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A Report on the Community Health Learning
Experience
REACHING THE UNREACHED: A JOURNEY IN COMMUNITY HEALTH
JULY 2013 to JULY 2014
Sabeena Lyngdoh
Fellow, SOPHEA- SOCHARA
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Contents
Acknowledgement
The beginning of my journey
Learning objectives
Key Learning from collective sessions
Learning from the field visits and workshops
Self reflection
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Acknowledge
I warmly thank you to Dr Thelma and Dr Ravi for giving a great opportunity to join as a fellow
in this learning programme and open my thoughts about community health. The knowledge I
received from here had enriched and developed my skills to work in the community.
I would also like to thanks all the facilitators which have seen me growing day by day and this
would not be possible without their help and support
My gratitude to all the field mentors Mr Ameer, Mr Francis, Mr Lepikho, Ms Dari, Mrs Sandra,
Mr Carmo, Dr Ravi D‟Souza and all the field staff who has helped me during my difficulities
and show the right direction on how to achieved our goals.
I thanks to all my co-fellows whom I start my journey and walk till the end and supported my
strength and weakness
Thanks to all the working staff of CHC Hari, Tulsi, Swamy, Ms Maria, Kamala Amma, Joseph
all were welcoming and helpful.
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Why I joined CHLP
I always dream of myself that I one day I will be someone and be successful in life, but as years
pass by my aim and ambition keep on changing where at one point of time my educational status
was very low though I was lost on the way to achieved my dream goals I was an optimistic
person didn‟t look back and move forward in life. My best day in life is when I joined Master in
Social Work where I get to explore things around and get to know about the community.
Then came to SOCHARA joined the fellowship programme made my entire world change and I
must say that am very bless to come to Bangalore and be a part of community health learning
programme. Before joining CHLP I had limited knowledge about Public Health if I think back it
ends till medicine and hospitals.
The word “Community Health” attract me the most when I came to know about the fellowship
programme and tried to think hard the different between community and community health
because what we learned in MSW is only community not community health.
I was keen to learnt about community health because some way it related to social works in the
way to serve people but the strategies and approach to the community are different.
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My objectives on CHLP
To learned about the whole process of this CHLP
To learned about the community
To learned about the approaches and strategies towards the community
To learned about NRHM goals and frameworks
Key learning from collective sessions
Social determinants of health – I was clueless on what are this big words meant to be but after
the session was taken I just felt keen interest to learn more about it. A social determinant of
health covers the housing, nutrition, water, environment, education, early marriage,
unemployment, poverty, alcoholism almost everything that affect health of a person.
Documentary of Ramakka story give us a clear idea on the various factor of social determinants
of health from the child health to nutrition, poverty, distance, lack of awareness, believes,
ignorant all the other factors lead to the dead of the child of Ramakka. The whole learning of
process of community health are based on social determinants of health and I have learned how
to look towards the community understand their problem and be as a facilitator to helped them.
Quantitative research
Research has been an important subject during master‟s degree but it was difficult to memorize
everything because it was totally new subject for me and had a tough time to consume it
everything about the subject. We had a session with Mohammad sir on quantitative research he
explain like research do not arise when there is one solution to the problem, only if there is one
or more solution than a comparison can be done and find out the appropriate solution to a
problem than research could be conducted. Quantitative research is classified into – survey
research, correlational research, experimental research, causal comparative research.
He also taught us the quantitative goal is to generalize „the truth‟ found in the sample population.
Generate the hypothesis prove with the hard factors/data inductive, the advantages is like it
provides estimate of the population at large, provides extensiveness to attitude held people,
provides result which can be condensed to statistics, allows for statistical comparison between
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various groups, has precision, is definitive and standardized, measures level of occurrence
actions trends etc., indicates the extensive of attitudes held by people. Common approaches to
quantitative research are surveys, custom survey, mail/ email/internet, telephone, self
questionnaire, omnibus, correlational, exploratory, experimental, descriptive and trend analysis.
Quantitative research has been taught us during my master‟s degree but the detail information I
received from SOCHARA is un comparable I had a better understanding of research here and the
methods to its approaches the steps of quantitative research are identifying the problem, collect
and evaluate existing information i.e. literature review, formulate research objectives and
hypothesis, identifying the study subjects, design and develop tools. Mohammad sir also talk
about validity meaning is a particular characteristics of that reflects what is suppose to reflect
and depends on the sensitive and specificity.
Qualitative research
Qualitative research is a new term for learning because we never had sessions on qualitative
research before, I learned the qualitative research is more useful to know the in depth problem of
the community the strategies is different from quantitative research the sample size is small and
yet we can get lots of information from the people and analyzed it later for knowing the problem
at the grass root level. One of the approach of qualitative research is in-depth interview uncover
the deeper incidence, insight story, we can get into stream of conscious, empathetic
understanding and good relationship with respondents. Focus group discussion is another way to
know the problem of the community and get the way as to where exactly the problem lies and
how to tackle with the problem.
Paradigm shift
Paradigm means world view the session helps me to learned on how we look and take upon
things like
Patient as person
Population as society
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Disease as health
Providing as enabling
Professional control as demystification
Drugs technology as knowledge/social process
Medical pluralism
The medical pluralism session was taken by Dr Ravi explain the fellows that modern medicine/
allopathy/ western medicine is taking control alone in the health system in India they have been
trying to monopolise the market. This topic has given me broader look that we should have
medical pluralism in the country like the traditional medicine provide by local healers and
traditional birth attendant must be encourage and get recognize or AYUSH as an alternate
medicine or make it optional for the people to choose which treatment does they prefer rather
than only allopathy medicine. The delivering system at the hospital has made it mandatory for
the mother that they are helpless for not going to the dias for delivering the baby but in reality
the dias performed well than the doctors in the hospitals the care provided by the dais at home
during the delivery and after the delivery is a great job that also without being paid.
System thinking and Institutional design
Session conducted by Sam Joseph helped to learned about what is community, is a group of
people who have an understanding and share a one particular issue.
I learned how to approach the community by not going in the community as an expert but we go
and learned from the community people. System has parts/ boundaries/ purpose/ hierarchy he
explain us by giving an example of a tree its boundaries are the roots, purpose to bear flowers
and hierarchy are the branches.
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JOINT USE
Low
Easy
E
high
Private good:
Club/ association group good:
Chalk, pen
Cricket stadium
food, private doctor, can
cinema
Common pool resource:
Public good:
Pasture, village pond
Road, hospital, school
Fish in the sea
Air, national radio
X
C
L
U
S
I
O
N
ADICO
A - Attributes of membership, I – aim/goals/purpose, C- condition of coming together D –
Difficult
deontic O – or else
This ADICO implies a community coming together and work for the action it‟s a kind of
working rules for the movement.
Casual loop diagram – was the best way to learned about the community‟s problem and it‟s a
people participation they know it better were the problem lies and what are the solution to it.
Social mapping- help us to identify the major landmarks of the village and if we take any
particular issue it‟s the easiest to reach the respondent house for example if we want to know
under 5 children in the community social mapping is the best way to give us direction.
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Occupational health
I find the session very interesting moreover it‟s a new topic for me to learn about it I think as a
community health we should we aware of all rounder health issue happening in the country. We
hardly talk about the health of the people working in factories or anywhere else, Adithya talk
about the dalits people who use to clean the dirty pit holes in the city down the tunnel and if
death happen in case of accident but no one is takes the responsibility of the death. People
working in chemical factories has also bad health condition because they never take protection to
cover themselves when the gas is tested and the waste coming from the industries is affecting the
people in general through water or air.
