaths such as seen in certain types of
diseases such as autoimmune diseases, heart diseases, stroke,
most cancers, asthma, diabetes, chronic kidney
disease, osteoporosis, Alzheimer's disease, cataracts, and many more. While
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sometimes (incorrectly) referred to as synonymous with "chronic diseases",
NCDs are distinguished only by their non-infectious cause, not necessarily by
their duration. Some chronic diseases of long duration, such as HIV/AIDS, are
caused by transmittable infections. Chronic diseases require chronic care
management as do all diseases that are slow to develop and of long duration.
The World Health Organization (WHO) reports NCDs to be by far the leading
cause of death in the world, representing over 60% of all deaths. Out of the 36
million people who died from NCDs in 2005, half were under age 70 and half
were women. Of the 57 million global deaths in 2008, 36 million were due to
NCDs. That is approximately 63% of total deaths worldwide. Risk factors such
as a person's background, lifestyle and environment are known to increase the
likelihood of certain NCDs. Every year, at least 5 million people die because of
tobacco use and about 2.8 million die from being overweight. High cholesterol
accounts for roughly 2.6 million deaths and 7.5 million die because of high
blood pressure.
Types of NCDs:
Cardiovascular disease (e.g., Coronary heart disease, Stroke)
Cancer
Chronic respiratory disease
Diabetes
Chronic neurologic disorders (e.g., Alzheimer’s, dementias)
Arthritis/Musculoskeletal diseases
Unintentional injuries (e.g., from traffic crashes)
Importantly, deaths due to NCDs are becoming more common in low- and
middle-income countries, where the majority of NCD deaths occur and where
health systems are often not equipped to respond. The WHO reported in 2010
that 31% of deaths in developing countries are caused by communicable
23 | P a g e
disease, while the remainders of deaths are caused by these noncommunicable diseases and injuries:
Cardiovascular disease – 25%
Cancer – 12%
Injury - 11%
Chronic Respiratory Disease – 8%
Diabetes – 5%
Other – 8%
Key NCDs:-
24 | P a g e
1.
Cancer: For the vast majority of cancers, risk factors are
environmental or lifestyle-related, thus cancers are mostly
preventable NCD. Greater than 30% of cancer is preventable via
avoiding risk factors including: tobacco,
being overweight or obesity, low fruit and vegetable
intake, physical inactivity, alcohol, sexually transmitted
infections, and air pollution. Infectious agents are responsible
for some cancers, for instance almost all cervical cancers are
caused by human papillomavirus infection.
2.
Cardiovascular disease: The first studies on cardiovascular
health were performed in 1949 by Jerry Morris using
occupational health data and were published in 1958. The
causes, prevention, and/or treatment of all forms of
cardiovascular disease remain active fields of biomedical
research, with hundreds of scientific studies being published on
a weekly basis. A trend has emerged, particularly in the early
2000s, in which numerous studies have revealed a link between
fast food and an increase in heart disease. These studies include
those conducted by the Ryan Mackey Memorial Research
Institute, Harvard University and the Sydney Centre for
Cardiovascular Health. Many major fast food chains, particularly
McDonald's, have protested the methods used in these studies
and have responded with healthier menu options.
3. Diabetes: Type 2 Diabetes Mellitus is a chronic condition which is largely
preventable and manageable but difficult to cure. Management concentrates
on keeping blood sugar levels as close to normal ("euglycemia") as possible
without presenting undue patient danger. This can usually be with close
dietary management, exercise, and use of appropriate medications (insulin
only in the case of type 1 diabetes mellitus. Oral medications may be used in
the case of type 2 diabetes, as well as insulin).Patient education,
understanding, and participation is vital since the complications of diabetes are
25 | P a g e
far less common and less severe in people who have well-managed blood
sugar levels. Wider health problems may accelerate the deleterious effects of
diabetes. These include smoking, elevated cholesterol levels, obesity, high
blood pressure, and lack of regular exercise.
4. Chronic kidney disease: Although chronic kidney disease (CKD) is not
currently identified as one of WHO's main targets for global NCD control, there
is compelling evidence that CKD is not only common, harmful and treatable but
also a major contributing factor to the incidence and outcomes of at least
three of the diseases targeted by WHO (diabetes, hypertension and CVD).CKD
strongly predisposes to hypertension and CVD; diabetes, hypertension and
CVD are all major causes of CKD; and major risk factors for diabetes,
hypertension and CVD (such as obesity and smoking) also cause or exacerbate
CKD. In addition, among people with diabetes, hypertension, or CVD, the
subset who also have CKD are at highest risk of adverse outcomes and high
health care costs. Thus, CKD, diabetes and cardiovascular disease are closely
associated conditions that often coexist; share common risk factors and
treatments; and would benefit from a coordinated global approach to
prevention and control.
5 cs during delivery
Clean hands
Clean place
Clean blade
Clean stump
Clean thread
Health care expenditure:
•
Total health expenditure
26 | P a g e
•
Public health expenditure
•
Private health expenditure
•
Out of pocket health expenditure
•
Per capita health expenditure
Public health expenditure is expressed in terms of % of GDP.
GDP= gross domestic production
(All incomes of the country including foreign income, donations, and funds +
local income)
GNP= gross national product
(All domestic incomes, they don’t include foreign revenue)
Total health expenditure of country = 5.8% of GDP
Public health expenditure= 1.1% of GDP
Private health expenditure= 4.7% of GDP
Therefore total health burden on public of their health is around 19%
(i.e. 5.8/1.1)
It indicates that out of 100 Rupees of health expenditure the government is
putting only 19 rupees and rest is done by the person itself means out of
pocket expenditure.
Unfortunately the 2nd biggest reason for loan in India is health expenditure.
4 principles of health financing in insurance
•
Risk pooling
•
Cross subsidy
27 | P a g e
•
Solidarity
•
Equity
Tax based insurance is the best health insurance system working in India. It is
based on Beveridge model also called as National Health Service model.
Principle of public private partnership:
B--- Built
O--- Own
O--- Operate
T--- Transfer
But there are certain conditions for this partnership
•
Provider should built the physical infrastructure
•
Risk should be owned by the contractor.
In India there is no public private partnership which follows the above mention
condition.
Mental health: burden of mental disorders had risen over last few decades.
Mental health is a state of well-being in which the individual realizes his or her
own abilities, can cope with the normal stresses of life, can work productively
and is able to make a contribution to his or her community. Major proportions
of mental disorders come from low and middle income countries . There are
lacunae in psychiatric epidemiology due to intricacy related to defining a case,
sampling methodology, under reporting, stigma, lack of adequate funding and
trained manpower and low priority of mental health in the health policy. Most
common causes of disorders especially in adolescents could be depression,
alcohol abuse, schizophrenia and bipolar disorders. Various studies had shown
that the prevalence of mental disorders is high in female gender, child and
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adolescent population, students, elderly population, people suffering from
chronic medical conditions, disabled population, disaster survivors, and
industrial workers.
women issues: The health of Indian women is intrinsically linked to their status
in society. women’s status has found that the contributions Indian women
make to families often are overlooked, and instead they are viewed as
economic burdens. There is a strong son preference in India, as sons are
expected to care for parents as they age. This son preference, along with high
dowry costs for daughters, sometimes results in the mistreatment of
daughters. Further, Indian women have low levels of both education and
formal labor force participation. They typically have little autonomy, living
under the control of first their fathers, then their husbands, and finally their
sons. While women in India face many serious health concerns, this profile
focuses on only five key issues: reproductive health, violence against women,
nutritional status, unequal treatment of girls and boys, and HIV/AIDS. Because
of the wide variation in cultures, religions, and levels of development. it is not
surprising that women’s health also varies greatly from state to state. I
personally can say that until or unless we won’t improve the status of women
in society diseases like Anemia can’t be just cured by distribution of iron and
folic acid tablets in free of cost .Women need more high-quality nutrients
when they are pregnant or nursing; however in some areas of India women
typically eat last and least. More than half of all Indian women develop anemia
due to lack of essential nutrients. While women’s rights and professional
careers have come a long way, there are still segments of Indian society where
women are very much discriminated against.
