Family Planning and Health Care: A Case Study from Rajasthan

Item

Title
Family Planning and Health Care: A Case Study from Rajasthan
Creator
Ritu Priya
Date
1987
extracted text
I

C’iJ

COMMUNITY HEALTH CELL
47/1, (First FloorJSt. Marks Hoad
MEDICO FRIENDS CIRCLE BANGAlO.13 - SCO 001

XIII ANNUAL MEET

Family Planning and Health Cares A Case Study from Rajasthan.
- Ritu Priya.

I. INTRODUCTION :
I approached this filed work with an idea of using it as an
opportunity for filling a gap in my understanding of the
health system by getting a first-hand knowledge of the
functioning of the Primary Health Centres, studied from
a perspective other than that of a medical studynt ( the
only other exposure I have had to a PHC).

The Block in which the PHC is situated, falls in the tribaj
belt of Rajasthan, comprising approximately one third popu­
lation of tribalsmainly Bhils. Most of them live in distant
■fillages in the hilly, rocky part of the Block.
Some have
settled down in the plains but live in seggregated 'bhilwapas'
The village in which the PHC is situated as well the village
around it do not have any Bhils. The poor condition of the
tribals were in sharp contrast to the others in the village:
while most ef the houses are pucca in the village, the
bhilwaras were always of dilapidated, small'huts of mud and
tiles. No tribals were ever seen in the buses through they
could be seen walking to the distict town with heaflloads
of firwood er grass. They were never seen at the PHC either.
Though a drought-prene area, the last two years havd. been
especially dry and so part of the block has been declared
famine-hit. Famine relief work was seen in progress
(building and repair of roads). Perceptions about the
famine showed a great polarization in the society. While
one heard of the tribals who had lived on boiled leaves
ef trees before famine relief work started, most of the
people travelling in the buses seemed only midly affected and x
some were almost unaware of it. In the district town,
people laughed at the suggestion of a famine at their
doorsteps,. The famine influenced the PHC work only by
helping fulfil FP targets. People came in for the
incentive money, the MO said, sometimes both the husband
and the wiefe coming in for sterilizations.
Working in this setting, the PHC is bringing a number off
'private practitioners' into the area (the unofficial role)
and in implementing the Govt. Health Programmes. Provision
of medical care in a negligible f-unction as the PHC.
itself catered to only 9922 OPD cases (an average
33/ day) which is insignificant for a population of
1 lakh. The MEWs are given almost no drugs and are
perpetually short of supply of even aspiring and parace­
tamol. But all of them keep a stock of their own meidcines
I
i

I

2
t

and do private practice, of the 22? in-doors patients, 180 were
cases cf laparoscopy sterilizations and vasectomies,
(vasectomies had been registered as in-patients to inflate
the figures. ) No deliveries had been conducted at the PHC.
The two ANMs attached to the PHC attend to the deliveries
at home itself. In the other villages, the ANMs are called
only in case of emergencies by those who can pay at least
Rs. 50/- per delivery. Implementation of the health progra­
mmes is the official function the PHC is engaged xk in.
It basically means a primary focus on family welfare a
euphemism for Population Control, and some attention to EIP,
Malaria and guinea worm control. The NTP, leprosy and school
health programmes are conspicuous by their absence.

+•

Since the primary focus of work is son the achievement of
targets in Family Planning, it was clear that all the other
activities of the PHC suffered in consequence. Firstly,
the greater amount of time spent on FP activities meant
there was a reduction in time for other activities. Secondly,
the frequent 'drives' and FP camps were not conducive for
carrying out systematic work. Thirdly since supervision
by the higher level staff was limited to checking on the
fulfillment of targets, the other activities were considered
non-important by default.

*

In thas paper, by comparing the performance of FP programme
with EPI and NTP •> an attempt has been made to show that the
Primary Health Centres are functioning primarily as exten­
sion centres for population control.
II. THE FAMILY WELFARE PROGRAMME: Promotion of birth
control is the major preoccupation of all workers at the PHO.
Motivating cases, and keeping them ready for a sterili­
zation camp, bringing them there and later following them
up, takes up most of their time. While little pressure
tactics have been employed so far, the workers can see which
activityx® receives priority at higher levels -- the
enquiries the officials make whenever they come on tour
the intensive drives organized at state and district
levels, the incentive money giben to the 'cases', motiv­
ators, and the PHC, — all emphasize the importance
•f family planning above all other programmes. The official
circulars of minutes of the meetings and of instructions
to all the staff by the Collector are illust-ractive of
this. Results can be seen from the targets achieved.

FP achievements

April 1Q8^- Nov. 1985.
Sterilizations

Target
Achievement

800
690 (86%)

IUD

Condoms

290
52(21%)

l>+80

Orall
pill

2

I,

Contd..3.••

I

♦

- 3 The district data show that in the previous year results
were very different as the. official instructions had a
different emphasis.
Djstrict Targets and, achievements?

