Loose Pants, Loose Government

“Jaise maire patloon dheeli hai, vaise sarkar dheeli hai (Just like my pants are loose, like that the government is loose)” – Me, irritated.

The days are getting slightly warmer here. I had just made the walk (road by road) to the panchayat ghar in the village of Baret. A leucorrhoea health camp had been organized in conjunction with the local government hospital, the Primary Health Centre in Malla Ramgarh. At the last minute when the folks at the PHC flaked out, I gotta say I was pretty damn annoyed, and I had no choice but to speak on it.

As soon as I reached Baret the words that were slamming against the inside of my head went through the lacking translation factory of my tongue and exited as my utter frustration manifest. “What is the deal?! We’ve been trying to do one camp here with the PHC for like six months. Pradhanji has gone multiple times to the PHC, I’ve gone multiple times to the PHC, and received a confirmation from the doctor and his supervisor that the camp would happen today, and a written proposal has been sent there. And it’s not even about today. The PHC can’t give one day in six months when a Gram Panchayat, the local village government, is asking them to come provide some health services? The government is saying do this, do that. The health committees have been formed, they’ve written out yearlong action plans, they’ve written out formal proposals, now what?” (Yeah… it’s sounds so much better in Hindi).

Throughout my rant as I stumbled over my Hindi grammar, the Gram Pradhan and CHIRAG field workers nodded a long, some serious, others with the amusement beaming from their faces. But I was heated. It’s not just the fact that one camp didn’t happen. It’s a larger issue that has become quite clear, that there is an unwillingness or lack of interest from the local health infrastructure to work directly with Gram Panchayats on preventive health. Last month a proposal was submitted to the Chief Medical Officer of the entire Nainital District, directly, in his hand, on behalf of eight Gram Panchayat health committeees, and CHIRAG, about the need to hold leucorrhoea camps in the vicinity of their villages. Leucorrhoea has been identified as major health problem, cited as affecting anywhere between 50-80% of women in these given villages. While simply treatment won’t solve the problem completely, it will provide much needed relief in the short term. The CMO said he would take this up with the PHC and help ensure these camps happen. Despite attempts at following this up, no word or confirmation has come from the PHC.

“And I don’t buy the argument that this is India. This is how things work here. What is that even supposed to mean? I am not sure I know. What I do know is that the people at the hospital are competent, the facilities exist, and that over the span of five months there is a time to conduct a camp, when the Gram Pradhan, the Gram Panchayat, and the neighboring NGO have all expressed an active desire to organize such activities. Why can’t they come?”

A few days before I was in Bageshwar, another district that CHIRAG works in on a number of issues, including recently with Panchayats on preventive health. After a two-day workshop with health committee members, we had gone to meet the Chief Medical Officer regarding the supply of chlorine tablets, the absence of ASHAs (Accredited Social Health Activist) in many villages, and to discuss further coordination. The CMO in Bageshwar was quite straightforward. He didn’t know of any other Gram Panchayats organizing on health, though he knew that under the NRHM they are given a central role. He asked who the members of the health committee were supposed to be, how ASHAs were to be selected, and was all in all fairly clueless about a lot of the process. He called me a Gandhi-wallah, which, given the entire situation I guess was slightly amusing.

“What is the deal?! Sometimes I just don’t get how this is a nationally-devised scheme from the central government, that Uttarakhand is supposedly a high-focus state, and that the program is supposed to be on-going for the last four years now.” And it’s not even to say that nothing is happening, because things are, but sometimes it can be slightly unnerving to see such gaping holes in the system.

But just as my pants tend to dangle a bit, so it goes. And yeah, a letter to the District Magistrate, and the CMO, has been drafted, and hopefully further attempts at coordination will prove to be more fruitful. But, if this is supposed to be something that exists not simply on paper, there needs to be some accountability. The Panchayats are doing their part, as is the NGO, but where is local government?

National Rural Health Missing?

National Rural Health Missing?

“This is activism."
“This is what I know how to do.”