Sanitation and hygiene : Access to improved water and sanitation facilities
does not, on its own, necessarily lead to improved health. There is now very
clear evidence showing the importance of hygienic behaviour, in particular
hand-washing with soap at critical times: after defecating and before eating or
preparing food. Hand-washing with soap can significantly reduce the incidence
of diarrhoea, which is the second leading cause of death amongst children
under five years old. In fact, recent studies suggest that regular hand-washing
with soap at critical times can reduce the number of diarrhoea bouts by almost
50 per cent. good hand-washing practices have also been shown to reduce the
29 | P a g e
incidence of other diseases, notably pneumonia, trachoma, scabies, skin and
eye infections and diarrhoea-related diseases like cholera and dysentery. India
has the highest rate of open defecation in the world (WHO-UNICEF,
2010). People who have their own land have space to practise open
defecation. The poorest people, however, who own little or no land, often
have to walk for miles each day to access relatively safe and private open
space. At the very least, this is a huge waste of time, effort and human
potential. For the more vulnerable members of communities (women,
pregnant women, children, and sick, elderly, or disabled, people) fulfilling their
basic human needs can be a dangerous and degrading ordeal. Defecation near
water sources and where food is being grown can spread disease.
Privatization: India has achieved substantial improvement in its health
indicators. Life expectancy has increased, infant and maternal mortality has
declined, and the coverage of most of the National Health Programmes is
better. However, this progress is uneven; there are large State-wide
variations, and performance in some States is abysmally low. Lack of
accountability is plaguing the Indian health system. The productivity of
public health sector has been rather low, and it is often considered one of
the 'sick unit.' A popular 'treatment' to this 'sickness' is public-private
partnership (PPP), which has become a buzz word today. Although PPP does
not imply privatization alone, it has many other options available; but it
may lead to privatization in its current format. Providing land and
infrastructure to private players and letting them operate the health
facilities in their own way cannot be labeled PPP. Monitoring the regulation
capacity of public health system is very much inadequate currently, without
which PPP is not possible. At this stage, privatization means that around
20% of the people who are very poor and depend on government system
will be left with no option. The term privatisation refers to the growth of
the ‘for profit’ sector and its inter relationship with the public sector. It also
includes the introduction of market principles in the public sector viz. user
fees, contracting out and private insurance schemes. The trends in
privatisation are analysed in terms of the increase in private institutions and
beds relative to public provisioning across rural and urban areas and states.
This trend is a result of states facing a fiscal crisis and therefore, opting for
30 | P a g e
loans and grants from multilateral and bilateral agencies that advocate
policies to make the public sector generate its own resources. The net
effect of such a restructuring process on the utilisation patterns for
outpatient and inpatient care across states and income groups are analysed
in relation to the structures of provisioning
Disaster management: India has been traditionally vulnerable to natural
disaster on account of its unique geo-climate conditions. Floods, droughts,
cyclones, earthquakes, and landslides have been a recurrent phenomena. We
have no policy on systematic disaster Management. It is only after a disaster
strikes that the wheels of the government, both at the centre and at the states,
move and that too slowly. Despite the need to build up capabilities to meet the
challenges of disasters, the thrust has unfortunately been on alleviation and
relief. Even the relief has not been quick and adequate, as few disasters such
as Orissa super cyclone, Tsunami of 2004, Gujarat earthquake etc are still in
our mind. Not only this they need psychological support/ counselling as well
which is usually being neglected. And the basic priority is only given to shelter,
food and clothings.
Environmental pollution: One of the greatest problems that the world is facing
today is that of environmental pollution, increasing with every passing year
and causing grave and irreparable damage to the earth. Environmental
pollution consists of five basic types of pollution, namely, air, water, soil, noise
and light. Improper management of solid waste is one of the main causes of
environmental pollution and degradation in many cities, especially in
developing countries. Many of these cities lack solid waste regulations and
proper disposal facilities, including for harmful waste. Such waste may be
infectious, toxic or radioactive. Municipal waste dumping sites are designated
places set aside for waste disposal. Depending on a city’s level of waste
management, such waste may be dumped in an uncontrolled manner,
segregated for recycling purposes, or simply burnt. Poor waste management
poses a great challenge to the well-being of city residents, particularly those
living adjacent the dumpsites due to the potential of the waste to pollute
water, food sources, land, air and vegetation. The poor disposal and handling
31 | P a g e
of waste thus leads to environmental degradation, destruction of the
ecosystem and poses great risks to public health. Air pollution is cause by the
injurious smoke emitted by cars, buses, trucks, trains, and factories, namely
sulphur dioxide, carbon monoxide and nitrogen oxides. Even smoke from
burning leaves and cigarettes are harmful to the environment causing a lot of
damage to man and the atmosphere. Evidence of increasing air pollution is
seen in lung cancer, asthma, allergies, and various breathing problems along
with severe and irreparable damage to flora and fauna. Even the most natural
phenomenon of migratory birds has been hampered, with severe air pollution
preventing them from reaching their seasonal metropolitan destinations of
centuries. Water pollution caused industrial waste products released into
lakes, rivers, and other water bodies, has made marine life no longer
hospitable. Humans pollute water with large scale disposal of garbage, flowers,
ashes and other household waste. In many rural areas one can still find people
bathing and cooking in the same water, making it incredibly filthy. Acid rain
further adds to water pollution in the water. In addition to these, thermal
pollution and the depletion of dissolved oxygen aggravate the already
worsened condition of the water bodies. Soil pollution, which can also be
called soil contamination, is a result of acid rain, polluted water, fertilizers etc.,
which leads to bad crops. Soil contamination occurs when chemicals are
released by spill or underground storage tank leakage which releases heavy
contaminants into the soil. These may include hydrocarbons, heavy metals
Collective session includes the self-refection for a proper paradigm shift to
evaluate both the sides of coin. The people of BHARAT and the other side is the
changes which is actually occurring at the cost of people’s livelihood. Most of
the development is pushed by World Bank and IMF. But we should realize it’s
not actually development it’s just distortion of environment and the resources.
Ultimately the poor people continue to suffer a lot.
32 | P a g e
Presentations:
There were few presentations which I prepared during my fellowship. It
consists of the different topics.
1. Challenges in domestic violence counselling---- by CEHAT
Key Learning’s:
Counselling is a close relationship between counsellor and counselee.
Counsellor has to make decisions as to what one should do or not to do
in critical situations.
Ethical codes of counselling describe:
Rights and responsibilities
Standards of principle
Values
Conduct
Most importantly welfare of clients
CEHAT has its collaboration with private hospitals for a counselling for
domestic violence issues.
Domestic violence has bought into public domain in india by Feminist
moment 1980s.
DILAASA – first public based crisis centre
Components of counselling at DILAASA:
Counselling practise with a feminist perspective
Response system to psychological and social needs
Process of dealing with suicidal ideation
33 | P a g e
Sensitisation of health care provider on DV so that could identify abuse
amongst patients coming to them.
