Public Health in Kalahandi: A Brief Overview ‘Troubling Survival: Mounting Resistance’

For me, learning and unlearning are intrinsic aspects of the social development sector. If you remain aware and open-minded in your surroundings, they will allow you to gradually phase out old beliefs and knowledge and introduce new ones. It was really exciting to be selected as an AIF Fellow, to come here at Kalahandi and start my learning-unlearning journey. Being an AIF-BIF fellow, I have been placed at Seba Jagat in Kalahandi, Odisha. Seba Jagat is a non-governmental, voluntary organization that has been working in Kalahandi District since 1992. It works in the fields of education, health and livelihood through people-centered actions with the active participation of women, tribal, Dalit, and other marginalized communities.

‘Seba Jagat’ office (Picture credit: Author)

Almost a month was spent in the hospital before joining the fellowship. Frequent visits to doctors, asking for different prescriptions, constantly walking around patients and hearing sobbing sounds was mundane at that time. What is a medical emergency? Which hospital can we go to? Is our health system good or bad? These questions were accompanying me that month.

After coming to Kalahandi and getting to know the public health care system, I again started thinking about what people do here in medical emergencies. Where do they go? One day in the field, a woman narrated her story. She was about 50–55 years old and her husband had died some years ago. She had one son and one daughter. Being a single mother, she sent her children for education even when they lived in acute poverty. Her son later got a job as a teacher. But within a few days, he fell ill and died. The cause of his illness and death remain unknown. Out of concern for the future, she got her daughter married at an early age. Her daughter now lives far away with her husband. Now in her old age, the mother lives alone here. So, what will she do if there is a medical emergency? Another woman lost her husband eight years ago, and all she can say is that he was ill and received no medical care. One major thing I learned while studying feminist history and feminist standpoint theory is that lived experiences are monumental in addressing vulnerabilities. We cannot discard an individual’s personal lived experience just because it is not experienced by the public.

When thinking about good health, I believe good health is an individual’s physical, mental, and emotional happiness. Good health is one of the fundamental needs of individuals for their socio-economic development. We have some collective efforts by the government system to provide good public health care services because, as humans, we live in groups and communities. Having seen the terrible COVID pandemic, many of us can agree that the high pressure of diseases, infections, and deaths can only be addressed if and only if our public health system is strong and equally accessible to all. India has a history of health crises and pandemics like plague, malaria, tuberculosis, leprosy, HIV, high maternal and child mortality rates, malnutrition and so on. Given the magnitude of the problem and the population, we are confident that it can only be addressed through a collaborative effort by the government’s public health system.

In India, private sector, especially NGOs, play an important role in the public health care system. For example, in Maharashtra, the Maharogi Sewa Samiti, led by Dr. Baba Amte, has done tremendous work in controlling, curing, and rehabilitating people affected by leprosy. NGOs, public trusts, and community-based organizations (CBOs) assisted government health departments during pandemics, including the recent COVID pandemic. In the recent Covid pandemic, we understood that the threats to people’s health are clearly threats to the development of both individuals and nations.

The public health care system is funded and controlled by the central government and planned and implemented by state governments. In some states, they have their own public health care initiatives. Building a strong health-care system in collaboration with the private sector and non-governmental organizations (NGOs) can thus be an effective way to promote public health.

About Kalahandi:

Kalahandi is a district in Odisha, with Bhawanipatna as its district headquarters. It has archaeological evidence of human settlement dating back to the Stone and Iron Ages. It is believed that it was a well-civilized society, having paddy cultivation and a treasure of precious stones. It was a princely state of British India during the colonial period. The present Kalahandi district occupies south-western Odisha. Except during the rainy season, Kalahandi has extreme weather. The economy is largely agrarian-based, with paddy cultivation and forest resources. The severe drought and irregular rainfall cause crop failure and an income generation crisis, which tends to lead to poor health. Acute climate changes, irregular and unplanned development, and deforestation have terrific economic and social implications. Rural unemployment, abject poverty, migration, addiction, hunger and malnutrition and child marriage are common problems here. The district comprises a large number of Schedule Caste and Schedule Tribe residents. Around 46% of the district’s population is made up of these two communities.

Public Health System:

The public health system is run by the National Health Mission of Odisha. At the district level, Kalahandi has a District Health Mission that works under National Health Mission Odisha. The district has its own government public health infrastructure. It has 1 district hospital, 1 sub-divisional hospital, 10 community health centers, 8 health and wellness centers, 20 public health centers, 234 sub centers, and 26 public health centers. As a part of the implementation of the National Health Policy, the strengthening of sub centers and public health centers is being done by converting them into health and wellness centers to deliver equitable, accessible, comprehensive primary health care service.

