Fractured/Earth

On the 23rd of January, Savitri Sahu was woken up by the family of a woman who had gone into labour. We borrowed a tractor, she says, took her to the primary health centre, woke up the doctor and the nurses, got the delivery done. Given that most rural clinics we hear about lack doctors, nurses, medical supplies and are shuttered most of the time, what explains this unusually conscientious health centre, that too in underdeveloped Bastar? Is this a micro-experiment by a committed bureaucrat or NGO or an especially aware and vigilant community? No. Savitri Sahu and Ushamani Kashyap are Mitanins. They were trained by the government of Chhattisgarh to work as community health workers. At last count, Chhattisgarh had 60,000 such women, spanning all 54,000 hamlets in the state. Between them, they have almost halved infant mortality, radically improved childcare practices, and forced the health system to improve.

At a time when debate is raging on whether the Indian state can effectively deliver social services, the Mitanin programme illustrates one side of the discussion — that, with a little reform, the state can indeed deliver.

Read the complete story here.

ps – i am also appending the original raw text of the story here. the story as originally written was a good 1000 words longer than what was finally carried.

A group of women are sitting under a banyan tree, discussing their recent experiences with rural healthcare. There is Savitri Sahu, talking about how she was woken up by the family of a woman who had gone into labour. We borrowed a tractor, she says, took her to the primary health centre, woke up the doctor and the nurses, got the delivery done. This is a recent improvement, adds Ushamani Kashyap. Till a couple of years ago, she says, the doctor lived at the nearby town of Sonarpaal, and travelled down to the health centre every day. Some days, he would come late. Other days, he would not come at all. Those times, the wardboy did the diagnosing and administered medicines! And then, the doctor began coming on time. Later, he moved closer to the rural clinic itself.

Given that most rural clinics we hear about lack doctors, nurses, medical supplies and are shuttered most of the time, what explains this change, that too in Bastar? Is this a micro-experiment by a committed bureaucrat or NGO or an especially vigilant community? No. Savitri Sahu and Ushamani Kashyap are Mitanins. They were trained by the government of Chhattisgarh to work as community health workers. At last count, Chhattisgarh had 60,000 such women, spanning all 54,000 hamlets in the state. Between 2004 and now, they have almost halved infant mortality, upped the percentage of births in clinics, almost trebled the incidence of breastfeeding within the first two hours of birth….

How did they manage this? Briefly, partly by pushing better health practices within their hamlets. And partly by defining the right to healthcare as nothing less than a fundamental right, and demanding better service from the public health system. The assumption was that as the clamor for better healthcare grew, the state would have to respond. In the process, it has provided a good balance between state action and individual behavioural change towards improving health in this poor, poor state. Further, before it came along, it was believed that scaled up community health programmes by the government do not work. Mitanin broke that assumption.

In these times when debate is raging on whether the Indian state can deliver social services well, the Mitanin programme illustrates one side of the discussion — that, with a little reform, the state can indeed deliver.

For all that, the story of how the Chhattisgarh government used community health workers to fix its public health system, navigated a political and bureaucratic maze to create a cadre of women who would challenge the state’s own health department, and scaled up the programme without sacrificing impact — the usual waterloo for all indian social sector schemes — has not been told.

Fixing the health system
In his room in Nirvachan Sadan, Alok Shukla, deputy election commissioner now, and erstwhile health secretary in Chhattisgarh when Mitanin was being conceptualised, is talking about healthcare in the state when it came into being in 2000. Diarrhoea, malaria, leprosy and tuberculosis were a major problem. Rural infant mortality rate was 95, the second highest in all India. Ten of its 16 districts did not have a functioning district hospital. The state had 146 blocks but just 114 Community Health Centers (there should be one in each block). Its 3,818 health subcentres, each with one auxillary nurse and midwife (ANM), had to cover 18 million people across 54,000 hamlets.

Worse, even this existing infrastructure was not fully used. Partly because the clinics rarely had doctors or medical supplies. Partly because, as one of the villagers ET met in Sarguja, a district in northern Chhattisgarh, said: “Villagers were apprehensive of the hospital. We did not know where to go, whom to talk to.” And partly because, in tribal-dominated forest-covered chhattisgarh, much of the state’s population lives in scattered forested habitations. Health workers found it hard to reach the villages. And villagers found it hard to access health centres.