Ethics in counselling is concern:
How should the counsellor act?
How should the counsellor justify holding one set of moral values rather
than the other?
Principles of counselling ethics:
Autonomy—respect and protect right and dignity of the client
Non maleficence—causes no harm to the client in particular and the
community in general
Beneficence—ensures positive contribution towards the welfare of
clients.
Justice—benefits and risk of any intervention should b fairly distributed
amongst people.
Fidelity—notions of loyalty and commitments towards client
Self-respect—fostering the counsellors own knowledge and care of self.
Critical evaluation model in ethical decision making:
1. Identify the problem—therapeutically, legal, professional dilemma
2. Apply the codes of ethics
3. Determine the nature and dimension of the dilemma
4. Generate potential course of action
5. Consider the potential sequence of all options, choose a course of action
6. Evaluate the selected course of action
7. Implement the course of action
My reflections:
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By going through this book I have learned how one should control your
own emotions as a counsellor when you are dealing with very much
personal and saddest part of someone’s life.
There has to be a barrier not to involve yourself fully in the case mean
while you should also think that what would you have done when you
were placed in that particular scenario.
To motivate the sufferer and to make the second backup for her life is
really very much important.
It is the basic job of a counsellor to make feel the sufferer secure
emotionally and physically.
Overall it was a guideline for me how to deal with the cases of domestic
violence and the people who need support and help from us.
2. Verbal autopsies to study the gaps and causes contributing to child
mortality in rural Chhattisgarh.
District profile:
At the time of the 2011 census, the population within the Municipal
Corporation area of Raipur was 1,010,087.
The Municipal Corporation had a sex ratio of 946 females per 1,000
males and 12.3% of the populations were under six years old. Effective
literacy was 86.90%; male literacy was 92.39% and female literacy was
81.10%.
Raipur has a tropical wet and dry climate, temperatures remain
moderate throughout the year, except from March to June, which can
be extremely hot.
INTRODUCTION
The under-5 mortality rate is the number of children who die by the age
of five, per thousand live births in a year.
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As per AHS Report 2012-13, total under 5 Child mortality rate is 60 per
1000 live births for Chhattisgarh, out of which it is 65 and 40 per 1000
live births for rural and urban population respectively (data for 2009 to
2011).
As per World Bank’s Report (2013), the Child mortality rate in India was
56 per 1000. As per NFHS-3, this rate was 74 for India.
There is a need to study the gaps that lead to such high levels of child mortality
in rural Chhattisgarh so that steps can be identified for improving
policy/programmes.
OBJECTIVES:
1. To identify gaps contributing to child deaths in Chhattisgarh in:
a. Health seeking behavior of the family
b. Access to referral transport
c. Provision of healthcare services
2. To identify probable medical causes of child deaths.
3. To compare the gaps and causes for districts showing different levels of child
mortality in the state and to explain the reasons behind the extremely high
child mortality rate seen in certain districts (Sarguja (93), Jashpur (87), Koriya
(75) and Kwardha(74)). (Data source : AHS 2012-13)
4. Suggest a strategy to address the systemic gaps thus identified.
METHODOLOGY:
1. Study period: Child Deaths happening from January 2014 to December
2014
2. Sampling :
1. Mitanin trainers (MT’s) fill up the death register during monthly VHSNC
meeting which contains details about child deaths (under 5 years age). Efforts
are made that recording of no deaths is missed in this register.
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2. These deaths are further compiled at block level each month by MTs in a
Block Death register
3. Out of this list, three child death cases are selected randomly every month
for each block (145 blocks out of total 146). Around 5000 verbal autopsies of
child deaths will be done during the study.
3. Method of data collection and tool:
Verbal autopsy: A verbal autopsy is a method of finding out the cause of
a death based on an interview with next of kin or other caregivers.
A pre-designed questionnaire is used for recording the chronological
events of child death.
Process of data collection:
1. Block surveyors (Swasth Panchayat Coordinators) are trained to conduct
verbal autopsies and fill up this questionnaire. They have good rapport in
community and are familiar with local context and dialect, terms etc. used
there.
2. These questionnaires are then submitted to SHRC every month for analysis.
4. Analysis method
4.1 Every filled questionnaire is checked by a Trained Reviewer and discussion
is done with each surveyor for getting complete information about the case.
4.2 Data from the questionnaire is entered in computer.
4.3 A descriptive Case Summary is prepared for every case by reviewers that
capture the key events, gaps and medical cause/s.
4.4 Based on data on key variables, the reviewer interprets and enters the
categories of gaps for each case (TABLE A: Interpretation Form – Neonatal
Form, TABLE B: Non-neonatal Form)
4.5 Quantitative analysis of these entries is done.
Preliminary findings (Summary):
Sample analyzed till June end:
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Child deaths – 400 (during January to March 2014)
CHILD DEATHS
Neonatal- 269 (67%)
Post – neonatal- 131 (33%)
CHILD DEATHS- GAPS:
DELAY AT FAMILY LEVEL
1
FAMILY LEVEL
ALL CHILD
DEATHS
(N=400)
POSTNEONATAL NEONATAL
(N=269)
(N=131)
1.1
Family did not take preventive steps
24%
27%
17%
1.2
Family sought treatment with delay or
did not seek any treatment.
38%
34%
44%
1.3
Family did not approach mitanin
32%
28%
38%
1.4
Mitanin did not give right advice to family 4%
5%
2%
1.5
Family sought healthcare from
Inappropriate provider
57%
51%
69%
Proportion of deaths involving delay at
family level
73%
69%
82%
CHILD
DEATHS
(N=400)
NEONATAL
(N=269)
POSTNEONATAL
(N=131)
2%
2%
2%
DELAY AT TRANSPORTATION LEVEL
2. TRANSPORTATION LEVEL
2.1 Came late after call
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2.2 Did not come
2%
3%
1%
2.3 Did not pick
0%
0%
0%
2.4 No phone coverage
1%
1%
1%
Facility to facility referral support was
2.5 needed but not arranged by health
centre/ hospital.
4%
3%
5%
2.6 Money taken for transportation
2%
2%
1%
2.7 OTHER
1%
1%
0%
10%
10%
8%
3. GOVT. HEALTH FACILITY LEVEL
CHILD
DEATHS
(N=400)
NEONATAL
(N=269)
POSTNEONATAL
(N=131)
3.1 The required service/ procedure was
not available at the appropriate level
24%
25%
24%
Money taken by the hospital (other
than JDS charges)
5%
4%
5%
Delay in treatment
2%
3%
1%
Govt. facility Referred to private facility 11%
12%
8%
Family was sent back to home without
3.5 proper treatment or did not pay
attention during stay
19%
22%
13%
47%
38%
2.8
Proportion of deaths involving delay at
transportation level
DELAY AT HEALTH FACILITY LEVEL
3.2
3.3
3.4
3.6
Proportion of deaths occurring involving
delay at Health facility level
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44%
NEONATAL DEATHS- MEDICAL CAUSES (N=269)
Discussion : above 3 table states that there is wide gaps when it comes to
death of infants because of lack in awareness of the family. Effort has to be
made for healthcare in people to make utilization of the fascility provided by
government. Some how the family is not updated
updated about the consequences of
death. Basic health awareness is very much needed amongst the people. The
next gaps lies in the sequence is gap in hospital facility . we should check the
PHC and CHC whether they have full fascility as per their requirement or not
because chhattissgarh consists of villages more than cities, so the village
people should get the facility in PHC and CHC. And the last is because of
transport. When it comes to reference it takes time to move from one hospital
to other hospital which also add figures in mortality.
