Addressing health amidst human deprivation: An experience in Chhattisgarh

In the last few months, we have been closely watching the health space  in India. In our attempt to stay abreast with new innovations in healthcare, we have been mapping the sector for individuals, ideas and  initiatives that are valiantly trying to plug the looming gaps in the infrastructure for health in India today. During one such conversation regarding the Right to Food movement in Chhattisgarh, I happened to hear the name of Dr. Yogesh Jain and his organization Jan Swasthya  Sahyog, that he co-founded with three friends, working to revamp the  public health system in India. 

I was truly fascinated by all that I read about Jan Swasthya Sahyog’s work in rural Chhattisgarh, and their story: of four young founders who gave up lucrative practices as specialists at AIIMS, Delhi, to find and work in what they thought would be the ‘poorest place’ in India, back in  1999. To learn more about the work of the organization tackling complex health challenges amidst deprivation, hunger and poverty in Chhattisgarh, and its involvement in issues around public health policy, I  went to Bilaspur to meet with Dr. Jain and his colleagues in person.

For a layperson like myself, with little understanding of issues related to public health, it was the first time I actually saw health playing out as a deeply political subject. Dr. Jain viewed most of the illnesses in  this  region as ‘the biological embodiments of deprivation’. As we discussed issues of ‘hunger’ as opposed to ‘malnutrition’, I was struck by the seemingly subtle yet stark difference between the two terms. In  these regions of Central India, the problem wasn't as much about the  availability of nutrient-rich food but the very availability of food. 

I also had the chance to learn more about the structural changes in the  design of healthcare delivery that JSS has implemented in the region. In  the current healthcare set up, the Asha worker, or in the case  of  Chhattisgarh, the mitanin is a volunteer health worker, providing primary health services at the PHC level.With minimal training, they do not have basic diagnostic capabilities, which poses many practical difficulties as, in a set up like this, it becomes necessary to tell from the pallor of one’s skin if the patient is suffering from malaria or the after effects of a snake bite! The capabilities of these village health workers often, are no match for the complexities posed by the health needs of the people. While there is no doubt that there is an urgent need for the scaling up of health services in rural areas, it is important to ensure quality is maintained, without dumbing down the nature of services itself. Also, the lack of availability of qualified doctors to set up base in rural areas has only grown in numbers, and the government has been unable to find a viable alternative.

Towards this end, JSS has set up a Senior Village Health worker program, as an intermediary between a mitanin and a doctor. This new cadre of health workers, who go through a 9 month training course, are equipped with special skills including that of diagnosis, counseling, laboratory skills, and extended knowledge skills. In parallel, while the idea of a 3year course for training of rural medical professionals is also being mooted, it was amply clear that there is an unquestionable demand for the enhancement of skills and quality of healthcare workers in rural areas. 

I watched these Senior Village health workers in action at the tribal village of Bhamhni, as I accompanied Dr. Ramani, a senior gynecologist, who manages the Community Health worker programs. Located within the Achanakmar tiger reserve, with rivers flowing on either side of the village, it has kutchcha roads, no electricity, poor water supply, and is cut off from its neighbours during the monsoons, when the rivers flood.  This is possibly true of most tribal villages, as the state of Chhattisgarh has large forest cover with many remote villages and tribal districts have low population densities, making the delivery of public health care a greater challenge. 

All of JSS’s outreach clinics are located in villages that are in forests or at the forest-fringe, and many of them lack access to all-weather roads. While the village health workers are available around the clock, the JSS outreach team comprising a doctor, nurse, and laboratory technicians with lab equipment, visit the village twice a week. The village health workers are trained to handle common illnesses such as malaria, diarrhoea, respiratory tract infections, and scabies, which are major causes of morbidity and mortality in young children, especially in the region. I was also surprised to hear of the high prevalence of cervical cancer amongst the women here. The hospital at Ganiyari, and the outreach clinics conduct regular cancer screening and awareness through their women’s health centre.

Deeply disturbed by the escalating levels of malnourishment in the region coupled with the inefficiencies in the current anganwadi system, JSS has also set up its own ‘Phulwari’ or crèche programme. This Phulwari programme seeks to cater to children between the crucial ages of 6 months to 3 years of age (before they can be accepted into the anganwadis), where timely feeds are as important as the quality of the food served to the children. The Phulwari that I visited at Bhamhni was run by 2 women, each watching over 10 children, from crying infants to playful 6 year olds. While high protein foods like sattu and eggs are served with khicdhi and oil, the phulwari also conducts TB control screening on a regular basis.

My final stop was the hospital at Ganiyari, about 40 kilometres from Bilaspur town. At first sight, it was overflowing with people waiting for consultations or medicines. Those who had travelled long distances or crossed the state borders had brought along utensils and firewood to cook meals and had set up camp while the treatment process was underway. When I spoke to an elderly woman about why she hadn’t sought treatment for her grandson at a health centre closer to home (in this case a village bordering Madhya Pradesh) she simply told me there was none. Besides, she had also suspected he may require more than a ‘sardi- khaasi dawa’ (a routine cough and cold pill) and trusted the hospital at Ganiyari to care for him better. 

I was struck by the reality of the state of public health infrastructure here, which in this case wasn’t just ill equipped, was virtually non -existent. [A recent WHO report has estimated that the state of Chhattisgarh has about 3818 sub centers, 517 PHCs, 116 CHCs, 30 civil dispensaries, besides 16 civil and 15 district hospitals, catering to a population of 20 million people, 79% of which comprises rural populations and about 31%, tribal.] To add to this state of affairs, Chhattisgarh does not have a functioning public transport service, further crippling access to healthcare, among other things.

In the midst of this, it was truly heartening to note the impact of Jan Swasthya Sahyog, working in conditions where healthcare was probably needed the most. As Dr. Jain put it, the doctors were here to explore and address human deprivation as medical technicians! That too, at a time and place, where the public health system has seemingly, failed the people.

By Prianka Rao