The gun was placed on my forehead. There were eight to ten men who started enquiring about my whereabouts,” recalls  Balmati Devi, an auxilliary nurse midwife (ANM) of Gumla block, Jharkhand. Holding a stern gaze on me, she takes a pause  and continues, “They were Naxals.” She had an encounter with the armed group this year while passing through the interiors of a forest area to reach a village. The 40-year-old admits that she does not frequently come across them but one incident has scared the life out of her. “I had to bow my head down and keep on answering until they were sure I was an ANM and trying to reach out to the villagers in providing healthcare services.” 
Balmati’s role is to train accredited social health activists (ASHAs), look after aanganwadis in her block and create awareness about family planning and reproductive healthcare in village communities.

“Safety and security due to Naxal activities affect our movement. So, we ensure that our work is finished before four in the afternoon and return to our homes,” says Balmati. 

In order to understand how family planning as a reproductive healthcare service is promoted in these areas, this reporter had to move from one Maoist affected district to another.

It was thirty minutes past four and I was in a hurry to leave Giridih, a Naxal-affected region some 180 km from Ranchi, before the night swept in. Giridih district is the base for security personnel from at least five major paramilitary forces who upped their ante against the Maoist insurgents by launching Operation Hill Vijay this year.



Dhanbad was the nearest destination for me to stay overnight. But to reach there, I had to cover at least 70 km before the clock struck 5.30 pm and cross the central reserve police force (CRPF) barricade on the border of Giridih. A calculated risk which I had to take; otherwise I would have to wait for hours in the Naxal-dominated area until the police completed its surveillance and allowed our vehicle to pass through.

I was anxious to cross the Naxal belt as fast as possible, but Dr Joseph Jeevan Sighamony, sitting beside me, was calm and relaxed. He was accustomed to his surroundings.

A native of Hyderabad, Dr Sighamony works as a clinical services manager for Population Health Services India (PHSI), an NGO which provides family planning and reproductive healthcare services to the vulnerable population in the interiors of Jharkhand.

After joining PHSI in 2015, Dr Sighamony has been moving across rural as well as urban areas of Gumla, Ranchi, Giridih, Dhanbad, Dumka, Deoghar and Bokaro districts. He looks after the clinical services provided by ‘Jyothi’ clinics, set up by PHSI, in these districts.

“Initially it was difficult. But when you are aware of the specific time, like before evening, when security cannot be breached it becomes slightly easy,” says Dr Sighamony.

He admits reaching people in interior areas is a challenge as these places lack reliable transport facilities. “I, though, do not travel alone. I move with someone who belongs to that area and can be trusted,” he says.

Moreover, working in such a terrain is also a herculean task, but Dr Sighamony believes that when people are to be served roadblocks can be easily crossed.

For him the more troublesome part, however, is to explain to villagers what his team is doing and why. “It took more than six months to give an answer for ‘what’ and ‘why’ of our work. The question of ‘why’, when addressed properly, opens a gateway to fill the gap in the services provided by the government hospitals,” says Dr Sighamony who is in his mid-thirties.

His job is to mobilise communities and create awareness about contraceptives and other reproductive health services. His role becomes crucial as India made a commitment at the London Summit 2012 on family planning to give impetus to the regulation of family size by reaching out to 48 million new users by 2020.

The situation at ground

Gumla is a tribal pocket in Jharkhand where most of the people work as daily wage labourers either on agricultural land or at nearby factories. Some households survive by selling wood, fruits, vegetables and forest produce in nearby states, especially Chhattisgarh.
It was not even noon and the Jyothi clinic in Gumla was flooded with women, mostly in the age group of 19-35 years. Many were unaware of their reproductive health and the importance of contraceptives.

Mushtari, 30, had travelled almost 20 km to seek help in limiting the size  of her family. “I already have three kids. We want to safeguard their future and provide education to them. So, I don’t want another child. But our religion [Islam] restricts operations that prevent childbirth. After coming here I learned about injectable contraceptives that can prevent a pregnancy for three months,” says Mushtari.

Similarly, 25-year-old Shahdunin Nisha was waiting at the clinic to know about the ligation procedure. Nisha has two sons and has suffered two miscarriages. Now, like Mushtari, she wants to undergo a ligation procedure or have injectable contraceptives.