Unknown, 13%
NEONATAL DEATHS
Others, 4%
Meningitis, 3%
Malaria, 2%
Asphyxia, 35%
Jaundice, 5%
Diarrhea, 3%
Pneumonia, 20%
Sepsis, 22%
Congenital
anomalies, 6%
40 | P a g e
NON-NEONATAL
NEONATAL DEATHSDEATHS MEDICAL CAUSES (N=131)
Unknown, 12%
POST-NEONATAL
NEONATAL DEATHS
Accident, 4%
Sepsis, 8% Congenital
anomalies, 5%
Others, 6%
Meningitis, 5%
Malaria, 4%
Pneumonia, 43%
Measles 3%
Jaundice, 5%
Typhoid, 2%
Diarrhea, 21%
There were few presentations on mental health also which I would like to
include in my report.
1. Electroshock :the gentleman’s way to batter women
Introduction:
From the perspective of most adherents to the medical model of
psychiatry, electroconvulsive therapy (ECT) is a safe and effective
treatment for severe and intractable depression.
ECT is a psychiatric procedure which consists of passing sufficient
electricity through
ugh the head (100
(100—190
190 volts) to produce a grand mal
seizure or convulsion—hence
convulsion hence the term “electroconvulsive therapy”.
41 | P a g e
ECT is generally (although not universally) considered a valid, although
relatively invasive, option for the treatment of major depression when
all else has failed, especially when a patient is actively suicidal.
Invented in fascist Italy, ECT was inspired by the sight of animals en
route to the slaughter being rendered docile by an electrical cattle prod.
The first human recipient was a homeless man who was dragged off the
street and administered it against his will.
THE SCIENTIFIC FINDINGS: ECT AS DAMAGE
Typically, a single ECT series consists of at least six to ten treatments.
As early as the 1950s, animal experiments established that ECT causes
brain damage.
On the basis of observable brain damage (cell death and haemorrhages),
with almost complete accuracy, he was able to identify which animals
had been administered shock.
To cite relevant research on human beings with respect to both
unilateral and bilateral shock, Weinberger (1979) found more cerebral
atrophy in the brains of “schizophrenics” who have had ECT than those
that have not.
Memory loss, intellectual impairment, and the creation of
neuropathology are standard and well documented.
Breggin’s extensive literature review (1998, p. 27) culminated in the
following conclusion: “ECT causes severe and irreversible brain
neuropathology including cell death. It can wipe out vast amounts of
retrograde memory while producing permanent cognitive dysfunction.”
In a rigorously controlled double blind study, Lambourne and Gill (1978)
found that a month after shock and simulated shock, there was no
discernable difference in improvement between the shock and control
groups.
THE LATEST SIGNIFICANT PIECE OF RESEARCH
42 | P a g e
Ross (2006) finding, the largest and most ambitious study in ECT history
was concluded.
It involved 346 shock recipients, used a barrage of different measures,
and involved six month follow-up.
The study established cognitive impairment, brain damage, and memory
impairment to the level of statistical significance—moreover, a high level
of significance—with respect to both unilateral and bilateral
electroshock, and indeed, for every method of delivering electroshock,
including the newest.
STATISTICS:
1974 study of electroshock in Massachusetts reported in Grosser(1975)
revealed that 69% of those shocked were women.
In Ontario in 1999—2000, 75% of the shock administered was
administered to women.
Another statistic that seems relevant is that approximately 95% of all
shock doctors are male.
The simple fact is that the people most damaged by electroshock
(women) are administered electroshock two to three times as often as
the people less damaged by it (men).
WOMEN IN SPECIAL JEOPARDY:
Several of the populations of women at particular risk of being subjected
to this medicalized assault are evident in the foregoing.
They include: women who are distressed, abused women, women who
are in conflict with others who hold power over them, women who have
received ECT previously, women who have not “improved” on
psychiatric drugs, women who present as “suicidal,” women who are
depressed.
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CONCLUDING REMARKS:
Battery which is highly damaging and which is unleashed on women at
their most vulnerable.
It is a particularly insidious form of battery, more over, and one difficult
to mobilize against because it is done in the name of help. What adds to
the problem, it is committed by professionals; its victims are
automatically defined as “not credible”; it is state-sponsored; it is seen
as legitimate; it is underpinned by a huge industry with vested interests;
it is routinely done with the cooperation of family members; and mere
are no shelters to which its victims or potential victims may flee.
It is beyond the scope of this article to provide detailed suggestions
about what feminists can do about this form of woman abuse, though
clearly, we have a responsibility here.
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2. Adolescent mental health
Introduction:
• Adolescents aged 10–19 constitute about one fifth of India’s population
and young people aged 10 - 24 about one third of the population.
• The most common causes for adolescent deaths, worldwide, have been
found to include communicable diseases such as HIV/AIDS, tuberculosis,
and respiratory tract infections, and non- communicable diseases such
as road accidents, self-harm, violence, substance abuse and early
pregnancies.
• Over 35% of all HIV infections occur among young people 15-24 years of
age and a large proportion of young women - around 16% of 15 to 19
year olds - have experienced pregnancy or childbirth.
• 15% of all deaths among rural women ages 15-24 years can be
attributed to maternal mortality and morbidity.
• An estimated 10-20% of young people worldwide experience mental
health problems, leading to related health and social problems such as
adverse school performance, delinquency risky sexual behaviour and
substance abuse with suicide being the third leading cause of death
among young people.
• The suicide death rate in India is among the highest in the world with
40% of Indian suicide deaths among men and 56% among women
occurring in the age group 15-29 years.
• 40% of adolescents start taking drugs between ages 15-20.
However mental health of young people is a neglected public health
issue in low and middle income countries.
CorStone’s resilience based work in India
• CorStone is a non-profit organization with the mission to provide
evidence-based personal resilience programs to improve mental and
45 | P a g e
physical health and increase academic achievement among marginalized
youth.
• Resilience has been defined as the ability to achieve positive life
outcomes despite significant stress, challenge, or adversity.
Recent research has shown that resilience can be developed or ‘built’
through interventions, and interest in resilience-based interventions for
improving youth outcomes is growing worldwide.
Outcome:
• Preliminary results including demographic covariates.
• Gender attitudes were measured through questions that asked about
the rights of girls to attend school, bear a child before 18 years of age
and their attitude about sanctions on violence.
• Similar results emerged for a number of mental, social, health and
education outcomes in the Surat study.
• In the boys’ cohort, we found that boys improved their emotional
resilience, self-efficacy, school performance, and social well-being
statistically significantly
• Girls were able to advocate to parents to stop their own and others’
early marriages by using their persistence, emotional awareness, and
assertive communication skills they gained through the resilience
curriculum while communicating the facts about the dangers of early
marriage to their parents using what they had learned in the Health
curriculum.
Conclusion:
• Mental health promotion with a focus on building personal resilience
among youth may be one key missing link in youth programs in India.
• We must consider strength-based mental health work as a core program
that can lead to better outcomes not only in overall wellbeing, but also
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in specific but related areas as in the field of health, education, and
livelihoods.
• However, these attempts need to be reviewed and there is a need to
build evidence on their effectiveness.
3. Grand Challenges to Global Mental Health
Introduction:
Announced research priorities for improving the lives of people with
mental illness around the world, and called for urgent action and
investment.
The largest ever international Delphi panel was assembled in a project
starting March 2010 to formulate the “Grand” Challenges to Global
Mental Health project.
The panel consisted of a scientific advisory board from the US National
Institute of Mental Health.