Sterilizations
Target
a/° ach&ived
Apr.'8b—Mar '85 19,^00
Apr.'85-No-P '85 ,19,^00

h-3.8
62.9

19814--1985-

IUD'
Target

r.

% achieved.

57.8

5,83.®
5,830

5b-.o

Sterilization Operation?

The sterilizations conducted so far have been performed
relatively 'honestly' in that the over age persons, and
sterilizing both the husband and wife together, etc., have
net been used to achieve targets. But as ' cases'become
more difficult to come by, the more compliant having been
motivated and sterilized, and as targets set by authoriti­
es increase, rhe MOs were hearci felling the workers,
- get both husband and wide
- over age will also do,

- Motivate those with copper T to get sterilized (thus
the same person can be counted twice as an IUD- and
sterilization acceptor).

The scheduled tribes get Rs. 150/-' over and above the
usual Rs. 160/- which each tnbectomy case and Rs. 130/- which
each vasectomy case gets. Room the drive starting in Jan.
1986, it has been declared that the scheduled castes
will also get the extra Rs. 150/As other governmental agencies, workers of the agricul­
tural department, school teachers, revenue staffetc. Kaxd
have all been allotted targets to motivate case tension
have built up in a number of aareas between these and the
health workers, one accusing the other of seducing their
cases away. In a number of instances £his has become the
cause of personal enimity and physical assault and the
police were called to diffuse the situation. The health
workers also complain that these.other workers offer ince­
ntive^ to get cases by promising them loans while they being
health workers have nothing, not even medicines, to offer.

e

The FP Camps?

The sterilization camps are a curious mix of public relat­
ions drama and mechanical assembly line. On the day of
the Camp, a ■vehicle
’ ’ ’ is
’ made
' available
-- - - .by the —
£8 -Dy --CMHO(FW)
office whichl brings
1
each case from their homes. A medical
college team consisting of 3 „
gynaecologists
„ .
an anaesthetist, and a theatre
■
• - • technician
come with the linen and

h-

- 4 4

equipment. The PHCS M0s have the patient ready with a
preliminary check up, a gynae exam., and a TT injection. Two
operating tables are set up. While the equipment is set up
pre-,edication
and. lined
lined.
the patients are assembled, given pre,cdication and
up outside the ’theatre1. Once everything members get
into their place in.’assembly line’? one for giving inject­
ions, one for holding the uterus, one to use the laparoscope,
and ligate the tubes, and the fourth to put suturesi The
unconscious patient is then transferred to a stretcher and
carried out by two male workers (class IF rtr MJW.s) to be
promptly Replaced by the next patient. The sterilized
patient is taken to the ’recovery’ room (generally another
room but may be the verandah or the open) where a dari
is laid out on the floor. With the relatives standing arou­
nd the patient is picked up by the two male workers by her
ankle and wrist and put on the floor. Her ’lengha’ flies up
and is pulled back in place by the male worker at her feet and
she is covered by her ’odhni* . Boon the next is brought in
and placed down beside the first one avoiding as much of
space as possible so that soon the room looked like a
morgue. The relatives, some of them crying and trying t»
sooths the women's brew or massage her feet (and adding
the only human touch to the proceedings) are shoodd out.
During one such comp, The junior gynaecologist looked in
before leaving which was as soon as the cases were all done.
Money and certificates whe were given to the cases by the
BEE. The FHC staff went home only after all the cases had
been taken home. The Sarpanch of the area came in to take
a look once during the first camp and the one held during
the intensive FP drive was visited by the SDO, BDO and CDPQ.
The staff present at the camp were the 3 MOs, 2 LHOs, the BEE,
and MI, 3 Sector supervisors, U- ANMs, M- MIWs (male), sweeper,9 one
peon, 2 drivers and the projectionist, 5 members of the
medical college team, i.e. 27 in all. In the first camp
there were only '*+ tubectomies and 1 vasectomy and in the
second (held on the first day of the intensive FP drive)
there were 7 tubectomies and 2 vasectomies. In the first
camp a patient had eaten before coming and also had a
history of amenorrhoea and a bulky uterus on PV examina­
tion but was undertaken for MTP and sterilization because
there were only four cases.

FOLLOW UP? The incentive money is given in two
instalments, one at the camp and the second one when the
follow up visit is paid by the PHC staff 7-10 days later
when stitches are removed. Luring one such visit, there
were 8 cases to be followed up from 4 different villages.
We literally had to chase after them into the interior
illages and even to their fields to make the payment and
for the doctor to enquire if "everything was OK, No? One

5

4

; 'Hl lf Iji I I.f|j ■ |M;[•!