Basic type of Non Government is charitable
Society – more formal, transparent and they are broad have bi-laws of governing bodies
Trust – non formal, it’s more like family business and less transparency in financial and activities
For a good NGO frequent meeting is important, monthly meeting is a must because all these
more responsibility, accountability, transparency in the NGO and external must come and
evaluate the whole process.
Chander – urban health
Dr Ravi – inner learning checklist
Who is urban poor?
Street Children
Unorganised labour
Pavement dwellers
Recent rural migrants
Sexual minorities
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The uncared aged
People with disabilities and mental ill health
Urban health Challenges
Inadequate housing,
Unsafe water,
Poor or non existent sanitation,
Unemployment or Underemployment
Various pollutions affecting the
environment.
Accidents including occupational hazards
Social conflict including virus of communalism
Where do they live?
Most urban poor live on places that are overcrowding with poor sanitary conditions, not mean
for human habitation lacking facilities such as water supply, toilet facilities, and place for waste
disposal. Some of these places are permanent and others are temporary, (UN Habitat 2003).
The location may be classified as follows
•
Slums located around industries
•
Slums located around residential areas
Slums located around commercial areas
Checklist
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1. Values
Equity
Gender
Rights
Quality
Integrity
2. Social / communication skills
Class
Caste
Gender
Hierarchy
Stigma
3. Social action
Empathy
Listening
Leadership
Conflict resolution
Supportive supervising
4. Learning skill
Self learning
Learning facilitation
Group discussion
Communicate
Creative
Globalization
Prasanna took a session on globalization he scratches from Alma Ata declaration and said to
have social justice we have to have equitable approach with fundamental rights.
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Components of Alma Ata – nutrition, education, water and sanitation, maternal and child health,
prevention of endemic diseases, immunization, treatment of minor ailments/disease and essential
medicine.
WHO works on equity principle each government pays a funds differently but when it comes to
vote each country must gave one vote not according to the fund i.e. is called social equity logic.
Capital logic works if they give 22$ they should get 22 votes. Like in 1978-98 the US stop to
share the amount in WHO the developed countries starved of funds and it became marginalized.
In 1983 Africa 1st recession balance of payment than International Fund Monetary and world
bank demand the government have to work for them for continuing the funding i.e. called
structural adjustment programme it works as reduced import, increase export (devalue the
currency), reduce budget, user fees, liberalize (leave to the private sector for development),
devalue the currency and health medical care will be taken care by the private sector. After the
recession in 1983 they start with selective primary health care by treating the disease one by one
its 18 programme in total.
Globalization is a global village no borders and no barriers. Cooperate led globalization this was
interesting part of it how government is monopoly, inefficiency, low performance so government
is barrier because they put tax on private and never go bankrupt. This means less tax more
private investment, less private more efficiency they will produce more GDP and there will be
more income is called percolation theory.
Health is not a market logic failure because we are not a direct consumer, informative cemetery
and externalities. Health does not follow market logic because health is beyond efficiency so we
need equity and market logic failed because poor or sicker need more care but they are charge
more vis-a-vis rich people goes sometimes but pay less.
Learning from Field visits
Joining SOCHARA has given me a great opportunity to focus on different area and interests. I
was always confused as to what interest me the most because all the health issues seem to be
important and interesting. Different organization visits have shown me the way as to what I want
to focus and performed my fieldwork for the rest of the journey in SOCHARA.
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Snehadaan organization - work with the people living with HIV/AIDS, our one day visit have
taught me a lot on about HIV/AIDS. Learned on how the organization take care of the people
suffering from HIV provide them medical treatment plus healthy food and rooms for them to
stay. I really empathize to the people who are living with a dreadful disease and maximum of the
patient said they got it from their partners, they are being rejected and isolated from family and
friends, thrown out of the house which is very painful scenario if we think about. I had a great
time playing with HIV/AIDS children are very innocent and full of life. One think it motivates
me is that the children knew what they are suffering and why they are having the medication but
still they love their life and each children have aims and goals it is really a positive side to feel
about it gives me hopes to on how to live a beautiful life.
Dommasandra PHC – this is my first visit to PHC in South Indian states and I am excited to go
and had pre concept idea about the PHC would be same as in Meghalaya i.e. it is not working
and it would be just a building. We travel by a bus and walk a few minutes to the PHC, I
observed some writing in kannada and posters on health awareness about tobacco, tuberculosis,
HIV/AIDS etc. we met two ANM they are busy in immunizing the children with a long quene of
mothers with their babies. The ANM lady was kind she showed us the sterilize syringes, band
aids, pain killers, other medicine and the box a kind of refrigerator to keep the medicine for
immunization, tai or mother card is necessary during the immunization for the recording. We met
block extension officer explain us about the population covers is 7 villages and some it happens
that the nearby place where the PHC is not covering people will come for the treatment, she
shared some of the problems and one is the transportation where the staff members of the PHC
never reached on time. The officer was a bit hesitant to show us the health report of the PHC
though she was polite to us but did not share the whole information. For any emergency case the
people have to rush for about 40 kms this is one of the main issue that struck my mind and
cannot imagine how will a severely ill people have to travelled such a long distance. We also
came to know that the doctor was absent during the particular day and the ANM is performing
all the activities and be responsibility towards the patient. I also observed a lady who was in a
labour pain and standing in the door for her call and support. Then we all move to the pharmacy
the pharmacist showed all the medicine available and explain us about each medicine.
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Siddapura slum visit
Usually slums I have seen only in television and movies and heard lot about it, I was extremely
excited to go for a slum visit and get to learned so much from the people and their living
condition. This slum was situated behind the NIMHANS quarters of doctors it was a big area the
houses were attached to each other and it‟s a crowded place. We were divided into groups so we
went some house visits and interacted with them. People were sharing their problem and
difficulties like land eviction, sanitation, Anganwadi center is small, water problem , drainage
system was lacking and lots more. Mostly the women staying in the slum are domestic workers
and men would be drivers or mason. One of the family we interacted the husband died so the
wife have to take all the responsibility along with five children and she is earning 3000 per
month she also shared she was having a difficult time in supporting her family. The environment
of the slum is not fresh and clean open defecation was high because the common toilet
constructed is far from the main population and houses this is the reason people never use the
toilet and they prefer to go and defecate outside. There is also high of people going to private
hospitals than government they feel private hospitals provide better treatment than government
hospitals and they are happy in spending more because the service is good. The people living
slum are having lots of the problem the government want them to move away from here but the
people are trying hard to raise their voice for not letting them go because they feel they would be
homeless in this big city. This slum is a mixed community of Tamilians and Kannada people are
living in this slum but they have a good bond and respect towards each other.
Tamil Nadu visit
One week visit to Tamil Nadu with the Madhya Pradesh group was fun and get to learned lots
about community action for health. We visit Vellore in Dr Chandra organization met the village
health sanitation nutrition and water committee along the panchayat leaders and animators from
the village. I really get inspired by the works in changing the community and empowered
themselves and fight for their rights. For me it was amazing to get and hear all these kind of
stories from the local people it really feels the greatest power lies in the people and nothing is
impossible if they want to bring change for the country. Dr Chandra and her team members had
really worked hard to motivate the people and bring change for the welfare of the community. In
the afternoon we went to CMC (Christian Medical College) Vellore, observed the hospitals they
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have different department for every illness we met the medical social worker she helped us
around to see the whole building of the hospital from OPD to HIV/AIDS testing center, they
have separate compound for leprosy patients, tuberculosis patients, malaria patients covering
with mosquito net around the bed. The hospital was clean and with big environment it‟s amazing
to see all the new things around especially me who did not even think I will get to visit in this
kind of place. Later in the evening we move to Chennai it‟s a 4 hours journey and we stayed in a
hotel, next day we went to golden beach Chennai had a good time with the fellows and MP team
we sat on many thrilling rides and it was one of the memorable day for me. The day after we
went to CHC community health cell unit, Chennai met the working santosh, naresh, suresh,
sudha had a short presentation about the whole process of community action of health and their
approach to the community after that we had discussion on our 4 days visit in vellore and what
was our key learning. It would we first time in my life to see a kind of people‟s health movement
though the project has stop but the tremendous worked they had performed was head off and
inspirational for me.