The panel listed 25 grand challenges including biological, social and
genetic factors that needed to be identified and tackled.
They argued that MNS disorders constituted 14% of the global burden of
disease surpassing cancer and cardiovascular.
The main framework for the project utilised a narrow “medical” model
for understanding mental distress that emphasised treating mental,
neurological and substance- use (MNS) disorders through improved
understanding of the brain, its cellular and molecular mechanisms
The main problems with adhering to the Grand Challenges
proposal:
1. Concerned about the approach of the Delphi panel. The data on
which the Delphi panel bases its recommendations is also
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questionable and could grossly exaggerate the global burden of
mental disorders.
2. The focus on “molecular and cellular mechanisms” in the brain
for the complex problems of living ignores the experiences of
ordinary people and the different settings in which mental
health problems manifest.
3. The recommendations overlook indigenous healing, social
support networks, rights-based organisations and family
support.
4. The assumption of a global norm for mental health and the idea
that deviations can be subsumed within a simplistic biomedical
framework is restrictive and disconnected from the real-lived
experiences of potential service users.
5. Mental health services should not be dependent on funds
driven by pharmaceutical, insurance and other industries with
potential conflicts of interest.
4
MENTAL HEALTH POLICY IN INDIA- UNPACKING THE ‘RIGHT
TO MENTAL HEALTH CARE’
Introduction
This paper is an attempt to foreground the contradictions
inherent in different policies related to mental health and
promotion viz., the NMHP, the UNCRPD, the proposed National
Health Policy (NHP) and the Mental Health Care Bill (2013). The
paper is a call to shake this status quo by examining critically
the continuing ‘medicalisation’ and ‘individualization’ of mental
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illness whereby ‘distress’ is being continuously diagnosed as
‘illness’ stripping the ‘agency’ of suffering individuals.
National Mental Health Programme (NMHP):
The first one to be rolled out in India was the National Mental Health
Programme (NMHP) in the year 1982.
The NMHP has failed to address the social determinants of mental
health and illness through inter-sectoral engagements.
There is little data on community mental health from a community or
developmental perspective.
Prevention and promotion’ of mental health has always been a policy
objective through the National Mental Health Programme 1982, ground
level practice has focused on mental illness and tertiary care
treatments.
United Nations Convention on Rights of Persons with Disabilities (UNCRPD):””
The UNCRPD adopted on 13 December 2006 at the United Nations is
intended as human rights
The aim of changing attitudes and approaches to the persons with
disabilities.
Article 26 of the UNCRPD states that:
“States Parties shall take effective and appropriate measures, including
through peer support, to enable persons with disabilities to attain and
maintain maximum independence, full physical, mental, social and
vocational ability, and full inclusion and participation in all aspects of life.
To that end, States Parties shall organize, strengthen and extend
comprehensive habilitation and rehabilitation services and programmes,
particularly in the areas of health, employment, education and social
services”.
Article 28 states:
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“States Parties recognize the right of persons with disabilities to an
adequate standard of living for themselves and their families, including
adequate food, clothing and housing, and to the continuous
improvement of living conditions, and shall take appropriate steps to
safeguard and promote the realization of this right without
discrimination on the basis of disability”.
UNCRPD has thus brought about a social perspective about mental health
replacing ‘mental illness’ with a forward looking term of ‘psychosocial
disability’ drifting away from the earlier biomedical model of mental illness.
Yet, how far it would be implemented in letter and spirit in India remains to
be seen.
Mental Health Care Bill (2013):
The Mental Health Care Bill, 2013 piloted by the Ministry of Health and
Family Welfare, Government of India is intended to replace the Mental
Health Act, 1987 to push forward reforms in the mental health sector.
The Bill has narrowed down the scope of mental health care to merely
increasing access and availability of psychiatric facilities and medicines
free of cost.
This is far from what is envisaged in the UNCRPD which exhorts mental
health professionals to recognize and address the social barriers to
wellbeing and to design disability-sensitive mental health programs
The Bill further states that “Mental illness of a person shall not be
determined on the basis of,––
(a) political, economic or social status or membership of a cultural, racial
or religious group, or for any other reason not directly relevant to
mental health status of the person;
(b) Non-conformity with moral, social, cultural, work or political values
or religious beliefs prevailing in a person’s community.”
Draft National Health Policy (2015):
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A preliminary survey of the proposed National Health Policy reveals that it
has also not been able to conceptualize mental health in its psychosocial
aspects; it is silent about addressing the root problems of social inequality,
injustice and other deprivations that give rise to distress. The focus has
been on telemedicine linkages, integration with primary health care, easy
access to follow-up medications and increasing access to mental health care
services by increasing the number of mental health professionals to fill the
gap.
Medicalization and individualization of distress:
“Mental illness is a brain disorder”.
The disadvantaged people’s attention is deflected from the deprived
socio-politico-situation in which they are in, towards their supposedly
compromised brains.
Every distress arising out of a person’s compromised social environment
is termed as illness and treated with psychotropic drugs reinforcing the
false notion that pills can cure life’s ills.
Disability scholars like Mehrotra (2013) have drawn attention to the
need for a social paradigm of mental health that frames distress as not
just rooted in one individual but as affected by the micro and macro
forces surrounding the person.
Reducing discrimination against sex, caste, disability and socioeconomic
status is an important aspect to reduce mental disorders.
Poverty and unemployment are both causes and effects of disability.
Pharmaceutical companies add to this by employing disease awareness
programmes.
All these studies draw attention to the need for a holistic approach
which is rights based. For this to materialize there is a dire need to shift
the lens to asocial model of distress and to redefine mental health as
entirely different from physical health which cannot be simply reduced
to the brain.
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5. Mental Health services during Natural Disasters.
Dr. K. R. Antony
Background:
A social activist was visiting a coastal village in Orissa post Super-cyclone
in 1999.
The level of depression any victim of Natural disaster can go into.
Often it is unrecognized and not acted upon by the relief workers in
many natural disasters due to low priority and due to lack of technical
experts to intervene.
These hysterical blindness and deafness can be considered an escape
mechanism for a traumatised mind.
Facility:
Relief Commissioners and their government staff as well as voluntary
organizations get busy with setting up relief camps, telecommunication
networks, power supply, approach roads, shelter camps, community
kitchen and toilets. Provision of drinking water, food, medical aid and
prevention of communicable diseases all get priority, but not mental
health needs of the survivors and victims of disaster.
Lacking behind:
Many of the states do not have even absolute minimum number of
Psychiatrists and clinical psychologists in their government service. The
nearest medical colleges also do not have enough persons on pay roll to
satisfy even the MCI Inspection teams. No wonder mental health needs
of displaced communities in relief camps are ignored or kept as last item
in the priority needs.
The fundamental Principles of PFA:
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Handbook of International Disaster Psychology-Practices and ProgrammesGilbert Reyes and Gerard Jacobs 2006” are as follows:
1. Protection
2. Social support
3. Arousal reduction
4. Assisted Coping
5. Supervision
6. Helping the Helper
Conclusion:
Psychological needs of displaced communities in transient shelters and
victims and survivors of natural calamities living in their homes are
seldom addressed systematically by government or international donors.
Often it gets low priority and last attention by relief workers and civil
society organizations.
This also reflects the extremely inadequate training in mental health
given to undergraduates in the Indian medical curriculum.
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6. Pebbles from a lonely beach-- Jagannath Chatterjee
Introduction:
What people with health issues go through has never been fully
described in any medical textbook, cannot be mapped through clinical
tests, is not subject to rational thinking, and does not limit itself to the
label flung at the patient in the form of a diagnosis.