Public Health Care Center Barabandha, Kalahandi district, Odisha (Picture credit: Author)

 

Policies and Programs:

The district health care system is handled by the district health mission, which is controlled and guided by the state health missions. The objective of the district health mission is to achieve equal access to equitable, affordable and quality health care services that are responsive and accountable to people’s needs. The district health mission works with some programmatic components like strengthening the health system, reproductive, maternal, neonatal, child, and adolescent health, and communicable and non-communicable diseases.

The National Health Mission of India and the National Health Mission of Odisha approve plans according to the National Health Policy for budget, infrastructure development, implementation modes, human resources etc. The Kalahandi District Health Mission has a program implementation plan under various themes like immunization, maternal and child health, pre-conception and pre-natal diagnostic techniques, adolescent health, family planning, nutrition, the national vector-borne disease control program, tuberculosis, leptospirosis, cataract surgery, mental health, dental, deafness clinics, development of infrastructure, human resource, remunerations, technology and innovations.

Current Situation:

The maternal mortality rate is 126, infant mortality rate is 32, sex ratio is 1011 female per 1000 male and child sex ration is 898 female children per 1000 male children. Despite the area’s abundant natural resources, the majority of its residents lack access to basic survival necessities. Though Odisha has shown an impressive increase in health indicators as per the National Family Health Survey 5, survival indicators for both children and mothers in a district like Kalahandi are still poor as compared to other parts of the state. Even for children who are introduced to their first doses of immunization, there is a significant drop in children coming for subsequent immunization sessions. Similarly, while Odisha’s institutional delivery has risen to 85.4%, it stands at 74.5%in Kalahandi. The district still has 25.5% of home deliveries, with only 6.4% of the total home deliveries assisted by trained and skilled birth attendants. Only 46.7% of mothers in Kalahandi receive full Antenatal Care (ANC) service, with only 58.8% receiving Postnatal Care (PNC) within 48 hours of delivery. These practices have a high impact on the survival of children, especially neonates.  It is also experienced that the impact of development has not been uniform in all communities, and tribal communities stand at a special disadvantage when it comes to receiving and accessing health services. In terms of general health, there is a high incidence of tropical diseases like malaria and diarrhea. This is especially acute in remote areas where access to quality healthcare is inadequate. The level of malnutrition in the area is also high, which increases the need for a quality primary healthcare system and community health-seeking behaviour in Kalahandi.

Challenges:

The health system in Kalahandi district has many challenges. The district has still not recovered from the COVID pandemic crisis that caused the entire health care system to collapse. It has also had a significant economic impact on people’s income generation. Disparities between urban and rural areas, as well as between rich and poor, are having an increasing impact on society. There is sound evidence that shows poor economic conditions and poor infrastructure cause poor health. The scarcity of skilled human resources makes it even worse for the health care system.

Communicable diseases such as tuberculosis, malaria, tropical diseases, dengue fever, and HIV coexist with noncommunicable diseases such as cardio-vascular disease and chronic diseases caused by tobacco and alcohol.

The district is located in deep forest and mountains. Environmental causes like drought, irregular rainfall, excessive mining, unplanned and unregulated development and unregulated land use all contribute to risk factors in public health care accessibility and developing infrastructure.

Kalahandi has a large number of tribal populations, which suffer from various health crises such as communicable and non-communicable diseases, malnutrition, addiction and mental health issues. The people from the district are not very well integrated in socio-economic development, as it is socially and geographically isolated. It leads them to poverty, poor health and poor literacy. The patriarchal system creates barriers to getting or accessing health care for women and girls in cultural challenges. The silence surrounding sexually transmitted diseases, child marriage and mental illness has serious consequences for people’s health.

Overcoming the challenges:

The National Health Policy 2017 recommends strengthening primary health care and designating health and wellness centers as the platform to deliver comprehensive primary health care. These centers will bring health care closer to the homes of people, covering maternal, neonatal, child and adolescent health services and non-communicable diseases, including free essential drugs and diagnostic services. The goal of the programs is to keep people healthy and reduce the risk of developing diseases and morbidities.

In the district Program Implementation Plan, there is a two-way referral system and follow-up support that actually help address the grievances. Public-Private Partnership (running public health care centers with the support of NGOs and CBOs) and Rashtriya Kishor Swasthya Karyakram launched to ensure holistic development of adolescent population. These programs, which are national level initiatives by National Health Mission, expand the scope of adolescent health programming in India – from being limited to sexual and reproductive health, it now includes in its ambit nutrition, injuries and violence- including gender-based violence, non-communicable diseases, mental health and substance misuse. These initiatives promote public health action through active engagement and capacity building of community platforms, such as ASHA workers, peer educators, and individual volunteers. The provision of appropriate remuneration encourages human resources to participate more actively. Technology and innovation are the major keys to improving access to health care advice and treatment initiation, enabling reporting and recording, and eventually progressing to electronic records for individuals and families. Collaboration with NGOs and the private sector helps to close gaps in the delivery and evaluation of public health services. Because implementation has its own limitations in remote locations like Kalahandi, there should be an ecosystem between the government and the private sector, including NGOs. With the help of public-private partnerships, these gaps can be filled.