Association of People with Disability visit
We visited the APD school there were differently able children sitting and playing in the
classroom some kids where talented they like to dance and sing with us, they were all loveable
when they see us they were so happy start hugging and kissing all of us. Children with
locomotors, hearing impair, speech impair and some children mental illness at the early stage of
life, there were more mentally retarded children in the school. Overall it was a great learning by
spending such a short period of time with the children has given me thought of on how to reduce
the growing disability in the country.
Basic Needs India visit
We start the journey in the morning went to visit a slum where BNI and APD are collaborated
with each other, reaching there we went for home visits focusing on the mental health issue of
the community. First house we met a lady who is developing mental illness because of her
husband death she have two sons and the only earner of the family, the second son also has
mental illness and stays at home most of the time. The mother was normal earlier but due to the
sudden death of her husband she stop behaving normal and start taking things in a negative way.
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Then we went to visit another house we sat outside on a mat interacted with her she is unmarried
and stays with her elder sister, she work before in the petrol pump and earned for her livelihood
though she has got mental illness but her way of living is very positive may be she goes out of
the house and interacted with lots of people which helped to bring change in her personality and
stay healthy. After the home visits we went to BNI office met Guru and Mani relax for 10
minutes introduce ourselves and Guru presented on the whole process and the works of BNI
about goals, achievements and challenges. We had a very interactive discussion lots of questions
were being raise throughout the presentation and also learning from out slum visit on mental
issues we had in the morning.
Foundation of Revitalization of Local Health Tradition visit
FRLHT is a registered Public Trust and Charitable Society, which started its activities in March
1993. The institutional agenda of the Foundation for Revitalisation of Local Health Traditions
(FRLHT) is derived from its vision: "enhancing 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" and thus revitalize Indian medical heritage”.
This is the best field visit ever in my entire life I just love the place the environment is so fresh
and clean its natural beauty has attract me the most and I would love to visit the place again and
again. We went for two days trip in FRLHT and stayed their one night we met the director he
was very welcoming to us and told us to explore the area and learned about different type of
traditional plant medicine and let him know by the end of the day. We start our day in the
conference hall introduced ourselves and our visit objectives, than we move out exploring the
plants names and what are its speciality along with one of the staff from the organization. It‟s
beautiful to see traditionally we are so rich in with plants and get cure without using allopathy
medicine, we visited the hospital which provide medicine made by the pure plants for the people
coming for treatment, the laboratory was big and the lab technician explain how from each plant
they transformed into a medicine, there are shampoo, face cream, massage lotion, lip balm lots of
product they have produce. Very interestingly they have made human body with the bricks in the
garden and they plant according as to what is required like for the eyes, nose, mouth, hands, legs
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and to the other parts of the body. I had a great day and learned so much about plants and it is
amazing to see some of the plants which we grow at home but did not realized it‟s a medicinal
plant and how useful it is, in the evening after we observed and note down all the medicinal plant
we went back to our room and rest. I got to learned a lot from the visit especially the plants
which we see normally in the road side those are all medicinal plants, as per the explanation by
the director he working hard on traditional medicinal plant to be recognized and available in the
market so that the people will have optional to take medication and not only the English
medicine is important for the people to get cure they can also feel relieved by taking AYUSH
medication.
Fieldwork placement and learning
My first fieldwork was place in CHC Chennai as I was interested in communisation or
community action for health after the field visit from Tamil nadu I really want to learned more
about it.
Overall objectives and learning outcome
To know about the community
We have been place in Perambalur Distrivct for our field work, under Dawn Trust
organization we select four panchayats for our field work they are Bommanapadi,
Ammapayalam, ladapuram and Easanai Panchayat.
In these panchayats agriculture is one of the main occupation they cultivate cotton, rice,
onions, maize, sugarcane, ragi, drum stick vegetable, in which they earned their livelihood. We
observed that most of the houses are pucca and some are semi pucca houses. There is proper
transportation in all the four panchayats, in every panchayat there are Health Sub Centres,
Government Schools, Anganwadi Centre, Panchayat office, Ladies toilets, Village Library,
Village well and water tanks.
To understand the relationship of the Panchayats with the local NGOs
We learned when the CAH project was functioning the NGOs or the animators give
trainings in conducting different health awareness programme. The people along with the
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VHSWNC members are being motivated to demand their rights and how to take care of their
own health. Since the project has ended the animators does not visit the panchayat anymore the
VHSWNC members is not functioning and are not being motivated anymore.
While interacting with the animators we learned that they have faced difficulty, since the
project has been ended the president and the VHN does not conduct meetings and rarely contact
the committee members, they faced problem in making the people understand about the reason
of them not visiting the panchayats.
We learned that the animators plays an important role and have a good communication
with the people when the project was still functioning, but at present the relationship between the
people and the animators is not as strong as before.
To understand the function of the local organization
To achieve this objective we have interacted with the Block Coordinator of the project
from Dawn Trust Organisation Mr. Raj and from Udaya Trust Mr Shiva. They are the main
person in taking the initiative in implementing the project in Perambalur and Ariyalur District.
These NGOs have played a significant role in implementing the project at the panchayat level,
they selected the animators and give them training on various aspect on health and keep on
motivating the VHSWNC members to take responsibility for their own village health and do not
depend on others.
To understand the role of the local NGOs in motivating the community or the Women
section of the community in implementing the project
Role plays and cultural programmes were conducted in different villages to aware the
people especially the women section of the society to come out of their house in fighting their
own rights. The implementation of the CAH Project has mostly empowered the women in
demanding their rights not only in the Gram Sabha but also to the higher authority such as the
BMOs and to the District Collector.
To understand the function of VHSWC
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The committee members have their roles and responsibilities in their own panchayat.
They are function under the present of the VHN and the panchayat president, Anganwadi
teacher, SHG member and health Inspector; these members along with the VHSWNC
representatives looks after the healthy functioning in their own panchayat they also look after the
function of the different health system falls under the panchayat. The following aer the main
functions of the VHSWNC
Every village Panchayat with the population of up to 1500 can form Village Health
Sanitation Water and Nutrition Committee
The committee should work along with the development committee of the panchayat on
matters relating to health, water and sanitation.
The committee can have special invitees as required to enable them to function better and
achieve the goals. Special invitee can include other elected representatives of the
Panchayat including Panchayat Union or District Panchayat any official connected with
the issues, any individuals the Committee decides to invite.
The Committee can form sub-committees as required and include in its special invitees as
members
The committee should try to have all hamlets represented and covered in its members/
special invitees/ sub-committees.
The committee will meet every month and the chairperson may himself/herself call,
meeting of, the committee any time and on the receipt of such requisition, from the
members.
Orientation and Training
Every VHSWNC after being duly constituted will be oriented and trained to carry out activities
specific to the villages to meet the NRHM goals.