This, Shukla says, is the larger reality of healthcare in this country. India’s public health system is a giant bureaucracy dominated by clinicians. In the system they created, treatment of diseases takes precedence over prevention of diseases and improvement of public health. Further, it demonstrates a strong urban bias — the availability of doctors, health infrastructure, etc, drops as one moves from cities to the villages. On the whole, there is a mismatch between what people want and what the system provides. The result is predictable. Says Shukla: “You go to community health centres with 30 or so beds and you find under-utilization. You see x-ray machines that take no more than 1 or 2 x-rays in a day. Or labour rooms where there has not been a single delivery.”

The question in Chhattisgarh was how to extend healthcare deeper into the state. Given the low utilisation, it was not clear how opening more clinics would help. This doubt was amplified due to the state’s high IMR numbers and the presence of cultural norms militating against good healthcare — colostrum, the mother’s first breastmilk after delivery, was considerd unhealthy; no water was given to mother or newborn for the first 24 hours after delivery.

These are preventive/promotive problems that community health workers (CHW) can fix best. In an essay titled “People’s health in people’s hands: a review of debates and experiences of community health in India,” Harsh Mander, who worked on the Mitanin project while at ActionAid, reproduces this definition of the CHWs: “Part-time semi professional workers from among the community itself who would be close to the people, live with them, and in addition to promotive and preventive health services including those related to family planning, will also provide basic medical services needed in day to day common illnesses which account for about 80% of all illnesses”.

Accordingly, Shukla recommended to the state government that a CHW programme, to be called Mitanin, be started. The word itself was derived from a Chhattisgarhi custom, where a ‘mitanin’ is a girl bonded ceremoniously in her childhood to another girl as a lifelong friend.

Easier said than done
So far, CHWs have been used in two ways to fix healthcare in this country. The first response came from doctors who tried to create an alternative to the public health system. They moved to the hinterland, set up hospitals and trained locals to offer simple healthcare in their villages. These models, like the one started by Raj and Mabelle Arole in Jamkhed, Maharashtra, delivered very high results. For instance, between 1972 and 1992, the Aroles brought IMR in their area down from a staggering 176/1000 to 20. However, one criticism of these models is that they are not scalable. After all these years, Jamkhed covers 60 villages directly. And another 300 indirectly.

Then, the health bureaucracy has been running its own CHW experiments. Partly to extend curative healthcare into villages by grooming locals into quasi-paramedics. Partly to boost capacity utilisation by getting these CHWs to bring more complicated cases to clinics. For instance, Madhya Pradesh’s Jan Swasthya Rakshak programme, launched in the nineties, trained local men at primary health centres for 6 months. As it were, the programme bombed. In part because most of the training was curative. Which created an incentive for the men to make money by seeing as many patients as possible. They rapidly became quacks.

The outcome is a binary mess. Large CHW programmes have not worked. Small CHW programmes, while high on impact, do not scale. And yet, given the size of the country, what is needed is effective social sector programmes that can work at scale.

Now, Chhattisgarh tried to forge a middle path. It was decided that only women could be Mitanins. They would be chosen at a hamlet level. Since hamlets are more homogenous than villages, this would reduce the likelihood of the Mitanin not entering the house of an upper/lower caste. To ensure local elite didn’t capture these positions, the women would not be paid for their work — having one woman per hamlet (about 40-60 households) also ensured the workload would not eat into her livelihood. To emphasize the public health role of the mitanin, curative would play second fiddle to preventive and promotive healthcare. And the mitanin would be selected by the community — not the health bureaucracy.

Subsequently, it was decided that her main function would be to assert the community’s right to healthcare before the health system. It was also decided to set up a technical support group called SHRC, State Health Resource Centre, to run the programme. Partly because the mitanins, owing to their activist mandate, couldn’t possibly be placed under the health department. And partly because programme implementation called for skills the health department lacked — like mobilising communities before choosing mitanins, collaborating with civil society groups for training, etc… And third, a larger process of reform to turn the health system on its head, so that it would begin listening/responding to the CHWs, was started.

