Perched atop the Aravalli hill range, the fort of Bundi overlooks a large expanse of houses painted white and blue. Scattered among them are a few havelis that remind the visitor of the region's rich heritage. At a stone’s throw, there’s a lake. Its view from Kipling’s Palace—the house where the famous British poet and novelist once stayed—will put even the most restless minds at ease. But travel further into the hinterland and realisation dawns that Bundi suffers a curse.
Many children born in the district don't survive infancy. For every thousand babies born in Bundi, 72 die. In Rajasthan’s context, this is one of the highest infant mortality rates (IMRs)—Jalore, with an IMR of 81, tops the list. This is particularly surprising because neighbouring Kota has a relatively low rural IMR of 44.
Gaping holes in infrastructure
Bundi’s health infrastructure is much like its fort. It looks strong from far. But inspect it from closer quarters and one finds it crumbling from inside.
I visited three Community Health Centers (CHCs) in three different blocks—Nainwa, Hindoli and Talera. At Talera, an immunisination camp was underway; the wards were full and nurses flitted about, giving the impression that it is a functional institution. Things were not radically different in Hindoli or Nainwa.
| Ray of hope
||Despite the poor healthcare system, the Janani Shishu Shuraksha Karyakram (JSSK), launched by the Centre in September 2011, seems to be fairly functional in Bundi. Under this scheme, women get free transport for delivery, medicines and food. Sick new-borns are given free treatment up to 30 days after birth. Besides, the district has a proactive district magistrate, Aarti Dogra. Excerpts from a chat with her:
The district of Kota, which is right next to Bundi, has a low IMR of 44 (rural). Bundi has 72. What's wrong?
There’s a huge difference in terms of economic variables between the two districts. Industrialisation is a big factor. We have a greater rural population, and our economy is dependent on mining and agriculture, while they have a number of industries. Differences in terms of literacy also make an impact.
What have you done at your level to reduce Bundi’s IMR?
We’ve carried out campaigns in Dabi and Nainwa. We’ve seen an increase in institutional delivery and decrease in home delivery now that transport is being provided free to women. Now that all these facilities are being provided, we think we will improve our IMR. We have a programme called high-risk pregnancy tracker, under which the local nurse-cum-midwife keeps track of pregnant women. If we find any abnormalities, that woman becomes our priority. PHC doctors check her medical history and regularly check her for anaemia and high BP. We put a circle mark on the houses of women with high-risk pregnancy. This alerts everybody in the vicinity. So if there’s any problem, the woman can easily get help.
IMR data collection is a challenge. Do you have a system in place for improving this?
We have a software, which we built in association with non-profit ARTH (Action Research and Training for Health). This has been going on since 2010, and is specific to Bundi. As part of this, all nurse-cum-midwives have mobile phones. They send us details of delivery and vaccination through an SMS. This message goes into our server and from there I get an SMS. If there is an infant death or maternal death, she sends an SMS which is forwarded to me and the chief medical health officer. This data is also simultaneously sent to ARTH which audits the data.
This system has increased reporting. Within 24 hours, we can track a case of maternal or infant death and figure out what went wrong. National Service Scheme volunteers track maternal deaths and home delivery. They go door-to-door to find out why the woman could not be taken to the hospital.
Why can’t the women in labour go to the hospital? What do your findings say?
We found that the number of home deliveries increased during rainy season. This is something we’re going to look into and see that rains don’t become a problem for expectant women.
We are running another special programme called Sakhi. Sakhi consists of college volunteers, who on Monday and Friday perform local songs and and plays to spread awareness among women about hygiene and nutrition. The DM also attends such meetings.
Our short-term plan to make sure the delivery is safe and we’re also very particular about the first month after delivery. We make sure we provide women with the best post natal care in the first month.
But a few enquiries threw up some mind-boggling facts. None of the CHCs had a gynaecologist or an obstetrician. Talera, in fact, has an ayurvedic doctor assisting childbirth. When asked, she said she had SBA (skill birth attendant) training, so it was not unethical on her part to attend deliveries. This training, which lasts six months, trains women in basic handling of pregnant women due for delivery.
