15th - 16th June
Our first field visit as CHLP fellows was to Hannur, a town in Kollegal taluk in Chamarajanagara, a district in Karnataka that borders Tamilnadu. We left early Sunday morning and arrived there in the afternoon. We had briefly discussed the plight of border districts – they tend to be neglected and usually have lower developmental indicators than the rest of the state. Chamarajanagara continues in this trend, with indicators more like northern rather than southern Karnataka.
In Hannur, a group of sisters of the Holy Cross Congregation run a community health intervention. It was initiated by Sr. Aquinas, a doctor who worked in a nearby Order-run hospital. She noticed the poor rate of retention of TB patients on DOTS (Directly Observed Treatment, Short-course). Patients who stop the treatment mid-course are more likely to develop drug-resistant TB, which can then spread in the community. She decided to train community health workers to provide follow-up for TB patients. As she and other sisters began their work, they realized that TB was the least of the problems that plagued these rural, mainly Adivasi communities.
Since then, the Holy Cross Comprehensive Rural Health Program at Hannur has trained a number of women in basic healthcare, safer deliveries and herbal medicines. Sister Teena gave us a brief presentation of their work. Beyond training CHWs, the Hannur Program has also organized health camps with GPs or specialists such as opthalmologists and has conducted sessions on health and nutrition in government schools that are designated as Health Promoting Schools. With help from Vellore Medical College (VMC) and CHC, they have developed a Health Information System that collects health data, analyzes the outcomes of specific interventions and makes the case for new ones.
The Program has partnered with a local NGO, MYRADA, to work on watershed development and some income generation activities. It is now actively involved in preventing child labour in the region. Child labour rates are very high in the district and in recent years, NCLP (National Child Labour Project) has focused efforts here. The Hannur Program works to identify children who have begun to work or who are at risk and places these children in a residential school.
This aspect of the Hannur program's work is controversial and Sister Teena was quite open and frank about it. Before NCLP got involved, the sisters would themselves go to meet the child, get the parents' approval for their child's placement through persuasion or with the threat of reporting their illegal action. In some cases, they have paid off bond money if the child was bonded to some landowner, factory owner etc. Now, with NCLP conducting raids and follow-up, their direct intervention is usually not necessary. But problems remain. Sometimes raids net children who are going to school and working evenings or weekends to pay school fees or buy books. The problem is: according to the law, children should not be working at all. Another aspect some of us found troubling was that children are effectively removed from their parental home and have very little contact with their parents afterwards. Sister Teena said that organizations working on the issue have found this to be the best approach.
The patience, strength and conviction exhibited by the sisters and staff when talking about their work was quite impressive. There is limited support within the church, as with most big institutions, for this kind of work that involves learning from the community and adapting to fit its needs. Yet these women soldier on and take satisfaction in every achievement, big or small.
The next morning, we went to visit the MYRADA office in Hannur. This centre coordinates the watershed development efforts in the area and conducts vocational training for TV repair, basic computer maintenance etc. They also provide operational support for a number of Community Based Organizations (CBOs). Most recently, they have started working with Panchayats on Participatory Planning activities.
From their talk, I received the impression that this is a typical NGO, which gets money to implement programs and therefore does them. One thing stood out – the charges for the vocational training. For training in driving, the NGO charges Rs. 2000. This seemed comparable to and maybe more expensive than commercial driving schools. I asked about job opportunities for this and other trainees and learnt that they mostly move out of the area to Kollegal, Mysore, Bangalore etc. and remit money home. How does this benefit the local community? Sure, more money flows into households, but is an NGO necessary for this kind of improvement?
Our next stop was the Hannur Primary Health Centre (PHC). At CHC, we have been learning about the basic amenities that government health services must provide and received a questionnaire that is being used by groups involved in community monitoring. We started our visit with the PHC Medical Officer (MO). This person was quite uninterested in us until he realized that Sukanya, who was coordinating this trip, is a doctor. Then he wanted her to be seated and have a cup of tea, which she very politely refused! He gave us some details of the PHC's operation and gave us permission to tour the facilities. All through our discussion, he continued treating patients, which was quite an education for us...
This PHC used to conduct minor operations but now is only restricted to deliveries. As with most other PHCs, it is understaffed – the lab technician and pharmacists alternate their time between this and another PHC. However, it had a functioning lab where we observed a simple haemoglobin test. They also conduct tests for various infectious diseases including TB. The pharmacist showed us their ice box which is used to store vaccines. It is able to maintain the correct low temperature for up to 24 hours without electricity. There are smaller ice boxes that the ANMs take with them on immunization days.
Later, the Block Health Officer (BHO) talked to us about his tasks. He is responsible for checking water sources to make sure they are fit for drinking, monitoring for malaria and other outbreaks, working with Village Health and Sanitation Committees (VHSCs) and more. He elaborated on the staff shortage – 4 of the ANM positions and 6 of the Male Health Worker (MHW) positions have not been filled. Each ANM is responsible for running a subcentre – if there is a shortage, many are responsible for 2, which means that many subcentres cannot open every day. The technician, pharmacist etc. shortages are rampant. Even this BHO is responsible for 2 blocks. With conservative thought dominant in India and throughout the world about the 'inefficiency of government' (paradoxically, alongside huge government programs), there is a deep reluctance to hire staff. This then leads to failures in the Health system, overworked employees and low morale. However, the BHO was still quite upbeat and positive about his work – kudos to him.
Finally, we went to see the delivery room with the staff nurse. There had been a delivery just that morning and the room still had a strange smell to it. A sterile delivery kit had been used and the room in which the new mother and her baby lay was in reasonably good condition. There has been a large drive nationwide to encourage institutional rather than home delivery. Families receive a cash allowance on the birth of a child, which is higher if the delivery is in the presence of a trained physician and also higher if they are Below Poverty Line (BPL). This scheme is called the Janani Suraksha Yojana (JSY).
In Karnataka, the new mother also receives a kit with a blanket, some clothes for the child etc. under a scheme called Madilu. We looked at a few of these kits. Finally, we talked briefly with a few ANMs. They looked so young, barely out of girlhood! Later, we learnt a snippet of history from Ravi (Narayan) that helped put this in perspective. After independence, one of the first needs of the young nation was to establish medical and nursing colleges. Rajkumari Amrit Kaur, the first health minister, pushed for training older married women as nurses. The dai tradition was strong and continues to be strong in India. As a rule, dais have experienced childbirth themselves. This helps them to be more empathetic to the to-be mother's pain. Further, by their age and experience, they have some respect and following within rural communities. How could young girls, fresh out of school, be expected to talk about family planning, child rearing techniques and more in rural India? But Nehru, in his continuing fascination with the West, vetoed this idea and the tradition of training girls right out of school was established. What a pity!