On a balmy winter morning, the primary health centre at Dengapadar village in Sheragada block of Ganjam district in Odisha was missing its doctors — the medical officer (an allopathic doctor), and the other (a homeopathic doctor) stationed as part of the ayurvedic, yoga, unani, siddha and homeopathy (AYUSH) programme under the national rural health mission (NRHM).

The only person in attendance claimed to be the compounder and told Governance Now that the pharmacist, who was also absent, had gone “somewhere nearby on some work”.

In a nutshell, then, here was a primary health centre (PHC) — one of the four in the block and the penultimate point for delivery of healthcare by the government in rural areas — left unmanned.

Though the ‘compounder’ at Dengapadar insisted that the doctors are fairly regular (visiting “three or four days a week”) at the PHC, locals said they would consider themselves fortunate if the case was so. A villager, insisting on anonymity, said, “They are always in Berhampur (a city nearly 40 kilometres away) — either on official work or for personal reasons. It’s not that they don’t come at all, but the sick can’t wait for the doctor to arrive at his convenience, can they?”

If this seems tragic, the case of the Solasola homeopathic dispensary seems a rung worse. When Governance Now visited the dispensary, a frail, old man at the doctor’s desk was giving a young patient some medicines and instructions on the dosage. The man turned out to be the caretaker at the dispensary and was handing out medicines in the doctor’s absence. Asked why he was giving the medicines, Sukhadeva (the elderly caretaker) said it was a normal practice there.

In the doctor’s absence, he was supposed to give medicines to those who sought out the dispensary. He wouldn’t, however, say who had authorised him to do it.

If this is anything to go by, Sheragada’s health is far from being in the pink. Irregular attendance of doctors (in cases of Dengapadar and Solasola) and other issues are crippling rural healthcare in this block of 22 panchayats.

The dilemma over human resource
At the PHC in Pitala village, the doctors (an allopathic medical officer and a homeopathic AYUSH doctor) see as many as 40 patients a day. They are fairly regular in attendance.

Arun Tripathy, a Pitala resident, said, “The lady who serves as the medical officer used to stay here before and was on call more or less 24 hours a day. But she has had to shift out a couple of months ago due to personal reasons. Nevertheless, she is at the PHC by 10 every morning and sees patients well into the evening.

“When she is not around, the AYUSH doctor fills in.”

However, Dr Epili Jagannath, the young homeopath at the PHC, feels grounded at times by a lack of clarity in the guidelines. “The rules aren’t very clear on AYUSH doctors handling emergencies. At the moment, I do take emergency calls at the PHC-level if the medical officer is not available but I have to often refer these to allopathic doctors elsewhere. I am not qualified to prescribe allopathic medicines but have to handle the first line of treatment.”

Expected to supervise the routine field activities of a primary health centre — including immunisation programmes, supervision of the activities of auxiliary nurse midwives (ANMs), accredited social health activists (ASHAs) —under NRHM and the anganwadi workers (AWWs) and the planning and execution of NRHM programmes such as school health camps, village health and nutrition days, the likes of Jagannath said they are overworked and underpaid. With the monthly salary at the base level at Rs 12,000 (there is a provision for additional performance incentives but it is never paid regularly, most AYUSH doctors say), it is only natural that the best talent the programme gets is often lost to opportunities elsewhere.

“We are all contractual employees. There is no move by the government to make us permanent so far. So, with low growth prospects it is only natural that most of us look outside for jobs, some even in non-medical fields,” Jagannath admitted.

There also seems to be no considered approach to rural healthcare in Sheragada. A blind following of the directives without contextualising them to field realities makes NRHM implementation here seems more like a compulsion than realisation of government policy. An illustration: AYUSH doctors and ANMs were given a 21-day skilled attendance at birth (SAB) training at Hinjlicut a few months ago. Ever since, they have been waiting for medical kits required to assist in such procedures. “It’s not just the kit. We can’t go ahead and help with a procedure unless we have permission letter or a guideline allowing us to do so. So, the government may have spent money on the training but we can’t use it,” said an AYUSH professional on condition of anonymity.

Good plans gone off course
In fact, some of the best-laid plans of the government in rural healthcare seem to have gone off course here, if not entirely awry.

Take the Janani Shishu Suraksha Yojana (JSSY) for example, which consolidates healthcare of pregnant and lactating women and newborns. From vaccination (infants) to diet advice (for pregnant and nursing mothers), and from weight and blood pressure monitoring (antenatal, or before birth) to free provision of essential vitamins and iron (for expecting mothers to check anaemia), JSSY seems to have envisioned care at each step.

There is provision even for women below poverty line (BPL) and those above poverty line (APL) to receive a small grant from the government for institutional delivery. But on field things run far from smooth. The auxiliary nurse midwife (ANM) at Pitala PHC, Sarita Panda said, “It is difficult to keep track of pregnant women from one PHC or anganwadi centre as the custom here is that women leave for their parents’ home late in the second trimester or third trimester of the pregnancy. We have a mother-tracking register with almost each detail of the beneficiary which is also stored online. Using a unique ID, a text message is sent to the expecting woman on a mobile number, informing her of the next dates of immunisation or regular check up.

“However, it is all undermined at the last mile because the SMS is in English.”

But unable to read the text, over 50 percent women drop out of the free healthcare scheme, Panda said. “In most cases, they come back after a dosage or scheduled check-up has lapsed.”
Panda admitted that physically tracking each beneficiary is almost impossible. “ASHAs have to be informed of the woman’s movement. Sometimes, it is difficult to arrange for such coordination if she leaves for a long time, or goes to a distant village. Even otherwise, the woman has to let us know when and where she will be leaving for in the first place. Most don’t despite the awareness drives,” she rued.

Missing medicines
One of the most damning lapses, however, had little to do with doctors, paramedics or health workers. Sohan Pattnaik, the block programme manager for NRHM, said AYUSH doctors (ayurvedic ones in two PHCs and at the block-level community health centre and homeopaths in the two remaining PHCs) have had worst of the lot with medicine supply being beyond irregular. “The last the homeopaths received their lots of medicines was way back in December 2009. They have made many requests but the medicines haven’t come. The ayurvedic ones received a lot each only recently, may be a few months back.”

With the AYUSH programme itself nearly four years old, it is likely that some of the doctors hired under the programme have received medicines only once! “Don’t ask us how we manage,” is the cryptic answer of one of the doctors. A health supervisor of one of the panchayats later revealed that in most of the cases, the doctors are forced to prescribe over-the-counter allopathic drugs. “It is arm-twisting, of sorts. When there are no medicines of one’s own discipline to give, what can he or she do other than choosing the alternative? After all, they can’t turn patients away or prescribe no medicines after a check-up,” he said.