Since my arrival last September in Kumaon, at the foothills of Himalaya, the focus of my efforts has been working to address issues of public health with local communities. This has mainly involved organizing alongside Gram Panchayats. Gram Panchayats are elected local village councils that deal with social, economic, and developmental issues of the community. The Panchayati Raj system is backed by the Indian Constitution, which gives certain responsibilities and authority to panchayats to address issues of social justice and development. Since September I have seen my work slowly moving along, progress and small victories here and there, but it certainly hasn’t been easy. It’s involved a lot of patience, waiting for people to get on board, both in the communities and NGO, for meetings to start and action to be taken. It’s involved a lot of walking, up and down hills, across streams and through villages, at times for eight, ten, twelve kilometers a day. And it has included an immense amount of learning – about rural India, development, public health, village governance, and myself. It’s the type of work where the results don’t necessarily show in any sort of immediate timeframe and the questions only increase as time goes on. And honestly, every so often I have found myself questioning what impact I am having. In the long run, are these efforts I am undertaking enough to make a difference? Sometimes I wonder. But enough about me, what about rural health?

In brief, over the past eight months the process I have been helping with has involved forming health committees through village panchayats, providing trainings and workshops to these committees on their roles, responsibilities and rights, identifying main health issues and problems, writing out yearlong action plans to address the major health issues identified, and beginning the implementation of these plans. The issues range from anemia to waterborne illnesses (diarrhea, jaundice, typhoid, worms) to women’s health problems such as leucorrhoea. Importance is placed on antenatal care and on child health, specifically, ensuring that children are receiving the proper vaccinations. Health committees also address basic hygiene, cleanliness, and sanitation. This type of organizing has also included ASHAs (Accredited Social Health Activist) and ANMs (Auxiliary Nursing Midwife), in short government health workers that in different capacities work to address various health-related issues in villages. And in recent months implementation of the action plans drafted by health committees has begun. De-worming tablets have been requested by health committees and distributed, hemoglobin tests to check for anemia have been done, and springs and water tanks have been cleaned to help combat waterborne illnesses. Health camps on leucorrhoea have been planned and letters to the block and district levels have been sent.

Here’s one really quick anecdotal example of something that’s been achieved. For up to two years in many villages Iron Folic Acid (IFA) tablets have not been available through local government health supplies. It is strongly recommended that pregnant women take 100 tablets while they are pregnant (200 if they are anemic as well). In an attempt to get IFA tablets restored I spearheaded a campaign where Gram Pradhans and health committees sent multiple letters to both block and district health departments inquiring over the lack of IFA supply. Gram Pradhans even took up the issue at Block Development Committee meetings, a place where issues of health are never raised. Four months after the initial letter was sent word came from the Chief Medical Officer of the entire district that IFA supply would be restored for the entire Ramgarh block, and has now reached the majority of villages. A similar campaign was initiated to restore the supply of Vitamin A dose for children, which has been absent for almost three years. A couple days ago a letter from the CMO arrived informing CHIRAG (the NGO) and Gram Panchayats that Vitamin A is also being fully restored to the entire block. Chalk two up in our column.

All of these efforts have been within the larger context and framework of the National Rural Health Mission (get it? Mission, Missing. I thought it was kinda clever…), an Indian central government program initiated in 2005 to better attend to health in rural parts of the country through a number of different programs. While the NRHM covers the entire country, there is special concentration on 18 high-focus states (including Uttarakhand) “where the challenge is the greatest.” The NRHM specifically focuses on a decentralized approach that gives much decision-making and planning power to the grassroots level through village panchayats. In theory, action plans made at the village level are supposed to help determine the block’s, and in turn, the district’s health agenda. The idea is to empower communities to take ownership over public health in their villages. Another portion of the NRHM is the realization of Indian Public Health Standards, which aim to improve the level of government health service delivery. While on paper the NRHM may seem quite solid in its approach, the reality on the ground is much different and in remote areas there are still many challenges to be faced.