But what made these women go to the Jyothi clinic? After all, the government-run primary health centre (PHC) was only half-a-kilometre away from the clinic. 

Pinki Kumari, who counsels women at the Gumla Jyothi clinic, gives credit to the clinic’s healthcare workers who have generated confidence among the villagers. Their interpersonal communication skills have created awareness on contraceptive choices, which the government-run centres have not made. Also the quality of care at these clinics is much better. It is a crucial ingredient that has the potential to bridge the gap between an unmet demand and the supply of services.

“Good quality care raises the overall demand. We have been thriving on it. The satisfied couples talk to others in their village about our services, which further increases our popularity,” says Pinki Kumari, a young woman from Gumla who has been with the clinic for more than five years.


PHCs, on the other hand, suffer from poor infrastructure, absence of modern methods and lack of accountability.

Dr JP Sangha, civil surgeon, Gumla PHC, admits that in the absence of counselling services, the frequency of government hospitals in reaching out to the masses is very low.

The government machinery, though, is dependent on ASHA workers (called ‘Saiyas’ in Jharkhand) to promote family planning. Balmati Devi, of Gumla block, talks about the Mahila mandal meeting organised each month on the day of Aanganwadi Poshan Diwas. “In these meetings we inform them about the temporary contraceptive methods to promote the concept of spacing,” says Balmati.

Also, ASHA workers, despite Maoist activities in the region go door-to-door to give condoms to women so that they can persuade their husbands to use them. “Since men are reluctant to use any contraceptives, women opt for ligation, medical termination of pregnancy, oral pills or IUCDs [intra-uterine contraceptive device],” says Balmati.

In such a situation, counselling and quality of service become vital. Across the country, the limiting method has been widely accepted as a preferred choice for family planning. And it is well known that 77 percent of all sterilisations in India are of women. This service is provided in all government hospitals.

Several ASHA workers in the four districts – Gumla, Giridih, Dhanbad, Ranchi – complained about the trouble they face in availing ligation at PHCs. “We have to run from pillar to post for one ligation,” says Anita, a Saiya.

These ASHA workers give the women an option to choose between PHCs and Jyothi clinics.

Anita Devi, a Saiya in Jamua block which is nearly five kilometres from Giridih town, says, “We have to go by a woman’s decision. If they wish to go to a PHC or a Jyothi clinic, we take them. In both the cases we are getting the same incentives. We do not push their decision because if anything goes wrong, it will be our responsibility.”

On the other hand, Dr Sighamony says villagers prefer their clinics because of laproscopic operation.

“Couples don’t prefer to go to family welfare centres in PHCs. They want ligation that is not painful. They often say, ‘cheere wala nahi karwana’ [Don’t want an operation with a cut]. They prefer laproscopic operations when they come to our clinic,” he says.

The permanent method has acceptance, but increasingly it is the injectable contraceptive that is becoming popular among women in rural areas. However, it is not available in government hospitals. This year the government took a giant leap and announced the introduction of injectable contraceptive to the basket of choice, but the supply has not yet started. Women, thus, prefer Jyothi clinics because of availability of this service.

Meeting the unmet demand

Jharkhand is one of the nine states which requires greater focus and commitment in terms of family planning. The fertility rate of the state is as high as 3.5 – and 3.7 in rural areas, which means that each couple, on an average, has three kids. Only 36 percent married women use contraceptives, compared to the national figure of 56 percent.

Across the country 65 percent of women have unmet demand for family planning during the post-partum period, that is, soon after the delivery. Only 26 percent resort to usage of any contraceptive method in this period. And one of the reasons is poor availability of services.
Till a few years back, there were no contraceptives available soon after delivery. Only recently, the government introduced PPIUCD (post-partum intra-uterine contraceptive device).

Dr Rita Remy, working in the Jyothi clinic at Giridih, says that women who are in dire need of controlling their family size opt for medical termination of pregnancy (MTP). “These women travel 20-30 km to come to the clinic. They are not aware of emergency contraceptive pills or any spacing methodology after the delivery of two babies. There is a wide gap in unmet needs, awareness and availability of contraceptives.”

Experts say providing a variety of choices accelerates fertility decline and reduces maternal, neonatal and infant mortality rate. According to Dr Remy, PPIUCD has not picked up fast because of the high infant mortality rate. “A family doesn’t want to go for sterilisation soon after a baby’s birth. But they want injectable contraceptives or tablets for regulation.”