Village Health Fund
As a part of NRHM the Government of India have provided to each VHSWNC Rs.10000/annually as untied grant with the intention to enable local action and ensure that public health
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activities at the village level receive priority attention. The fund could be used for any activities
related to determinants of health as approved by the committee activities:
For any village level public health activity like cleanliness drive, sanitation drive, school
health activities, ICDS, Anganwadi level activities household surveys etc.,
Emergency transportation of poor patients
The untied grant is a resource for community action at the local level and shall only be
used for community activities that are evolve and benefit more than one household
Nutrition, Education, and sanitation, environment protection, public health measures shall
be the key areas where these funds could be utilized
For emergency transportation of high risk pregnant women and new born children
Every village is free to contribute additional grant towards the VHSWNC
The untied grant is a resource for community action at the local level and shall only be
used for community activities that involve and benefit more than one household
For creating awareness , prevention and control of vector borne diseases such as Dengue,
Chikungunya, Malaria etc., at the PHCs and Sub Centres
Roles and Responsibilities of VHSWNC
Assessing. Analyzing, prioritizing and developing area specific health plans for each
village habitation
Building awareness on key issues on health and determinants of health
Community mobilization
Community resource mobilization
Facilitating the delivery of RCH outreach services
Promoting community involvement in disease prevention activities
Community monitoring of referral compliance of high risk mother and high risk
newborn
Emergency transportation of high risk mother and newborn
Surveillance and notification of communicable diseases for organizing control
measures
Promoting family welfare services with special focus to Non Scalpel Vesectomy
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Ensuring the provision of protected drinking water
Encouraging the unreached to avail the basic services
Demand generation for basic services
Facilitating the identification and distribution of cash benefits to the eligible
beneficiaries under Dr. Muthulakhmi Reddy maternity scheme, JSY, Female child
protection scheme etc.,
Facilitating growth monitoring and reading of ICDS children and antenatal mothers
Community monitoring of utilization of basic services like
o Conduct and utilization of monthly immunisation clinics
o Daily water chlorination
o Availability of ORS packet
o Weighing of newborn babies
o Regular school attendance of every child
o Cash benefits to all beneficiaries
To learn about Panchayati Raj Institution
This institution is formed in almost all parts of the country, the main person of this
institution is known as the panchayat president he is being elected by the people for the term of
five years. The president plays an important role and responsibility in supporting the panchayat
and taking care of the panchayat welfare. All the schemes are being implemented through the
panchayat president. He is politically responsible at the grass root level. It has been found that
Tamil Nadu is the only state where a DC can remove the president if he is not eligible or does
not perform well as the president. The people have to be from the SC community of the
panchayat only to contest for the president seat. There is also the shadow president who takes
care of all the works on behalf of the president.
To know the health system of Tamil Nadu
Tamil Nadu health system is very vast and different from other state in the country; at the
higher level they have the health ministers under it health secretary under which the department
is divided into Medicine Department and Public Health Department. The following is the
structure that we come up with from our learning.
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Health Minister
Health Secretary
Medicine
department
Public health
department
Public Health
Department
Medicine
Department
Preventive
and
Promotion
Curative,
Prevention
Government
hospitals
Sub health
centre
Primary
health
centre
Community
health centre
Government
Hospitals
Health Sub
Centre
Primary
Health Centre
Block PHC
During the fieldwork we got to learned about Dr. Muthulakshmi Reddy Maternity Benefit
Scheme is the scheme implemented in the state of Tamil Nadu, this scheme is implemented in
both rural and in urban areas; the pregnant mothers falls under Below Poverty Line is been given
an amount of 12000, only the mother above 19 years of age is able to apply the scheme, the
money is given in three installments; the first installment or rupees 4000 is given to the pregnant
mother who have been registered in Health Sub Centre, and came for Ante Natal Check up and
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availed- TT immunisation, blood grouping and typing, hemoglobin testing, weight measurement,
BP testing and scanning.
Another 4000 is again given when a mother delivers the baby only in Government
Hospitals. Then, the last installment of rupees 4000 is again given to the mother when a child
complete the third dose immunisation of DPT, Penta Valent, Hepatitis- B and Polio.
Second fieldwork placement
My second fieldwork was placed in Meghalaya under IIPH (Indian Institute Public Health)
Shillong, I did my research study in South West Khasi Hills District it‟s a newly form district in
2012 under Mawkyrwat Block but for the research and the study title A study on health care
services provided by governmental health care facilities. We were again place in Bethany
Society, Mawkyrwat to make the work easier for communicating since the organization have
closer contact with the people. We stayed in Mawranglang village with one family and the
mother was a traditional birth attendant and her children were working outside the village. The
area is full of greenery surrounded by hills and huge rocks it‟s a beautiful place for visiting it will
mesmerize us with the river flowing down the hills and the breeze from the tree are extremely
attractive and wonderful. Since it‟s a research fieldwork I spent most of the time with
respondents and visiting PHC, SHC, ASHAs and travelling villages to villages. The villages we
visited are Rangthong, Jakrem, Mawranglang, Pyndensakwang, Photjaud and Nongsynrieh but
for my study I concentrated in two villages Rangthong for PHC and Jakrem for SHC. The district
is a bit backward compare to other district in Meghalaya the road facilities is bad, the people are
more illiterate, schools are there but mostly closed especially government schools, transportation
is still very lacking like very difficult to get a local taxi to go from place to place and since I did
my research on the quality of health care services I found out that public health system in this
rural communities is very weak and people have less knowledge about their rights and duties as I
compared with Tamil Nadu rural communities. It was in this fieldwork got a chance to meet the
dias and interact with them I have learned that they are at the stage of extinction because of the
scheme Janani Suraksha Yojana the mothers are rushing to get delivered in hospitals and stop
going to the dias, but again I learned from the people they give much respect to dias because she
is a local person and always ready to helped during the time of need.
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Third fieldwork place
I was placed in Madhya Pradesh, Bhopal CPHE (centre of public health and equity) and worked
with the local NGO called Muskaan and worked on malnutrition on different slums in urban
slum Bhopal. Me and my co- worker visited three slums i.e. Guatamnagar slum, Bapunagar slum
and Rajivnagar slum we worked and observed things around the slum. The slums are worst as
compared to Bangalore urban slums which are far more better than Bhopal slums because of the
development taking place in the south are more better than the north no doubt about but it is so
sad to see that people are surviving and living in that condition of life. Muskaan is the
organization involved in various activities like education, malnutrition, building income
generations, women‟s health, awareness about rights and responsibilities of the people. We had
three weeks field visit to these slums and Muskaan have informal school in the slums were they
provide free education and food for the children from 3 to 6 years of age. One teacher from
Muskaan would come everyday accept Sunday to teach the children and educate them so that
their future would bright and their living condition would be better. After 6 years of age if they
want or depends on the family or children they can continue their schooling for higher studies in
Muskaan itself because they have the registered school till class 5 and they have a school bus
everyday coming to the slums and pick them up for the school or they can joined any other
schools to their convenient. I felt it was a nice approached to the community by the Muskaan and
worked in the slum itself in a small rented room enough for the children to be fit in and teach the
children on the importance of the education.
The slums which we visited especially Guatamnagar slum which is not registered under
government is worst among the two slums the houses are all covered with plastics which they
collect from the city and somehow cover them from the sun and rain but in fact this kind of
situation is almost in all the slums in Bhopal. The kind of work they use to do are rack pickers,
domestic workers, making puppets and sell in the market, labourers and one thing is common
among the all the slums that men will stay home drink and play cards and women will go for
work and earned and support the house and family. The slums kids if they get free time they use
to go and begged in the streets.