Health depends upon how the authorities or experts understand it.
If the understanding is correct it culminates in health and happiness. If
the understanding is partial or improper suffering spreads like the
plague.
Can we separate health issues on the basis of which part of the body is
affected?
Conclusion:
We talk of the increasing incidence of mental illnesses and the need for
infrastructure, trained manpower and policies to attend to those who
are affected or who will be affected in future.
We talk of the increasing incidence of mental illnesses and the need for
infrastructure, trained manpower and policies to attend to those who are
affected or who will be affected in future.
7. Response to Bagchi and Chaudhuri-- Suicide and the Law in India
Background:
The current discussion of suicide in India arises amidst extensive social
churning.
The developments are of varied origin and come together in a period of
rapid change.
In two Hyderabad universities with a student population of under 3000,
there have been 7 suicides of Dalit students over the past two years.
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Farmer suicides in Andhra Pradesh in the period 1999-2012 have been
recorded at 35898.
A total of 135,445 persons committed suicide all over India in 2012.
Today, suicide is understood to be a response of protest and desperation
against violence (familial, sexual, social or institutional); loss of respect
and social discrimination; and falling prey to a debt trap.
Pressing charges against a survivor of suicide is almost unheard of. But
criminal investigations are often launched to probe the much more
serious crime of abetment to suicide by those in social and familial
relationships with the deceased (or survivor).
When the bill, in its eagerness to ameliorate the patent injustice of
charging a survivor with crime categorizes suicide as an act of a
‘mentally ill’ person, it undercuts the concrete social gains made by
these movements.
A blanket presumption of mental illness on suicide attempts will
implicitly influence unreported cases of attempted but failed suicide,
which may be 20 times the number of reported cases.
In many cases familial and social relations that lead to the unbearable
tension realign themselves to correct the situation and relieve the
pressure.
If social attitude follows the law, this will result in the suicide survivor
being taken for psychiatric treatment and medication.
On the one hand, the normal corrective process will be abandoned and
the distress individualized as ‘mental illness”.
Current situation:
They argued that MNS disorders constituted 14% of the global burden of
disease surpassing cancer and cardiovascular.
An estimated 10-20% of young people worldwide experience mental
health problems, leading to related health and social problems such as
55 | P a g e
adverse school performance, delinquency risky sexual behaviour and
substance abuse with suicide being the third leading cause of death
among young people.
The suicide death rate in India is among the highest in the world with
40% of Indian suicide deaths among men and 56% among women
occurring in the age group 15-29 years.
There are just 3,500 psychiatrists in India. Three psychiatrists per one
million people in India compared to 100 in Australia or 150 in developed
countries.
THE PROBLEM WITH SOCIETY:
Stigma and discrimination because of mental illness are still major
obstacles to the development of mental health services, to the
rehabilitation of those impaired by mental illness, and to an investment
into mental health research.
Conclusion:
We conclude this response by simply pointing to the other side of the
picture in jails, police and judicial custody, and unfortunately in mental
health institutions too.
There is a violation of the rights of inmates in cases where suspicious
deaths are passed off as suicides.
These institutional environments are sometimes known to drive inmates
to suicide through physical torture, humiliation and loss of self-esteem,
as a result of taunting, heckling, and inhuman treatment by other
inmates or people in authority.
Thus far these have been seen as a human rights violation, but they will
become invisible if the law looks at all suicide as driven by mental illness.
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8. Small steps - context, learning and models of community and
primary mental health in North India
By Kaaren Mathias
Background:
Mental health – both illness and wellness are too entangled and
complex, to be tidily described with neat packages.
The boundary between mental distress and a mental disorder is blurred.
Country needs models of mental health care that are centred in
communities, appropriate to cultural contexts, work actively to address
mental health determinants such as employment and social inclusion,
and emphasise psycho-social interventions which are more durable and
have few side effects than drug therapy
At the same time, perhaps 90% of people in India with mental disorders
do not have any option of access to allopathic (bio-medical) care (World
Health Organisation, 2011).
People with mental distress (PWMD) in Low Middle Income Countries
(LMICs) include mental health’s low ranking in a hierarchy of needs
among populations who don’t have access to sufficient food, grossly
under-resourced mental health services.
The District Mental Health Plan (DMHP) launched in India in 1996, has
been imperfectly and incompletely implemented across the country
PWMD:
PWMD find social sanction, initiate further help-seeking and find support
and healing in a supportive and non-threatening environment of some
traditional healers and shrines.
PWMD, particularly those with severe mental disorders experiences of
social exclusion and live with significant stigma and discrimination.
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Emmanuel Hospital Association
One of the largest non-profit providers of health services in North India.
Framework for community health prioritises community participation
and empowerment, and seeks to address health determinants using a
rights based approach.
Most deprived districts with 20 community hospitals providing clinical
services and over 40 community health projects.
Context analysis:
1. Help-seeking efforts are monumental.
2. PWMD and their families are particularly vulnerable to the very worst of
the Indian private medical system.
3. There is very little knowledge about mental illness. E.g post-partum
psychosis may be understood by some as contagious, by others as a
‘drama’ to avoid work.
4. PWMD have a dominant experience of social exclusion which ranges
from more subtle distancing and negative judgements to verbal
violence.
5. PWMD have a hugely increased premature and preventable mortality.
6. There are millions of people in North and rural India with essential no
access to mental health care.
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Framework:
EHA - Model of care for people with mental distress:
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Wellness skills
Talking therapy - support
group, therapeutic
group, counselling and
CBT, IPT
Medicines - needed for some
people with common mental
disorders and most people
with severe mental disorders.
Part of this step is
acknowledging the power of
Dua and Dawa (Prayers and
Medicines) for many PWMD
Self-care and agency
5 Kadam (steps)
5 steps to wellbeing :
Summary:
There is huge capacity to bring healing and transformation for many
thousands of PWMD and families who are currently isolated without
care or support.
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There are also significant risks of doing harm if we use models of care
that do not acknowledge the cultural context and promote mental
health care exclusively dependent on pharmacology and Western
biomedicine.
Learning from field visits:-
1. SNEHADHAN:-- The main aim of SNEHADHAN is to provide needed care to
the sick, with a preferential option for the people infected and affected
with HIV/AIDS . It was establish on july 1997. The outstanding
infrastructure and service delivery of the multi-disciplinary team have
been duly acknowledged by the, National Aids Control Organization
(NACO), Karnataka State Aids Prevention Society (KSAPS), and Karnataka
Health Promotion Trust (KHPT). It also provides training for Doctors,
Nurses, Health Care Workers, Social Workers and Medical Students on
management of HIV/AIDS. The best service delivery practices Snehadaan
developed have been replicated in many care and support centres
across the country. At Snehadhan all the components of health are met
like Nutrition, socio psychological support, family support, treatment of
ART, provide Medical and nursing care, outreach programme, job
placement, networking with other NGOs and care centers, and
Physiotherapy & Personal Care. This is a tertiary center was people are
brought in for a human dignity and eventually ends up their life over
there. There is also a center for the children who are infected or affected
with HIV/AIDS. Due to discrimination these children are kept there for
Education and Care, and some children are according to the need other
activities are given.