-5woman who complained of burning abdomen was told that to take
less chillies but to eat everything, roti, curds, butter­
milk, Another woman for whom vie had waited because she had
gone to cut grass, was at the end of the interview, pattend
on the back and told "go take rest",. At another place we
found that one of the women had died a month after the oper­
ation '’why has more than a month elapsed before follow up?).
The doctor immediately ruled out the operation as the cause
of death without even trying to find the conditions under
which she had died. No attempt, was made to verify the cause
and we drove off to another village. The BEE informed the
MO in-charge that the relatives were entitled to Rs.5^00/if death occurred within six months of operation. The MO
promptly told him not to put such ideas into people’s heads
because "it will mean another headeche for us and we don't
want any such reports".
OTHER METHODS; IUD insertions wre done by the ANMs
themselves at the home of the willing persons and rarely
brought to the PHC or the camp. There are very few regular
users of condom (60) and because of the poor attention
paid to this method, even these acceptors break away as the
regular supply is not maintained.

i

The oral jill is not .being propagated because of the fear of
side effects and- the fact that the initial medical check-up
by the MO is necessary. No target was set up for it till
Jan, 1936, during which the requirement was of making 57
regular users. But this'attempt was made useless from the
start because the workers were told to distribute 3 cycles
each to women with a. child more than 1 year old (i.e. non­
lactating) whether they will use it or not. The MO
suggested that this could be done easily through the school
children by sending the pills home with them for their
mothers,

The Achievement s The PHC has an excellent performance to
its credit in terms of targets achieved this year. Many
of the workers metidned of entire villages where all eligible
couples had been sterilized ’-‘This village is complete".
The MO-felt that this year many more cases were coming
and death rate because of famine conditions.
Birth and death rates are not known and so impact of >e.
the■programme is difficult to assess. The registration of
births is mostly incomplete but no steps are being taken to
improve the condition. The degree of coverage by terminal
methods should have resulted in some impact .but as the Dy.
CMHO (IN.) said, most operations are done after h—5 children
and so may be the impact is not as great as it. would
appear from the achievement of targets.

III. The EPI programmes
The EPI. is linked, to the MCH programme but the two are
dealth with separately from the EN programme. Other than
BCG all other immunizations are done by the MFWs (both male
*

... .6..

6 and female) during their day to day work and through special
intensive drives.
The Cold Chain; A room at the CMHQs office has been conver­
ted into a cold storage for the vaccines and there is a
refrigerator at the PHO. Each worker is provided with a
thermocol box to keep the vaccines. The referigerator had
a defective lock and so the door remained partially open
all the time. Electricity supply was erratic, and the MO
was unable to say how long the electric supply actually
was abailable to the PHC.
The Intensive Drives; During a drive, the workers are
divided into 3-^ teams of 3-? workers each and the team
goes to each village and collect all the children and given
them the first dose of DPT and Polio. A similar exercise
is undertaken three times at 1 month intervals. The first
round had just been completed when this study was begun and
the second round was due to start soon after it ended.
Some experiences of the first round as narrated by the
MEW
’s were;
—'j

There was lack of facilities to sterilize syringes and
needles; generally 2-3 syringes were available per team
ard were sterilized before the team left but it was not
possible to sterilize them in the villages.

Abscess formation were reported but treatment (drainage)
was possible only in the PHCs or the dispensaries; the
workers had not antibiotics either.
Paracetamol was in short supply and so not given to
many or given only 2 doses, so that all or most had
fever and no treatment* (All this would tell on the
acceptance of the second dose).

Some parents had refused the immunization. One worker
submitted the list of children of an entire tillage
which had refused. The official explanation was that the
refusal was due to their "ignorance and illiteracy".
But on probing it was found that during the previous
drive one child had developed an absecess and another
developed convulsions after DPT.

Through the problems related to the short supply of drugs
and syringes were promptly attended to in view of it being
an intensive drive, there was little or no follow up,
althrough in case of sterilizations , the PHO team travelled
miles to check on complications and to giveincentive money.

7

- 7 Iflact during ±h one such follow up visit to a tubectomy
patient, the MO side-treacked an MPW's request to see a
child who had developed a swelling at the vaccination site
and whose house was no our route.