As the opening steps of implementation of these action plans unfold and village communities and health committees slowly become more familiar with health issues and use to the idea of taking action on these issues, there’s another idea I have had. The reality is that when illnesses or health problems strike, the majority of people make the several hour trips to the nearest towns of Haldwani, Bhowali, Almora, or Nainital. While more local facilities exist they are often underused and under-stocked. For smaller illnesses and injuries these local sub-centres can play an important role. As I see it, along with implementation of action plans, health committees could visit sub-centres to see what supplies and facilities are and are not available. Equipped with a list of what should be present, according to Indian Public Health Standards, such a visit would firstly familiarize committees and villages with what is available at their local centers, and secondly provide a platform for these committees to place pressure in order to ensure that the facilities and supplies that they are due will arrive. At this point I’d like to note that this is not to put all the blame on local government facilities or on the staff that work there. Nor is this is to say that the state is doing nothing. While health issues have not received the urgency they deserve, and there has been a slow response, some efforts have been made to address health. One example is 108, an emergency ambulance (and fire/police) service that has been introduced as part of the NRHM, is functioning fully in this area, and is used frequently (especially for deliveries). Even the name of this piece is posing a question. And the response is clear that things are gradually happening to address health and clear that there is plenty more to be done.

In my very-much-so imperfect Hindi what I have been pushing for with my colleagues and with committee members alike is for a more pro-active stance in seeing that health facilities provide what is needed. “­Dekho, apne aap kuch nahin hota. Thora sa dabana, thora sa hilana, phir kuch ho jayega. Agar log awaaz nahin uthayenge toh sarkar sochegi ki subkuch thik hai. Koi dikkhet nahin hai. Aur ye jhagara ke baath nahin hai. Ye apka adhikar hai. Aur ye main nahin bol raha hun, CHIRAG nahin bol raha hai, sarkar bol rahi hai ye sare subidha hona. Humen sirif dekhna kya hai or kya nahin hai. Phir is jankari ke saath hum kuch kar sakhate hai” (“Look, nothing happens on it’s own. You have to put a little pressure then things will happen. If people don’t raise their voice the government will think everything is fine. There’s no problem. And this isn’t about fighting. These are your rights. And I am not saying these facilities should be there, CHIRAG isn’t saying it, the government is saying all these facilities should be there. We’re just seeing what’s there and what’s not. Then with this information we can do something”). And so these visits have been planned. At this point it’s not entirely clear if it all will go as planned (but rarely is it ever). What happens from here and how successful this campaign will be are still to be determined – both in the short term and in the long run. Stay tuned though, and I’ll try and keep you posted.

So when my friend and colleague Manish points out that this approach I am encouraging is “activism”, I don’t know what to think. Maybe he’s right. But what are we talking about here? We’re talking about people following up on what is guaranteed to them. We’re talking about be able to have your blood pressure or hemoglobin count checked. We’re talking about pregnant women having access to Iron Folic Acid tablets, and communities being able to purify water with chlorine tablets. The ability to perform a safe delivery outside of a hospital, in an area where the majority of deliveries still happen at home. We’re talking about access to the basics. What I do know is that the background I am coming from is one of student organizing and social justice activism (in Washington DC and more so the surrounding suburbs, a context that is completely different from where I find myself now). And Manish is right when he goes on to say that it’s not necessarily the approach people are use to, but lets not forget that this is also the land of the Chipko movement and of Mahila Mangal Dal.

In any case, it’s been one way I have found myself engaging in my project and trying to build something here. Aside from being slow, and frustrating at times, there are moments where these ideas can also be exciting. Amongst communities and committees interest has been sparked and that spark has led to a little excitement from time to time of my own. It’s exciting to feel the potential of panchayats organizing around issues they haven’t normally done so in the past. Traditionally in this region panchayats have focused on physical development –building roads, sidewalks, and water tanks. Soft-development areas like health or education are relatively new, uncharted territory. This is the first time in this region that panchayats and communities are coming together in this way to address health. It’s been reassuring to see the priority women’s health has taken in this process, as issues of leucorrhoea, anemia, and maternal health, have been recognized as issues that must be addressed. What is more encouraging is that men have been active in identifying women’s health issues and pushing for them to be tackled in what remains a rather patriarchical society. And the moments I am able to see my work and time here through this lens, it’s pretty cool. To be a part of this course, though still in the opening steps, in a process that will take years and years. And it’s meaningful to me to be doing it here, however small my contribution in the larger picture, in rural India. In this corner of the world, in this place, which over the past so many months has become familiar. And if I may remind you, it is health we’re addressing, a fundamental human right, and a fundamental human need.