Dr Subhash Ranjan, a medical practitioner in Ratu block of Ranchi district, agrees that there is no end to couples seeking help for family planning. “Women visiting my clinic prefer having the birth control pill. However, hardly any choice is available in the market of such interior regions. Therefore, we provide them whichever pill is available.”

One of the ways to make contraceptives accessible in these hinterlands is social marketing. PHSI provides its own range of birth control pills (Khushi), condoms (Fire, Agni, and Thrill), pregnancy kit and injections. The government provides condoms at subsidised rates to private companies or NGOs which they sell under different brandnames at a low price.

Dr Ranjan points out an interesting fact here. He says that people prefer using Rs 10 condom pack instead of free condoms distributed by ASHA workers. “They are not confident about free condoms. Men are looking for options. But there are not enough choices available. The government should popularise condoms in villages by social marketing,” suggests Dr Ranjan.

Vijay Kumar, Gumla’s district programme manager of the national health mission (NHM), explains the government’s failure in creating awareness about contraceptives. He says, “We lack in social marketing. For temporary methods, which promote spacing between children, social marketing is a must. NGOs are serving this purpose because there is quality assurance and sincerity in dealing with the demand of the masses.

“The private sector is technically sound and its frequency of delivery is better. At the advocacy level the government has been playing its role. But there is no policy at the state level to give impetus to the scheme. Men are not interested in using free condoms given by the government because over the years we have failed to create acceptance. It is time to rectify the family planning policy and focus on assessment,” adds Kumar.

Funds crunch

Be it a government hospital or a Jyothi clinic, women who undergo tubectomy or men opting for vasectomy are paid a certain amount as incentive. Under the NHM, a woman gets a sum of Rs 1,600 and an ASHA or a motivator gets Rs 150. Similarly, a man gets Rs 2,100 and the motivator Rs 200. The facility that conducts the surgery also gets an amount of Rs 2,000.

Jyothi clinics are accredited by the government of India. They are paid per case basis. The NGO has to submit a claim report at the civil surgeon’s office. “But the claims are not cleared on time. It takes months. Moreover, less financial assistance mars the spirit of the programme,” says Arvind Jha, a retired bureaucrat from Bihar, currently working as an advisor with PHSI. 

Moreover, the National Population Stabilisation Fund (Jansankhya Sthirata Kosh or JSK) has been non-functional for quite some time. It is an autonomous society of the ministry of health and family welfare to make NGOs facilitators in population control. Like NHM, JSK provides incentives to NGOs working in the family planning sector.

“In the past two years we have not received any payment from the government under JSK. District health officials are unaware of the operationalisation of this fund,” says Jha. 

It is because of their personal effort that PHSIs are functioning in rural regions despite a financial crunch. Two clinics in Hazaribagh were shut down last year due to financial constraints, says Jha.

The entire family planning programme of the government is functional on the basis of incentive provided to the ASHAs or ANMs. An ASHA worker gets Rs 200 for tubectomy and Re 1 for condoms and tablets. For the PPIUCD, a spacing method, they get the highest amount of Rs 1,000.

Clearly they will also promote ligation because they get more incentive. “Why will they promote condoms for which they get Rs 1 as incentive? The same is applicable for tablets and IUCDs,” says Dr Rey.

It cannot be denied that the incentive given to the healthcare foot soldiers is little compared to what they do. Therefore, they will promote only those methods which have higher incentive.

Overall, senior government officials agree that joining hands with NGOs has helped them in showing improved family planning figures. “It cannot be said that they are running a parallel movement but they are coinciding in terms of getting better achievements,” tells Dr Manoj Lal, deputy director, family planning, Jharkhand.

Dileep Kumar of the family planning department, Dhanbad region, is not hesitant to say that almost 65 percent of family planning task has been performed by NGOs; only 35 percent of the target has been achieved by the public sector.

Dr Praveen Chandra, director in chief, health services, Jharkhand, mentioned the failure of the state in covering all eligible couples for the spacing method. “The achievement has been poor, be it temporary or permanent method. What should have happened for the population coverage has not been done. The family welfare projects are not working as they should. There is no dearth of money and no restriction from the government for the private players. That’s why we are encouraging more MoUs with the private sector,” he says.

archana@governancenow.com

(The article appears in the August 1-15, 2016 issue)