In May, 2002, pilots began in 14 of Chhattisgarh’s 146 blocks.

By this time, state elections were just 1.5 years away. Not only was CM Ajit Jogi pressing the model to scale up, the project itself knew that it needed to show results to retain political goodwill. Accordingly, once enough data had been generated to finalise the programme design, it was decided in January to scale up to 40 more blocks. That was completed by July. With the elections slated around the end of 2003, it was decided around October to scale the programme up across the state. By June 2004, there was a mitanin in all 54,000 hamlets.

The Godzilla Postulate (or making things work at scale)
To understand how Mitanin has tried to combine scale and impact, ET met Sundararaman. Now heading the National Health Systems Resource Centre at Delhi, a technical body advising the central government on NRHM, he had entered SHRC with almost unique qualifications — he was a doctor, he had helped scale up the total literacy mission, and was known for being very details-oriented — useful skills for someone who had to train lots of women about healthcare. Fast. “As one scales up”, he says, “There is a loss of motivated leadership. There is greater transmission loss in training. The quality of on-the-job support and training goes down as well. Also lost is the tradition of working with the local community.”

That afternoon, he drew a simile to electrical engineering. In a small CHW model, he said, where the founder trains every individual, there is no transmission loss. In a large project, there will be. And so, “What are the priniciples for reducing transmission loss? You have high voltage at the starting point, a clear channel for transmission, step-up boosters at different points, and you have to measure transmission at different points.”

And so, he did two things. First, he reconceptualised some aspects of the programme. For instance, the women would be trained every four months for as long as the programme ran (the Jan Swasthya Rakshaks had been trained only for the first six months). To ensure trainers and managers did not forget the ground realities, it was decided that only people living at a block level could join as district resource persons, and that trainers would have to double as field coordinators. Second, he laid down elaborate, standardised processes for everything — selection, training, on-the-job support, skill development, motivation, supply of drugs, monitoring learning outcomes, the spirit of the programme.

On the whole, SHRC was the high-voltage starting point, churning out training programmes, monitoring implementation, etc. The adherence to processes reduced transmission loss. The multiple trainings were the step-up boosters. Process evaluations measured transmission.

Take training. SHRC had created books on child health, maternal health, etc. Trainers had to go through these line by line with the mitanins. Says Sundararaman. “You are not allowed to give a speech on the book even if you can give a better speech. So that, whatever happens, the minimum set of things are conveyed.” The content itself was rooted in the practical. Take malnutrition in a child. The mitanins were taught to inquire about the child’s feeding practices, medical history, malnutrition in the family itself (economic factors, the mother’s age, spacing intervals between children, etc), its access to health, child-care and food security services. They were also trained to not convey gratuitous messages like “Give nutritious food”. Instead, they had to discuss the problem in the presence of the husband and the mother in law, and any suggestion they made had to be acceptable and pragmatic.

Or take the spirit of the programme. That was communicated through songs and kalajathas (skits) — an idea that came from their use by people movements to build and retain a sense of mutual solidarity. The songs, written in song-writing workshops by Chhattisgarhi folk singers and writers, paint a popular image of the mitanin in the local idiom – ‘Sukh mein sabei saath, dukh mein mitan’. The Kalajathas reinforced that image as well. In their first act, a familiar health scenario would be depicted – a patient suffering from diarrhoea, a shivering malarial victim, an underage girl weakened by pregnancy, all of whom pass away due to lack of treatment. In the second act, the same scenario ends differently with a woman giving oral rehydrate to the first, quinine to the second, and taking care of the third by first ensuring she doesn’t get married too early, and subsequently during childbirth. When the villagers asked who woman is, the Kalajatha team would say she was a mitanin, that she would be selected soon, from their own hamlet, and that she will be trained to look after them. Next, the mitanin selection team would come by and help villagers choose a woman as their mitanin.

The spirit had to be communicated well, says Sunderaraman. Partly because, for mitanin selection to be meaningful, a lot of women needed to come forward. For that, one needed to charge the place with a positive environment. And partly because different stakeholders had different views of the shape the programme should take. For instance, Sundararaman says one reason Jogi backed the programme was that a village-level cadre beholden to him would take shape. Similarly, the health bureaucracy, especially after Shukla moved off the health department, favoured a more instrumentalist role for the mitanins. If the spirit of the programme had been communicated through the government, its activist dimensions would not have come through.