The two children seen coming to the PHC with abscesses we»e
prescribed drugs to be purchased from the market (even when
substitutes were available from the PHC.) The parents seemed
alittle bewildered because the injection was supposed to
prevent diseases but infact had given rise to a another
problem for which they now had to spend money on treatment.
Data on the EPI performance is collected and reported to the
district office by the SI. It was not possible to contact
him because he was 'absconding' for a large part of the time
and was drunk at other times. The Dy, CMHO office had re^ei«
ved data from the PHC only till June which is given below(
Immunization from April to June 1985«

DPT

1st dose
2nd dose
3rd dose
P»lio 1st dose
2nd dose
IT (pregnant women)
1st dose
2nd dose

Target
2210

Afehievemeirt

^-06
131
73
>+0U

2210b •

65
M.

1535

The data shows how even the few immunizations done become
useless because the 2nd and 3rd doses are not administered.
The side effects with the first dose were perhaps the
reason for this.
It was not possible to assess the impact of this programme
because no data with regard to the communicable diseases
in childhood was available. But from the way. the cold
•hain was maintained for polio, one could say that tlie
polio vaccines were probably useless by the time they
reached the.village.
BT • THE TB CONTROL PROGRAMME;
While a few of the workers were aware of the symptoms of TB
none of them had brought a patient to the PHC for examina­
tion. Only 5 sputum examinaions had been done during the
year 1985, cn the MO's advice. The malaria technician does
the staining and examination for ABB but asks' the sweeper
to collect the sputum and make the slide because he i§
afraid of catching the infection.
.
■

8
5

*

- 8

The previous records show that in 198*4-, 13? sputum slides
were examined. But the technician freely admitted that
it was falsified data put in by the previous compounder. No
check could be made because the slides were not preserved.
No patient is under treatment from the PNC for TB.
BCG vaccine is not supplied to the p PHC and is administered
only by the BCG team of the District TB centre which is
supposed to visit the villages once in three years.
The district TB Programme?
The district TB centre (DTC) is supposed to oversee the
NTP work in the whole of the district. The district TB
officer assisted by the second TB officer is in-charge
•f the DTC for clinical as well as supervision and corrdin•"ation work. The district has a sanatorium to which TB cases
needing hospitalization is sent. 2? microscopic centres (the
PHCs and dispensaries which have facilities for sputum exam­
ination) and 1? referral aid posts (which only disburse drugs
to confirmed cases) are also attached to it.
It was a pleasant surprise to learn that the PTC has a
post graduate degree tn thoracic and chest diseases from
Udaipur medical•college. But his knowledge about the NTP
and the subject was shocking. For instance, his statements
■ that of the diagnoses are made by X-ray because
• - cases are mostly asymptomatic symptoms appearing only on
cavitation sanatorium treatment is given so as to isolate
eases and to provide them with fresh air, hygienic conditions;
TB is difficult to control because of poor hygiene,
. inability to isolate the patients, default due to illiteracy
and ignorance etc seemed to underline his 'ignorance' and
’his 'illiteracy'. He was unaware of the h— symptoms on
which sputum examination is prescribed in the NTP and
believes that resistence appears only in the late stages
t and so there is no need to do sensitivity tests.

The second MO has been here for 2 years having joined
immediately after his house job. But he was not confident
about telling me the details of the TB programme since
he was not really 'interested'.
4
V. CONCLUS ION
The observations made show clearly that the'■PHC'.is perform­
ing only one function efficiently i.e. to .'protect' the
eligible couples with the terminal methods of birth control.
The functioning of the PHC is skewed in favour of populat­
ion control because of several reasons.

- the insistence and emphasis placed on meeting F? targets.
- monetary incentives given to the health workers for 'moti­
vating' the 'cases'.

. . . »9* * *

- 9- Playing on the economic vulnerability of the poor people,
in the present famine situation, by giving relatively
large sums of money, (the tribals .were paid even more to
get sterilized)-

The same attention is not being given to immunization
programmes which is supposed to be an integral part of
Family Welfare Services. The third component, the material
health does not get even the little attention that is paid
to immunization programme. The description of the NTP leaves
one with a sense of disbelief. After studying the functioning
of the PHC from 'a perspective other than that of a medical
student' one is forced to end with the cynical remark that
the survival of the rural population has been independent
of and despite the functioning of the PHCs„

(This paper has been condensed from the report prepared
as part of the field work requirements for PHD in
Community Health and Social Medicine from Jawaharlal Nehru
University, New Delhi.
ABBREVAT TONS

USED

N

T H E

T E X TS

1. ANM - Auxiliary Nurse Midwife.
2. BEE.
3. DPT Diphtheria , Pertusis (whooping Cough) Tetanus vaccine
Dy. Cin & HO (FW.)
Deputy Chief Medical and
Health Officer (Family Welfare)
EPI Extended Primary Immunisation.
6. FP
Family Planning.
7. LHO
8) MI
9. MO Medical Officer.
10. MxW Multipurpose Worker.

11. MP? Medical Termination, of Pregnancy.
12. NTP National T'ubercalosis Control Programme
13. PEC Primary Health Centre.
1U. SI Sanitary Inspector,
19- TT Tetanus Toxoid.

1% il
$

Chavan./

S

** * *
*

£
V.ft
Media
MFCM062: Family Planning and Health Care: A Case Study from Rajasthan.pdf

Position: 714 (8 views)