2. VIMOCHANA:-- Vimochana is to strengthen women’s resistance to
violence both within the home and within communities, cultures and
politics. To make families, communities and the state responsible for and
responsive to the growing violence against women. To create alternative
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spaces and for a public debate and dialogue to bring about attitudinal
and institutional changes in our society vis-àvis discriminatory attitudes
towards women. To make visible the deeper connections between
increasing violence in the personal sphere of the home and the
increasing brutalization of the larger public policy. There is a Gender bias
against woman in the society and they are the victims of physical
violence,(dowry, and sex abuse, ill treatment at home). Burnt cases are
often neglected even in the hospital wards, no proper treatment is given
and normally they end their life at the hospital. Vimochana is fighting
against such atrocities against women. They also give counselling and if
necessary go to the court for these women’s issues. They teach them to
be self-supportive and self-caring. Vimochana grew out of the need for a
public forum that would stand for organized resistance to the increasing
violence on women and would be assertive in challenging the pervading
apathy to the problems of women in the context of larger structures of
violence and power.
3.
Foundation of Revitalization Local Healing Tradition (FRLHT)
The aim of FRLHT is to revitalize Indian Medical Heritage. The Vision of
FRLHT is to enhance the quality of medical relief and healthcare in rural
and urban India and globally by creative application of our rich medical
practices, action oriented research, education, training and Community
services based on India's Traditional Health Sciences. One can treat
almost 70% of the disease with the herbs. In a family some herbal plants
can be planted and this can be a source of remedy for some disease like
could, stomach pain, vomiting, diarrhoea, skin problems, diabetes and so
on. We don’t have any written evidence of how these medicines are
used and these medicines are known as grandmother medicines. It
would be good if this information can be shared with local people
especially traditional healers so that this could be an alternative way of
treatment. Each family could also have a small herbal garden in their
own homes.
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FRLHT are basically acting on few themes which are given below: Conservation of natural medicinal resources
Information technology and traditional knowledge
Bridge between traditional knowledge and science
Scientific repositories of natural resources
Revitalisation of folk healing systems
Research hospital
A herbal public ltd company owned by rural women and small farmers
Botanical repository
Rural health security
Scientific research
Rural livelihoods
Clinical services
Literary research
Educational Innovation
Conferences/workshops:-1. NATIONAL BIOETHICS CONFERENCE:It was Fifth National Bioethics Conference.
Theme: Integrity in health care practices and research.
Date: 11-12-13 December, 2014
Venue: St. John's Medical College Campus, Koramangala, Bengaluru
The conference aims to explore various sides of corruption and examines the
limits and dimensions of integrity for health professionals and the health
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system. In addition to the keynote addresses, there will be paper and poster
presentations and workshops which will be selected by a scientific committee.
There will also be screening of films centred around the conference theme.
“The Dolls Speak” is a special exhibition at the conference which is guaranteed
to enlighten and enthral. The theme of the Fifth NBC 2014 is "Integrity in health
care practices and research, and would cover the following sub-themes:
a. Integrity and upholding trust of patients in medical care;
b. Ethical imperatives of integrity in public health practices and health
systems;
c. Integrity in health care research (misconducts-plagiarism, data
fabrication/ falsification, etc.)
d. Conflict of Interest in health care practices and measures needed,
e. Curricular frameworks in ethics to ensure integrity in healthcare, public
health and research;
f. International symposium on December 13 on Corruption in health care
and medicine.
Six plenary sessions, including those in the International Symposium will
feature 18 keynote addresses and a panel discussion by well-known national
and international experts on the theme and sub-themes of the conference. In
each plenary session, sometime will be available for questions and discussion.
In addition, the Fifth NBC 2014 was also having scientific sessions where
individuals and groups working in the field of bioethics was able to make
presentation of papers (both oral and posters) and workshops on many
relevant topic in the field of bioethics . There were Parallel group’s sessions,
presentations and workshops organised on the first two days of the conference
and one joint parallel groups session for oral paper presentations and
workshops was organised on the third day.
2. Medico Friend Circle:
It was held in Pune.
20th to 22nd February
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Theme: Mental Health Rights and Care
MFC is a non-funded group of members from various backgrounds from across
the country – Public health professionals, medical doctors, nurses, health
activists, researchers, students and others. Annual Meets of MFC have
contributed to many debates and discussions on a range of health related
issues, for example, primary health care, universal health care, nutrition,
Occupational health, communicable and non-communicable diseases,
women’s health, medical education, etc. MFC (Medico Friend circle) initially
started with people who were of medical background. But later on people of
different background also joined this group thus a variety of social and health
interests were added to it.
3. Young environmental researchers meet:-A national level meet was organised for early career environmental
health researchers on the 29th and 30th of January, 2015 at Indian
Social Institute, by SOCHARA, Bangalore. This unique event provided a
platform for open discussion on the sector. Twenty six individuals
representing 12 institutions from 8 states participated. Among those
who were unable to attend, some created video-presentations to share
their work and reflections in the field. The participants were identified
through multiple methods such as snowballing, journals and institutional
websites. The identified individuals interacted deliberatively as a group
over emails to draft the agenda for the meet, which was broadly
conceptualised as a space for sharing and reflection. Over two days, the
participants presented about their research work and challenges, and
also about larger environmental health concerns in their respective
states. Top environmental health priorities included issues such as waste
management, health impact assessment, sanitation, equity and
sustainability-oriented developmental decision-making, environmental
health officers (human resources), organic farming, environmental
education, etc. The themes of research and action ranged from climate
change and health systems, to silicosis, industrial pollution and
sanitation. The presentations depicted an array of research methods and
philosophies, and also a passion for translating research to action. It was
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observed that some environmental health concerns are cross-cutting,
such as air pollution, sewerage systems, and waste management which
were affecting all urban areas, and poor access to water and sanitation
which was affecting rural areas. Besides this, issues such as fluoride
contamination of water were noted in Karnataka and Madhya Pradesh,
silicosis was noted among some communities in Madhya Pradesh and
Rajasthan, and pesticide associated farmers deaths was noted in
Maharashtra, Andhra and Bengal. Issues related to inter-state migration
which is affecting all areas were discussed as well. Policy provisions and
constraints, and innovative community-led and government supported
solutions were also discussed.
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My Research study report:
To analyse the maternal health seeking behaviour
Aim: - Pre and post maternal population in medical college at Chhattisgarh
state.
Objective: Identify the reasons for registering late ANC healthcare at later stage.
Identify the cultural practices related to pregnancy and deliveries.
To document preferences for seeking healthcare for pregnancy and
delivery issues from other systems of healthcare various health systems.
Background:India, which accounts for the largest number of maternal deaths in the world,
is unlikely to achieve the fifth Millennium Development Goal of reducing
maternal mortality to 109 per 1,00,000 live births by 2015. Only three states in
India have so far managed to reduce maternal mortality rate to less than 109
deaths per 100,000 live births—a millennium development goal (MDG) for
2015. The recently released report of the Registrar General of India shows that
India's maternal mortality ratio (MMR) decreased from 212 in 2009 to 178 in
2012. Assam recorded the highest MMR of 328 and Kerala lowest with 66. The
MMR in southern states fell 17% from 127 to 105, closer to the MDGs. Assam
and Uttar Pradesh/Uttarakhand were the worst performing states, with an
MMR of 328 and 292, respectively. Kerala and Tamil Nadu have surpassed the
MDG with an MMR of 66 and 90, respectively. Infant mortality declined
marginally to 42 deaths per 1,000 live births in 2012 from 44 deaths in 2011.