Talera, which is called the model CHC of the district, is short of specialists too. Out of six doctors posted there, one was an AYUSH doctor, one was a homeopath, and one had a diploma in paediatrics. The other doctors were just MBBS. The post of the gynaecologist has not been filled for the past two years. No caeserian operation is conducted in the hospital because there’s no surgeon. The hospital also lacks an incubator and a warmer for new-born babies even though it handles 140 deliveries a month. When asked why these were not in place, Mohan Lal Verma, the medical officer in charge of the hospital, says funds are not enough. The hospital gets an annual maintenance grant of Rs1 lakh, which was just enough to repair the windows and the drug store. They received untied fund of Rs 50 000. Verma says most of the untied fund goes into reimbursing mobile allowances of the staff.
In the CHC in the Hindoli block in Bundi, Seema Chauhan, the medical officer who handles the gynaecologist’s duties, says that doctors are reluctant to come to areas like Hindoli and Nainwa, mostly because there are no good educational institutes where their children can be sent. In contrast, Kota attracts doctors because of its education hub status.
One official informed that 80 per cent of the medical posts in Bundi are vacant.
A sub-centre in Laxmipura village in Talera block was locked. Enquiries revealed that the nurse-cum-midwife of the sub-centre was on maternity leave and had been absent for a month. A kilometre from the sub-centre, a quack doctor had a flourishing practice where he was preparing a syringe to inject ampicillin antibiotic to an 11-month-old infant for what looked like a case of flu.
Villagers near a public health centre (PHC) in Nainwa said that the in-charge of the hospital was hardly ever present. When I visited the place, a compounder was dealing with patients.
I also checked out an anganwadi meant for pre-school children. I found there were no kids there during school time. The accredited social health activist (ASHA) present there, who is supposed to take care of the nutritional needs of the children in her charge, was in a hurry to leave for some personal work. When asked if she was going to make the routine ten house calls to check on pregnant and lactating women, she said she wouldn’t because she had some other work.
The poor infrastructure and lack of staff at the CHCs and PHCs has increased the burden on Bundi's district hospital. Almost 45 per cent deliveries at the district hospital are referral cases from rural areas. The resident paediatrician, K G Gagireni, said the number one cause of infant deaths in the hospital is septicaemia, which is a type of deadly bacterial infection affecting blood. “There are not enough nurse-cum-midwives in the hospital, which handles 5,000 deliveries a year. Since this is a huge number for the available staff to handle, they cannot take adequate hygiene measures, leading to septicaemia.”
I observed a direct correlation between education and the health status of a district. According to the 2011 census, the overall literacy in Bundi district is 47 per cent, not much better than Jalore's 37 per cent. Kota, unsurprisingly, had the best literacy rate of 72 per cent. In Kota, I hadn’t encountered a single non-literate woman, but here in Bundi, every one in ten women I met had never held a pen in her hand.
The mothers-in-law played a key role in what the pregnant women eat. If women knew for themselves what they’re supposed to eat when they’re expecting a baby, they would be better off. Similarly, some women did not take their infants for immunisation for fear they would develop fever—a side-effect of some vaccines which lasts about a day or two. The nurse-cum-midwives and ASHAs, who spearhead the immunisation drive in the state, have a hard time explaining to women that a day’s fever is a small cost to pay for a life-time of health and wellness.
ASHAs not empowered
In a village in Nainwa block, I caught up with a couple of ASHA sahyoginis. Compared to some other states like Uttar Pradesh and Uttarakhand, the ASHA’s of Rajasthan are much better off. They get a basic salary of Rs 1,000 from the department of women and child. They get additional incentives based on the work they do, like ante-natal and post-natal check-ups and taking a woman to the hospital for delivery. The ASHAs moaned they’re not able to do their work properly because the department loads them with additional work. “We have to even go and register women with the rural bank,” one ASHA complained.
ASHAs are the spine of the rural health programme in Kota. However, in Bundi, there were several areas where villagers do not even know who ASHA is.
The reasons for Bundi's crumbling health infrastructure are many. After covering Kota and Bundi to extensively, one shortcoming in Bundi was glaringly apparent: lack of zeal.
In Kota, I met health stalwarts—doctors, nurse-midwives and lady health visitors (LHVs)—who, through tireless dedication, were propelling Kota’s health system to achieve better health for all. Kota’s health infrastructure wasn’t without fault—the best CHC in the district hadn’t been supplied with methergine (used to stop bleeding after delivery) for the past few months. But despite the shortages, the health stalwarts were indefatigable.
I met a number of ASHAs, nurse-cum-midwives and doctors in Bundi. They were at work, but that’s about it. They did not take it upon themselves to make the system work.
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