During my field placement I learned that under 5 children are very vulnerable to diseases and
illness and one of the major cause is Malnutrition. Malnutrition and affect the children both
24
mentally and physically we had a good orientation about malnutrition by Dr Ravi D‟Souza and
what are its consequences. I learned that taking weight of the children every month is very
necessary to know whether the child is growing or not and if he is underweight the child must be
taken a good care and eat nutritious food. We got an opportunity to take the weight of the
children in those three slums mention above and came across many malnourished children and
some are severely malnourished.
Visit to community health center NIMHANS in Sakalwara
All the fellows went to visit the CHC we reached there and met the psychiatrist and explain us
about the growth of mental illness is higher in the state compared to the past. There is a different
department in the center and since it was still under construction there are fewer patients staying
for now.
Visit to wellness center NIMHANS
This is a one of the unique center I have ever visited I really appreciate the work they are doing
here because they do not provide medical treatment in the centre except for some cases. I
appreciate the approaches they adopted like any one can step in the center and share their
problems without any hesitant and pay. I think for any human being the true happiness lies in
someone listening to them and show them the way on how to tackle their problem rather bottle
up the sorrow and made negative solution. The work they are performing in the center is mostly
counseling and help people to facilitate in the right direction.
Protest, Programme and Workshop attended
Headstreams organization - Self Help Group mela
It happened in the summer of 2008. A group of professionals came together to discuss issues and
challenges related to the life of the underprivileged in our society. The realities that were
unveiled in the course of discussions challenged them to do something about it. They formed a
Society and registered it under the Karnataka Societies Registrations Act 17 of 1960 and named
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it headstreams. The name spelt out their deep concern in the areas of Health, Environment And
Development, and expressed their commitment to add to the streams of development by way of
Support, Training, Research, Education And Mobilisation, thereby forming HEADSTREAMS.
The only capital they had was a genuine concern, passion and commitment to serve. The group
which included social workers, educationists and counsellors started working among the
homeless and neglected children in the market places of Bangalore by contributing their time and
expertise. Pooling their personal resources, though limited, they also availed the services of a
full-time social worker. The activities gathered momentum over the years as several people
joined the team and expanded the scope of work. Eventually the various initiatives to identify
with the marginalised in their struggle to attain fullness of life were brought under one umbrella
by the name aalamba meaning „help & support‟.
Vision and Mission
A world where every person has an opportunity to realise their inherent potential to live
a positive, confident intentional and socially productive life.
We achieve this through promoting opportunities for people to explore and develop
their capabilities in an environment that provides security, empathy and fosters freedom
through creative means and healthy social interactions
The Headstreams had organized the SHG mela where all the SHG members have come and take
part in the programme they were dancing, singing, acting and the crowd was so huge that it
almost covers the field. There were posters hanging and it‟s all about health issues, it‟s really
nice to see that the children and the SHG members are very much into the health awareness and
take part in the health issues happening in the country. The skit was the best part it reaches the
message to everyone though it was in their local language but it understood the acting was all
about traditional medicinal plant and how we can make our own recipe at home if we fall minor
illness. All the SHG members were very happy on that day, active in their activities and
performance it was a nice visit and capture all the good moments with all the people present on
the particular day.
26
National Urban Health mission
The launched of NUHM was a great opportunity for me to go and see the opening of NUHM all
important minister were present on the day and the speeches spoke by all of them regarding the
welfare of the people living in slum was promising and could happened if they go according the
plan of the project. The crowd were mostly filled will slum people, different NGO‟s, students,
parents and both private and government officials. It was very interesting to see one man was
dressing himself in no smoking attire and giving awareness to the people that smoking is
injurious to health and what are the bad consequences after smoking. Going on the opening
ceremony of NUHM I really feel being a part on one of the history moment and I thank
SOCHARA for all the opportunity. What I like the most about the programme was that the hosts
all the ministers accept Mr Azad health and family welfare minister of India spoke on kannada
and it was a wise thought for all of them to give the speech in local language because the project
is for the people and they are the important person to know more about the programme
implemented.
FEDINA (Foundation for Educational Innovations in Asia) rally cum protest
I was always enthusiastic in the action part of any health related issue, FEDINA had organized
the programme for all the slum dwellers, domestic workers, daily wage earners, elderly people
and all the marginalized group of the community to demand for their rights and to be aware of all
the government schemes provided for the people. All the protesters tied a piece of red cloth on
their head and marched from NIMHANS to labour department office. A huge community people
gathered for the rally from 5 year old kid to 60 plus years of age were present on that day.
Pamphlets were distributed to the people and slogans were being raise on top of their voice it
was really nice to see people were all demanding of their rights and improvement in their living
condition.
Nido Tania protest
Another opportunity to take part in the protest it was held in town hall Bangalore we prepared
charts and went for the protest. This protest has really touch my heart and angry for being
27
discriminated from the mainland India towards North eastern part of the country. This is not the
first time happening among the NE people being killed or humiliated within our own country,
many young students came and joined the protest and different student organizations of NE
living in Bangalore had joined the protest. I really feel this is an important issue to talk about to
reach the ears of the higher authority for the change we want to bring for the people of NE. It
was a sensitive issue to everyone present there because Nido was murdered it a very unpleasant
manner if I think back the people staying around the place how could they just pass by and did
not stop the fight if only one person could react at that point of time I think Nido would be alive
at this point of time. It‟s really sad to say that people are losing their humanity for not helping
other person in suffering from the pain, I feel this is an important aware not only to the culprit
but also to the people in general to observed or look around have some humanity and act upon it
if they see something wrong is happening around the place and helped the person if in need.
Headstreams summer camp
Summer camp organized by Headstreams I think it was an innovative idea for the children to
grow and helped to increase their knowledge. It was one week summer camp but we went and
attend the last day programme of the camp, it was fun the children were lovable most of them are
most of them are very talented in dancing, singing and acting. The programme was short and
informative the organizers had full of energy in working and participating in the camping.
Monsanto Protest against Genetically Modified Food
Before the day of protest Adithya have conducted a session with the fellows and provide
information about the GM food and reason for protesting against the company Monsanto. I
personally feel the protest against GM food was a unique protest because usually in the rally we
will walk straight but in this rally we walk backside which helped to attract the crowd and be
aware of what we are doing. The organization Greenpeace organized the rally the media were
playing a great role for transferring the awareness to the other states, slogans, placards were
holding by the participants and shouted on top of our voice.
28
Workshops
medico friend circle 2014
Topic – social discrimination in Health
medico friend circle annual meeting (40th) organized in Delhi from February 13th to 15th,
December, 2014. On the first day Sunil kaul did a welcome address followed by self introduction
done by all the participants.
The theme of the mfc meeting is about the‟ social discrimination in health‟ and the topics
discussed during the meet are
Case study of why satyam die
Muslim women and health
Caste and health
Intersectionality of discrimination in health and health care
Presentation on the different patterns of discrimination – caste, health and disease ,
nutrition data and mental health
Demographic anxieties on love Jihad
Presentation and discussion on public health approaches policies affect social
discrimination
Discussion on the responses by movement and ongoing struggles – strategies
My reflection
Social discrimination in health were the outcomes of social inequalities and unequal health
distribution and various factors influencing the health status of individuals and groups which can
coinage as‟ social determinants of health‟.
In mfc meeting I observed that the entire intellectual peoples who were present there were very
enthusiastic and how responsive in debating on the topic and different issues relating to social
discrimination in health.
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Social discrimination in health as per discussed in the meeting they bring out issues on how
children are dying of malnutrition and hunger, maternal mortality, infant mortality and neo- natal
mortality, low literacy and inadequately paid labour, migration in search of livelihood etc.
discrimination in caste is very high in rural communities like the dalit communities are being
look down by the upper caste and unpaid for their works.