The upshot of it all
So, how successful has the programme been at cracking this zero-sum game between scale and impact? Take Narayanpaal. Once training began, the mitanins sitting under that tree tell me, they were told to refer patients to the government clinics. In the early days, villagers who went there found the clinics locked. The mitanins reported these failed trips to trainers who passed the information onto block medical officers. Slowly, the doctors began coming on time. As for the ANM, as the villagers figured what services they were entitled to, they told the nurse to stay at her office between 8-9am before leaving on her beat.

At Raipur, Samir Garg, who now oversees the programme, told ET that rural infant mortality is down from 85/1000 in 2002 to 44/1000. A UNICEF study in 2005 found the incidence of breastfeeding in the first 2 hours after birth had risen from 24% to 71% of livebirths. A National Family Health Survey study, also in 2005, reported the use of oral rehydration salts had climbed by 12%. Much later, I talk to VR Raman, one of the team members who developed the Kalajathas, and he tells me that 500 of the state’s 717 PHCs now offer 24X7 service.

Now, while it is hard to quantify the precise contribution of Mitanin to indices like child mortality – there are too many other variables around poverty and disease at work — the dramatic improvements in childcare practices can be traced back to the emphasis on preventive and promotive care. That said, as Garg says, the rate of improvement in health indices is slowing. This suggests that the low-hanging improvements have been made. The larger question here is whether a health programme can deliver health on its own. Says Arole, the co-founder of the Comprehensive Rural Health Project, Jamkhed, “Health is also about ensuring nutrition, clean water, a healthy local environment and education. We need to have a good implementation of all these programmes.”

Like all development programmes, Mitanin has thrown up complex outcomes. In some areas, there has been elite capture. In others, young mothers were chosen as Mitanins. Elsewhere, weaker Mitanins are being ordered around by the ANMs, who see the CHWs as the lowest rungs of the health bureaucracy. And, yet, there are also areas where the programme has worked as planned. To go back to what Arole says, some Mitanins are indeed linking health to the proper functioning of the PDS, NREGA, etc, and are deploying the rights discourse there as well — Savitri Sahu started our meeting by saying she and other Mitanins make it a point to be present when the PDS shop is giving out rations to ensure that all households get their full 35 kgs. But this is not happening across the state. But, as Sundararaman says, the programme is dynamic. And, over time, the women will slowly make their own meanings of the programme.

The programme’s scale has drawn flak. For instance, Arole feels Mitanin has struggled to find enough good trainers, and that the women have not been monitored as regularly as they should have been. “At Jamkhed”, he said, “We find the women speak most freely in the evenings. and so, the evaluators spend a night in the village. On the other hand, at Mitanin, the trainers visit once every two weeks. and most of that time goes into collecting data.” But scale is needed too. Take what happened in the state elections mentioned earlier. Jogi lost. The BJP’s Raman Singh took over. Worried that he might discontinue what was a Congress programme, Sundararaman and Shukla were making a nervous presentation introducing Mitanin when Raman Singh cut them short. And said that Mitanin was working in his constituency, and that it was doing good work. Says Shukla, “If this had been a small project, he would not have known about it. And Mitanin would not have enjoyed the support it got that day.”

That said, challenges exist. Relations between the bureaucracy and the mitanins continue to be fraught. Some bureaucrats are complaining about mitanins meddling in PDS and NREGA delivery. The balance of power between mitanins and ANMs has shifted towards the latter since the creation of the Janini Suraksha Yojana which pays the CHW for every birth in a clinic. The ANMs are making the mitanins run around for that fee.

But the strangest footnote in the story of the Mitanins comes from NRHM. Once Mitanin proved that scaled up community health worker models can work, the government of India used Mitanin as a part of its template for NRHM’s CHW (ASHA, or Accredited Social Health Activist) programme. And yet, by the time that was finalised, nearly all of the Mitanin formulation was ignored — the ASHAs get paid, selection is at a village level, training sessions have been dumbed down…

More on that in the next story.