I feel like the mere establishment of more health facilities and infrastructure cannot overcome the poor health of the district population, which is largely in remote tribal areas. A skilled human resource is intrinsic and mandatory to deliver quality healthcare. Local knowledge is especially important in rural Kalahandi, where the role of traditional treatment techniques, community healers (Baidya/Vaidya- Ayurvedic Physicians, Physiotherapist) and herbal medicines are important in developing a healthy society.

Following the COVID pandemic, the public health care system should reassess itself in order to meet the goals outlined in the National Health Policy. It is observed that Kalahandi has a high percentage of government health services and infrastructure, which qualified for “Kayakalp” awards last year, but if we look meticulously, there are people who are still suffering.

As a part of the public-private partnership, Seba Jagat is implementing two government health initiatives: three health and wellness centers and the Rashtriya Kishor Swasthya Karyakram. These projects aim to strengthen community platforms and government institutions, as well as to build community capacity; sustainability is built into the project design. It helps in strengthening the capacities of the frontline functionaries to deliver services better and changing the social and behavioral practices of the marginalized communities on maternal and child health, nutrition and hygiene in Kalahandi district. This collaboration also aims to change social norms, cultural practices, and health-seeking behaviors by increasing the capacity of local communities. Changes in the communities would be long-term and sustainable. Furthermore, this partnership in the field of health aims to create community ownership through using participatory methods to mobilize communities and building the capacity of gram panchayats to ensure the establishment of efficient governance and social accountability mechanisms at the lowest administrative unit. The intervention does not create a dependency on civil society organizations but focuses on empowering community-based organizations to take on their social responsibility along with all equal stakeholders.

The ecosystem between government and the private sector/NGOs is one of the primary keys to successful public health outcomes. The gaps in the implementation, monitoring, and evaluation of the public health system can result in a weak public health system. The Public Private Partnership reduces the lengthy time span in planning, implementing and assessing the health care system. In addition, the shortage of skilled health professionals and human resources should be addressed in a timely manner.

Recommendations/Suggestions:

  • More investments should be made in health infrastructure with low-cost treatments, low-cost essential medicines and efficient medical equipment and tools.
  • Public healthcare should be a nation’s concern and should always remain democratic and people-driven, especially in India, where socio-economic disparities are a major challenge and people don’t have equal access to socio-economic resources.

References:

  • Narain JP. Public Health Challenges in India: Seizing the Opportunities. Indian J Community Med. 2016 Apr-Jun;41(2):85-8. doi: 10.4103/0970-0218.177507. PMID: 27051080; PMCID: PMC4799645.
  • Piotrowicz M, Cianciara D. The role of non-governmental organizations in the social and the health system. Przegl Epidemiol. 2013;67(1):69-74, 151-5. English, Polish. PMID: 23745379.
  • PHFI (2016). Role of Non-Governmental Organizations in Healthcare Sector of India (Eds: Nimai Das and Rajeev Kumar). Public Health Foundation of India, Delhi.
  • Douthit NT, Alemu HK. Social determinants of health: poverty, national infrastructure and investment. BMJ Case Rep. 2016 Jun 22;2016: bcr2016215670. doi: 10.1136/bcr-2016-215670. PMID: 27335366; PMCID: PMC4932367.
  • Government of India, Ministry of Health and Family Welfare. National Health Policy 2017.
  • Government of Odisha, National Heal Mission, Department of Health and family Welfare. The Program Implementation Plan of Kalahandi, Odisha 2021-22.

Dnyaneshwar is serving as an American India Foundation (AIF) Banyan Impact Fellow with Seba Jagat in Kalahandi, Odisha. He is a master’s holder in Gender, Culture and Development. He is a first-generation learner and belongs to a farmer’s family from rural areas of Maharashtra. He believes in fluidity and tries to dismantle binaries for the betterment of human rights. Being critical about add and stir approach of gender, he has written two research papers about media representations of gender, masculinities and sexualities during his academics. As an intern, he has worked with adolescent male children from the underprivileged communities in Pune on gender sensitization and leadership skills. He has short term research experiences with folk artists and young entrepreneurs from Maharashtra. He has worked with men against violence and abuse for a research project on construction of men and masculinities through different social institutions. He is a former Goonj Urban fellow where he has worked with different left out communities in West Bengal and Odisha. He intends to create safe spaces for people with different gender, sexual, social and cultural identities. He believes in ccceptance, awareness and advocacy for the rights of underprivileged people. As an AIF fellow, he will be working to strengthen and promote affordable health services, primary health infrastructure and resources at community level. For this, he will be engaged in research, report writing by doing data analysis and case studies. Along with this, he will handle social media for the project.

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