Discrimination in health can be various forms like social exclusion for the people living with
HIV/AIDS, people with disability, women, children, various occupational groups e.g.( sex
workers, agricultural labourers), people living in segregated geographical settings such as relieve
camps, slum etc. belong to various socially discriminated communities such as Dalits,
Adivasis/tribals, Muslims and other persecuted minorities. All this has a serious impact to health
and illness for example what is the health condition of aged men and women in the vulnerable
community? How does a poor muslim women who might be with disability or distress in least
developed pockets in the country cope with health?
In mfc meeting all the issues related to the topic have been brought out in a very clear and
systematic manner were I have learned and gain lots of information from the discussion. Health
is not merely a diseases is a wellbeing and dignity by social, economic, political and cultural
structure. Discrimination is a symptom of the embedded structural injustice example if a person
is not from a dalit family naturally we know how to treat them.
Current scenario
Inequality and health disparities, increasing polarization of wealth and capital
Axis of discrimination- caste, class, gender and religion, disability, age, sexual
orientation
Caste in nutrition perspective e.g. upper caste children refused to eat with dalit children
or the cooks were dalit and not acceptable to the majority of the village population
Social discrimination in mental health
Social discrimination in health care based on the vulnerable population is a biggest issue
in public and private sectors even till today.
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Clinical Establishment Act
In this workshop they talked about patient‟s right and the high growth rate of private sector in the
country, huge sway of private sector over health care related resources i.e. health resources,
services, medical education and materials a nice example related with it about a horse and
elephant is huge it‟s a private sector that we tend to ignore and give all the attention to the horse
which is public sector.
When the pain crosses all limits, this paves the way for all the treatment (Mirza Galib).
They also discussed about attitude of government towards private sector no evil, no hearing, no
speaking this is one of the reason for the increasing of private sector in the country. Private
practitioners play with emotions, excessive cost and unnecessary treatment. Lots of key learning
from this workshop like documenting the cases from the people has gone through misdiagnosis
from private hospitals this will be an evidence to fight against private health sector.
Social Justice in Health
It was 3 days workshop in St. John Medical College all the expert from public health
professionals were present on the particular day they raise the presenters presented on different
topics I remember someone spoke about community participation is the powerful tool to bring
change in the community. I find the workshop was informative because in anywhere part of the
world poor people‟s health is affected the most so to bring equity among the rich and poor is a
challenge but it‟s not impossible in real sense. The term social vaccine attract me the most means
to bring change in social and economic structural conditions to the community people who are
vulnerable to diseases.
Overall learning from SOCHARA
I feel am very worthful to join the CHLP and the knowledge I received from the collective
sessions and all the field experience is a rich knowledge and has help me personally to be strong
and motivate myself to work for the community. During the past 11 months SOCHARA has
showed me a direction how to approach the community and worked with them. Dr Ravi has
31
always been my role model and his lectures has always been interesting and motivating for me I
will never forget once he told us be the “Be the Lamp and not the Chandeliers” if we worked for
the community and live with them to understand them. I really feel happy and proud of myself to
be a part of this CHLP journey I learned to value people and respect their views and opinions, I
had learned a lot from the other fellows and respect their culture and traditions, facilitators are
there for us I appreciate their hard work but in the journey of community health I have acquired
more knowledge from the co-fellows too as we treat ourselves like one family and being in the
community ourselves we learned to respect each other and not to live the entire life thinking
about the negative thoughts about others because these would not helped us to work with the
community in real sense.
My understanding in community health I always thought health related to diseases and doctors
but I was wrong it actually related with social, political, economic and cultural factors of human
beings in the other hands it relates to all the social determinants of health in the country or world.
In the journey I learned that to take community action for health the process of community
participation and their involvement in their issues which they themselves try to solve the problem
is very important so as a community health worker we have to make them aware about the rights
and responsibilities and helped them to showed the way and they themselves will find the
solution. It is very important to understand about the community dynamics they have strong
believes in different communities we have to be conscious of the various dimension of the
problem if we worked with the community. For understanding the community dynamics we
should understand about the social, political, economic and cultural dynamics within the
community and how to go about for the welfare of the community.
I have got a lot of exposure during my fellowship programme plus I did not had any experience
before am fresh post graduate in MSW and if I think now I feel from thousands of people I got a
chance to be in SOCHARA family and learned about community health and truly speaking I
never dreamt of to be here and meet such a enthusiastic who are so concerned about community
and to achieved health for all. I will never forget Dr Thelma‟s saying that we are co-travellers
and learners from each other sharing experience her politeness, humble and wisdom talks have
really create an impact in my life, I have learned so much from her may be in future I want to
32
spread the spread the knowledge of community health like all the team members of SOCHARA
have taught us.
Some of the capturing moments during field work
33
PART B
RESEARCH REPORT
34
Background Information
In India the primary health care idea was brought earlier way back during the Bhore Committee
1946 this committee, known as the Health Survey & Development Committee, was appointed in
1943 with Sir Joseph Bhore as its Chairman. It laid emphasis on integration of curative and
preventive medicine at all levels. It made comprehensive recommendations for remodeling of
health services in India. The report, submitted in 1946, had some important recommendations
like integration of preventive and curative service of all administrative levels, development of
Primary and curative services of all administrative levels, development of primary health centers
in 2 stages i.e.
Short-term measure - one primary health centre as suggested for population of 40,000 and each
PHC was to be manned by 2 doctors, one nurse, four public health nurses, four midwives, four
trained dais, , two sanitary inspectors, two health assistants, one pharmacist and fifteen other
class IV employees. Secondary health centre was also envisaged to provide support to PHC, and
to coordinate and supervise their functioning.
A long-term programme (also called the 3 million plan) of setting up primary health units with
75 – bedded hospitals for each 10,000 to 20,000 population and secondary units with 650 –
bedded hospital, again regionalized around district hospitals with 2500 beds
35
Major changes in medical education which includes 3 - month training in preventive and social
medicine to prepare “social physicians”
The concept of primary health care is not a new to India but looking in to the situation the public
health system is still lacking in many ways. The Indian Public Health Standard is a health policy
set up by the government India to improve the quality care delivery and sensitive to the needs of
the community. These standards would also help monitor and improve the functioning of the
PHC‟s in the country.
West Khasi Hills, District covering an area of 5247 Sq. KM is the largest district in Meghalaya.
The district consist of 5 CHCs, 16 PHCs, 1 District TB Centre and 64 Sub-Centers which are
already functioned. West khasi hills district is divided into two district, i.e., west khasi hills and
south west khasi hills is a newly discovered district on 3rd of august 2012 and its capital is
Mawkyrwat 75 kms away and two hour drive from Shillong, the capital of Meghalaya. It
comprises all the villages of Maharam Syiemship and some villages of Langrin Syiemship and
Mawiang Syiemship. Mawkyrwat is the area conducted the study.
Meghalaya is one of the state were the quality of health care is the major concerned and the
health status of the state is improving at a steady pace. Still there is no proper infrastructure
facilities, drugs, doctors are absent, shortage of Para medical staff etc. Health care is the
constitutional right therefore it should be more accessible to poor and needy. But what is health
today since the day of independence till date people in rural areas are still facing health care
problems though standards has been set up for improving health status in rural areas. The people
residing in the borders and remote villages are almost adopted to the traditional health care
methods, due to non availability of better health care facilities. The National Rural Health
Mission in the state has tremendous challenges to overcome in the coming years.