Madhya Pradesh registered the highest infant mortality at 56, and Kerala the
least at 12. Among metropolitan cities, Delhi, the national capital, was the
worst performer with 30 deaths per 1,000 live births in 2012. One in every 24
infants at the national level, one in every 22 infants in rural areas, and one in
every 36 infants in urban areas still die within one year of life. There seems to
be some good news for Chhattisgarh as the state has finally witnessed a steep
decline in the infant mortality rate (IMR) and Maternal Mortality Rate (MMR).
The IMR (per 1000 live birth) has been recorded at 48 and the MMR (per lakh
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live births) at 263.
Introduction:The maternal mortality rate (MMR):The annual number of female deaths per
100,000 live births from any cause related to or aggravated by pregnancy or its
management
The MMR includes:
Deaths during pregnancy, childbirth, within 42 days of termination of
pregnancy, irrespective of the duration and site of the pregnancy, for a
specified year.
MMR (per lakh live births) at 263 in Chhattisgarh: Wide gap in the maternal
health seeking behaviour which leads to the huge number of mortality.
Study Setting:-The place where the study has been conducted is Dr. Bhimrao Ambedkar
Hospital .which is the with oldest medical college of Chhattisgarh state. It also
consist of largest Gynaecology and obstetrics department in state. In this
medical college more than 55 deliveries takes place on daily basis. It is a
tertiary care unit. The Patient come for check - ups are usually belonging to low
financial and literacy background.
Social demographic profile:The majority of women who came to hospital were of Low literacy level.
Belonging to poor financial background Living in joint family and are
dependent on husband for livelihood.
Situational Analysis:68 | P a g e
12% of women belong to 15-19
15
age group and they were already mothers
mothers. 4%
of women belong to 15-19
19 age group were pregnant with their first child
child. In
total, 16% women 15-19
19 have begun childbearing.
childbearing Son preference, though
reducing, still persists. 76% of women received two or more tetanus toxoid
injections. Among women who received ANC.
ANC Less than two-thirds
thirds had come
for their weight, blood, or urine taken, or blood pressure measured
measured. Threefourths had their abdomen examined in hospital. 36% were told about
pregnancy complications.. 56% of general population is married and 59% of
pregnant women are anaemic
anaemic.. So, are pregnant women getting iron and folic
acid (IFA) supplementation free of cost. Amongst the pregnant population 9%
of live births in the past 5 years were delivered by C-section.
C
16% of ffirst births
are delivered by a C-section
section. Among women who received ANC
ANC. Less than twothirds had come for their weight, blood, or urine taken, or blood pressure
measured. Three-fourths
fourths had their abdomen examined in hospital. 36% were
told about pregnancy complication.
omplication. 56% of general population is married and
59% of pregnant women are anaemic. So, are pregnant women getting iron
and folic acid (IFA) supplementation free of cost.
cost Amongst the pregnant
population 9% of live births in the past 5 years were delivered
delivered by C
C-section.
16% of first births are delivered by a C-section.
C
Birth intervals:
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Research Design
Method opted – Mixed
Mixed methods research takes advantage of using multiple ways to explore a
research problem.
Basic Characteristics
Design can be based on either or both perspectives. Research problems can
become research questions and/or hypotheses based on prior literature,
knowledge, experience, or the research process. Sample sizes vary based on
methods used. Data collection can involve any technique available to
researchers. Interpretation is continual and can influence stages in the
research process.
Data collection:-Sampling
Random selection for case history process. The Sample size is 60. And from
that 60 women there is filtered group of 14 women who were taken personal
interview which was purposive in nature.
Purposive Sampling (Selection) Benefits :
Wide range of qualitative research designs . Range from homogeneous
sampling through to critical case sampling, expert sampling, and more. Provide
researchers with the justification to make generalisations from the sample.
Useful in these instances because it provides a wide range of non-probability
sampling techniques for the researcher to draw on
Data Collection
Data for Quantitative analysis :
Patients Records from the medical college
Data for Qualitative analysis :
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In-depth interviews of 14 women who came to medical college for ANC. set of
questionnaires . lots of personal information came through interview
key findings :-Reasons for late ANC
Majority of women said that getting ANC from somewhere else. Some women
also said that they were busy. Some came with saying that their live far away.
Few women said they were lazy to travel and come for such a small thing like
ANC when they don’t have any problem associated with pregnancy. Few said
they Did not know where the ANC clinic is located. Some She had children
before so they couldn’t leave them and come . few said Doctors and nurses
don’t pay attention when early when they came to them. Few said that they
Got tired of ANC during past pregnancies. Some women said that they feel this
was the right time to come.
Analysis - Cultural practice related pregnancy care:-previous delivery details : reflect the consciousness of the women regarding
conception and family planning
ANC care
Home deliveries: Distance and cost to the health facilities matters for them.
Need for women to be close to their other children and the housework. Few
said the wish to follow traditional birth practices. Attitudes, quality of care and
care practices at the health facilities. Few had problem with Episiotomies, lack
of privacy and the presence of male staff
Hospital deliveries
Women feel secure and safe in case of emergency with presence of trained
doctors. Emergency care system are available within instant such as ventilators
etc.
Analysis:-71 | P a g e
• Experiences of seeking health care from other systems of medicine:
• By doctors for 72%
• By ANMs and other health personnel by 20%
• By dais or TBAs by 8%
• For only 20% of home births was there any postnatal care.
No significant difference between participants living in rural and urban
communities
• Reasons for not having sufficient access to health care :
• Transport/distance to health care facilities
• Financial constraints
• Problems with the service
• Provision and availability of medication
• Number and quality of the staff,
• Facilities (including equipment)
• Hours and capacity to attend patients
• Urban and rural participants preference differed significantly for a health
care provider
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Discussion : Maternal mortality is unacceptably high in developing countries
including India. Death of mother is a tragic event. In practical life, it has a
severe impact on the family, community and eventually, the nation. The young
surviving children left motherless,
otherless, are unable to cope with daily living and are
at an increased risk of death. Reduction of maternal mortality is the objective
of MDGs, especially in low income countries, where one in 16 women die of
pregnancy related complications
complications.There are certainly
tainly need for improvement.
Simply by building hospital wont work at all.untill or unless you wont make
people awre about their health. Some how the people are not analysis the
heath conditions or the health factor is not 1st at their priority list. As a
developing state chhattishgarh have got still bulk of people who are poor so
the trasport and treatment fare they cant effort also. Being a tertiary care
there is more load of poatient coming for small issues which can be taken care
at the level of PHC or CHC.
Conclusion: The MMR in our study is higher than the national averages. Most
deaths could have been avoided with the help of good antenatal, intranatal
and postnatal care, early referral, quick, efficient and well equipped transport
facilities, availability
bility of adequate blood and blood components, and by
promoting overall safe motherhood. To reduce the maternal mortality and
morbidity the main thrust should be on implementing basic and
comprehensive emergency obstetrics care. Analysis of every maternal death
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through maternal death audit, either at community level (verbal autopsy) or at
the institutional level should be carried out. It will help in identifying the actual
cause of maternal deaths and deficiencies in health care delivery system that
might contribute in formulating preventive measures to reduce pregnancy
related deaths.
Recommendations are formulated for :
Infrastructure investments in rural communities. Quality of health care and its
perception. Improvement of household socio-economic status . Further
research on the consequences of delay in health care seeking behaviour.
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References:http://nrhm.gov.in/images/pdf/media/publication/Annual_Report-Mohfw.pdf
http://health.cg.gov.in/ehealth/NFHS3_DLHS3Report/DLHS-3Chhattisgarh.pdf
http://health.cg.gov.in/ehealth/CRMReport/Chhattisgarh2ndCRMReport.pdf
SHRC
Thanks
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(2012 2015) and is
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