Communicable diseases such as malaria and especially tuberculosis are reemerging as epidemics
and the growing specter of HIV/AIDS is very high in the country, maternal rate, mortality rate,
malnutrition among children is increasing. Many of these illnesses and death can be prevented or
treated cost effectively with Primary health care services provided by the public health system.
The government has provided an extensive infrastructure for Primary health centre and sub
36
health centre exists in India, as per the norms, a typical Primary Health Centre should cover a
population of 20,000 in Meghalaya with 4-6 indoor/observation bed and it acts as e referral unit
for 4 to 5 sub centers. And as per the population norm, one sub health centre is established for
every 5000 population in plain areas and every 3000 population in hilly/desert/tribal areas. In
rural areas there are largely underutilized because of the dismal quality of health care provided.
In most public health centers which would provide primary health care services, drugs and
equipments are missing and unavailable, there is shortage of staff and absenteeism on the part of
medical personnel is a big problem in the public health centers.
In India most of the people, even the poor, choose expensive health care services provided by
largely unregulated private sector the reason would be various. Not only do the poor face the
burden of poverty and ill health, the financial burden of ill health can push even the non-poor
into poverty. On the other hand the over growth of population is the instrumental for both
poverty reduction and for economic growth these are two important goals for developmental in
the country. India spends less than 1% of its GDP( gross domestic product) on public health,
which is grossly inadequate. Public investment in health and particular in primary health care
needs to be much higher to achieve health targets, to reduce poverty and to raise the rate of
economic growth. Moreover, the health system needs to be reformed to ensure efficient and
effective delivery of good quality health services.
37
Title of the study
A study on health care services provided by the governmental health care facilities in rural
area of South West Khasi hills district, Meghalaya
Objectives
To understand the quality of health care services provided in Primary Health Centre and
Sub Health Centre
To find out people‟s perception on the gap in health services in Primary Health Centre
and Sub Health Centre
Operational definition –
Quality of health care services – infrastructure, behavior of Para medical staff, cleanliness,
water and electricity availability, toilet facilities, drugs availability, difficulties faced by the
people in the PHC and SHC, adequate time given to the patient for explaining their illness,
confidentiality maintained or not, people are satisfied or not with the services
People’s perception on the gap of health care services – are they satisfied with the services
received from the health centre‟s. In Indian public health standards policy have mentioned clear
what are the services and facilities should be available in the PHC and SHC
38
Methodology
Study Setting
The study was conducted in South West Khasi hills district under Mawkyrwat bloc, Meghalaya
the name of the villages are Rangthong and Jakrem where PHC and SHC is situated. In these
villages most of the people are schedule tribe and belong to khasi community.
Study design
Qualitative research method approach was used
Sample size
5 persons per PHC and 5 persons per SHC they were all adults age group between 25 to 45
Data collection technique –
The researcher have conducted in-depth interview followed by unstructured questionnaires. The
participants or respondents are the people in general who lives in the particular villages and
utilizes the health centre services.
Sampling unit
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One Primary Health Center and one Sub Health Center
Data analysis plan
The researcher have use a recorder during the interview and transcript in the Microsoft word and
analyzed with the helped of ATLAS.ti software for the data that have collected.
Analysis
Quality of health care services in Primary Health Centre in Rangthong Village
Maximum of the respondents said the PHC in this village has been performing well but they also
mention that since its government health care system our needs have taken it lightly.
Infrastructure of the PHC – the people response it is government building and newly painted
overall the building and water supply, electric supply, cleanliness is maintained well in the PHC.
Misbehave of para medical staff - the behavior of the para medical staff specifically
mentioning the nurse and the pharmacists they have been behaving the people with disrespect,
not approachable and unresponsive in the PHC.
Absent of the doctor – the doctor is not available everyday she use to come only on the big
local market that is twice a week
“one day I went to the PHC because I was having stomach pain and want to meet doctor so I
went I ask for the doctor from the staff working in the PHC they said she did not come today than
I said to the nurse give me some medicine because it was paining too much so she give me some
pain killer and I came back home”
40
The doctor hardly stay in the PHC quarter - people felt the doctor never stay in the village
after all she use to visit only twice a week
Shortage of medicine – the people felt there is shortage of medicine supply in the PHC and this
is the reason they tend to buy from private pharmacy and they ignore going to the PHC for
treatment though they are getting for free.
According to one elderly woman “I people find it difficult to go to the PHC because it’s a long
distance almost 7 km and the local taxi is not easily available, moreover if they reached the PHC
to get the medicine which they required are mostly not available”
According to one adult man “Drugs prescribe by the doctor are hardly in the PHC”
Quality of care provided in the PHC is poor - The participant also mentions the water in the
PHC it‟s missing. Majority of the mothers never get their delivery done in the PHC because they
don‟t want to take the risk of their life due to the ignorant of the doctor or nurse during the
delivery in the PHC. They use to get the delivery done in CHC Mawkywat which is 17 kms from
Rangthong PHC the Village where they are staying. The participants prefer to get delivery done
at home with the help of the traditional birth attendant rather than going to the PHC which they
are not sure about the services.
According to one of the mother “I had this incident when I was delivery my baby girl in the PHC
I started to get pain my mother call the nurse I was so in pain that I could not even walk but she
seems not to be worried about me and instead told me to walk to the labour room all by myself
but thank god my mother was there and with her support I reach the labour room and delivered
my baby”
No 108 emergency vehicle facilities- the people felt the 24 emergency vehicle is missing in this
village they have to take responsible for if someone fall sick or serious case and arranged the car
for the sick person.
Antenatal care checkup – the participants are quite satisfied with the ANC checkup performed
in the PHC
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According to one of lactating mother “They use to measure my height, weight, hemoglobin, BP,
injections and some medicine if required and for the baby also measuring weight and injections”
Medicine available – the medicine available in the PHC is mostly for minor illness like for
fever, coughing, headache and for stomach pain.
Quality of health services on the sub health centre in Jakrem village
Infrastructure – the people felt the SHC is constructed well the rooms inside are quite big and
it‟s enough for checkup
Behavior of ANM was good – the people felt that the ANM very good at heart, friendly with the
people and have a nice character
According to one adult man “The ANM is a humble person and talks well with the people, she is
from our place Mawkyrwat itself so that is the reason may be she is good to us otherwise AMN
coming from the town they act differently towards the villagers”
The SHC opens only twice a week- people felt that sometimes it‟s difficult if they need urgent
medication because it open twice a week and the people have to move out of the village and get
there treatment done. It opens only during immunization for children and ante natal care for
mothers and post natal care.
Availability of medicine is less – the people felt availability of medicine is less in the SHC and
for this reason most of the people do not utilized the SHC if its open at times.
According to one of the mother “I had one incident my 4 year old daughter cut her feet with the
broken piece of the bottle I went to the SHC so the ANM refer me the CHC the reason is they did
not have the proper materials for the care which is required. The medicine is not much available
and they should have open it every day because the people do not fall sick only on Tuesday and
Wednesday they may get it anytime during the week but what can we do as a common people the
system has made it like this we cannot change anything”
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Immunisation, ANC and PNC checkup is regular in the SHC- people felt for the children
and mother immunisation is done every week without fail
According to one young lady “I use to go to get immunize for my sister daughter the ANM has
got lots of children to get immunize in one day”.
People’s perception on the gap of health care services in PHC in Rangthong village
The PHC is central to the public delivery of primary health services in India the idea is to
provide curative and preventive healthcare to the rural population goes as far back as the Bhore
Committee in 1946. Primary Health center is the cornerstone of rural health services where the
people will go and treat themselves there before thinking of somewhere else.
Irregularity of the doctors - most of the respondents said the doctor is not available as per
IPHS availability of doctors and Para medicals staff in rural areas is important for the success of
the mission and to take preventive measures before its serious.
“I feel as a human being my life is important for me this an issue where if we go for check up in
the PHC we feel disappointment and regret to come to the PHC where there is no doctor to take
care for us”
Shortage of drugs – the people felt this a huge gap in the PHC were they open the health centre
but there is no medicine
Unnecessary waiting to meet the doctor and medication – the people felt we village people
have to earn for living everyday sometimes they feel going to PHC is a waste of time to wait for
the doctor and if they meet the doctor there is no medicines
Behavior of the medical staff is not pleasant – people felt the medical staff ignored the people
if they come for treatment and do not treat them with care
According to one lady “I don’t like the nurse in the PHC she is so rude and do talk with the
people in a decent manner”
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Services provided in the PHC are not satisfied – people felt they have been living in the
village for years and they could hardly see any changes in the PHC there are still lots of
improvement they should do for the betterment of the PHC
According to one lady” I use to go for treatment sometimes and I know the services provided in
the PHC I am not satisfied at it but as a poor person we have no other options if its not good
most of the people here they go for private clinics or CHC in Mawkrywat instead going to PHC”
No 108 emergency van
People’s perception on the gap of health care services in the SHC in Jakrem village
The SHC is the health care services at the grass root level provided all kind of primary health
care services where the approachable to the people is much easier because it‟s situated within the
village itself.
According to IPHS standards the SHC must be open every day but according to the people it
opens only twice a week
According to one lady “we never know when we are going to fall sick so what if we want
emergency care suddenly we have to rush to far more hospitals for that it is really a big
concerned for the people like us who are poor”
ANM is unaware about the Village Health and Nutrition Day – the ANM was hesitant to talk
about the VHND and she have no idea when and which day to conduct, people felt she is so
irresponsible for not having knowledge about the VHND
Shortage of drugs availability
“I prefer to go to direct to CHC Mawkrywat instead to trying to go to SHC which am not sure
they will have drugs for minor illness or not”
Not satisfied with the SHC health care services
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According to one of the lady “I have stayed for years heard from people talking about the
facilities provided in the SHC but myself I rarely go there because if its good people would not
talk bad about it. I find the SHC incomplete opening twice a week for immunization and no other
facilities also not even medicine”
.
Limitation of the study
In any social science research endeavour, there are limitations were the researcher faced lots of
problems. One the limitation of the study is that some of the respondents were not willing to
open up with their view which is a drawback for the researcher to get appropriate answer. The
other problem would be, the study may have shortcomings due to lack of experiences on the part
of a researcher. Proper guidance for the researcher to conduct the study in the field was lacking
as it was in the remote village the only source for communicating is through phone that depends
on the network availability. Time was constraints because the people were not available during
the day have to go and meet them in the morning but again they are busy to go for their work and
so the work keep on delaying and ultimately the researcher has a shorter period of time to
conduct the study. Transportation is one of the major drawbacks there is no local taxi available to
come down to the village, there would be very less local cars available if we reach on time
otherwise we have to walk.
Discussion
The study that have been conducted was focus on one PHC in Rangthong Village and one SHC
in Jakrem village the objectives of the study is to know the quality of health care services and the
gaps in the health care services provided in the PHC and SHC where from the community people
in general are the target group for the study.
The findings which found out from the study are the quality health care services of the public
health system are actually very weak in rural areas lack of drugs , no doctors , less cooperation
from the para medical staff, unnecessary waiting in the health centre and no emergency van in
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the PHC. The gap between the public health system is very vast that has effect the people at the
most. IPHS standards have been set up for both PHC and SHC for improvement in providing and
reaching to the villages and help the poor but still in the state like Meghalaya especially in rural
villages no such improvement has been made.
The quality of health care provided varies from state to state in the hilly area of Meghalaya the
quality of services in the PHC would be backward i.e. the terrain where the PHC is situated its
difficult for the health care providers to go and stay in the area and followed by high risk of
maternal and infant death rate.
The public health system in rural areas of Meghalaya is weak because the government fails in the
health sector and do not have a systematic efforts to track the health system and health facilities
distribution. There is no system in place to collect data on a regular and standard basis from
service providers nor evaluation of health personnel on their technical competence and ability to
provide medical care. Its only in the paper written about things like inspection and supervision
that visited to health care facilities which most of them are not actually done and they lack
behind on monitoring process and there is no kind of assessment done in this kind of work as to
look upon whether the health facilities and services are working well or not.
One of the most important global health care efforts was the Alma Ata Declaration of “Health for
All by 2000 AD”. The declaration defines health in the following terms “health is a state of
complete physical, mental and social well being and not merely absence of disease or infirmity
and is a fundamental human right”, implying that health involves social and economic well being
and is an entitlement of every human being. The Bhore Committee report 1946, mentioned that
“no individual should fail to secure adequate medical care because of inability to pay for it” and
that “health services facility should be placed as close to the people as possible in order to ensure
the maximum benefits to the communities to be served”.
Out of pocket expenditure is one of the major problem who eats up poor people‟s income I think
if the public health system is strengthen especially in remote villages there would be less
growing of poverty in the country and people would get to save more income for their daily
activities and future used. On the other hand we could say economic growth and population
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health are correlated because poor people are likely to be suffering ill health than the non poor.
Thus improvement of people‟s health is an important for attaining of the twin developmental
goals of poverty reduction and economic growth(Gupta & Mitra, 2004).Out of pocket
expenditure has another result i.e. people going for treatment in private hospitals because they
find being treated well and their services are better compare to public hospitals.
Recommendation
Have to strengthen the public health system for the better services in rural areas
People must be aware about their rights and responsibilities in receiving of any kind
resources which they are rightful off since they already paid taxes and on top of that we
are spending out of pocket more
Improving of transportation and road facilities is important for better health care services
reason the doctor might be interested to serve the community and stay in the village but if
there is no proper road connections how will she/he be interested to come and work these
kind of area.
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Awareness should be given to the people time to time to the community people about
diseases and prevention.
Medicines have to be available in the health centre this would reduce for the people to
spent out of their pocket and going to private sectors.
Available of 108 emergency van
Conclusion
The quality of health care services is good areas of interest to be studied further though recent
efforts have began to focus on it. Quality of health care services is a broad area of study it
include various variables covering availability of drugs, equipments to respect shown to the
patients during visits by health care providers. Major findings from the study is that the quality
of health care services in the villages are still lacking behind and the gap between the demand
and services in the public health centre‟s is the major issue for the government to take up some
improvement measurements. People are not satisfied with the services delivered for them in the
villages though their living standard is low but their expectation for the improvement of public
health system in the community for the better health care will be their great achievement. Yes its
true quality of health care provided in PHC and SHC is low on which quality can be judged i.e.
infrastructure, availability of drugs and equipment, irregularity presence of doctors but on the
other hand to strengthen the public health system it‟s important for the people to understand the
ways for strengthening the public health system and what are the reason that they are still lacking
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behind. Public health system can be improved if it‟s work systematically and work along the
private sector.
Reference
Indian Public Health Standard for Primary Health Centre and Sub Health Centre
National Conference on Evaluation of Primary Health Care Programmes, Indian Council of
Medical Research New Delhi April 21st -23rd 1980
Primary Health Care in India: Coverage and Quality Issues, Nirupam Bajpai and Sangeeta Goyal
June 2004
http://megplanning.gov.in/MHDR/3.pdf
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International Development Research Center, Canada.
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