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P i t t r r " . 1 .. . p 7 f , , ' : i ' i , , i i l : ( . A t l i

Pre natal care of the pregnant mothers is one of the important pfolfammes caf'ried out among the preventive services. This includes vaccination of pregnantwomen against tetanus and supplying them vrith iron folic tablets.

However, like other preventive programmes, this programme too, wefound, suf-

fered from incompieteness, particuladf in Dumka' While 70 percent of the womenin Birbhum reportedll, received tetanus iniections during pregnancy the figure forDumka v'as only 26 percent.

Concerning the receiving of iron folic tablets the picture was more upsetting'Only 46 pefcent of the pregnant women in Birbhum reportediy received the ironfolic tablets. For Dumka the figure was only 27 percent' A PHC in-charge in Dumkasairl that there was no deatth of iron folic tablets - bhare are hulehain'Yet, he admit-ted, most of the pfegnant women wele not covefed because (1) it tr"asdifficult tomake these tablets available to all pregnant mothefs as the numbet of health work-efs was much less than required; and (2) even when tablets v/efe supplied to the ben-eficiaries they did not bother to consume them out of simple negligence.

Hower,'et, a femalehealth worker presented it differentiy. First of all she cofltra-dicted the doctor's view about the availability of s.ufficient stocks of the requiredmedicines. "PHC me rehsakta hai, magarcentremenal:inaata- they may be available atthe PHC level, but not at the sub-centles". Secondly, she said that the negligence ofpregnant mothefs as legafds consuming iron folic tablets stems from ignorance'"wnko /

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leaflet distribution, etc. have their own limitations and the most effective way of creat-ing awarenessabout health and health services s direct contact with the villagers.

One male Health Assistant and one female Health Assistant at every sub-centreare supposed to spearhead he public health programmes in the rural areas.They aresupposed to visit each famlly vrithin his/her geographical arca o{ operation dulyfixed once in a morrth in a 16 days' cycle .e. 4 days n a week'1o.A Health Assistant Nlale) s supposed o perform different activit ies ssociatedwith malaria and othet communicable diseases, mmunisation, family welfare, nutri-tion, environmental sanitation, recording of vital events, first-aid and treatment ofcommon ailments. The duties of a Health As.sistant(Female)are associatedwith pre-natal and post-natal care of the women at home, care in the clinic (at the sub centre)care in the community (visiting the households in the villages), etc.

However, ^ mere list of the many different tasks assigned o health workers doesnot guarantee the effective delivery of health services. In a situation where some ofthe health workers themselves (in both distticts) were found to be unaware of theirassigned duties, the knowledge of the villagers concerning the services avallablefrom the pubJic health delivery system can well be imagined. The lack of access oinformation further exacerbates he lack of the availability of proper health services.

In our study only 37 percent of the sampledhouseholds n Birhhum ard26 per-cent of the households in Dumka were reportedly visited by any health worker dur-ing the year preceding the survey. Again, the majority of the visits were made byHealth Assistants (both male and female) and ICDS workers and not by doctors orsenior health workers.

In the househoids reportedly visited by health wotkers, a large number ofresoondents said that the visits were made onlv once in a vear or so.Table 8.3. Periodicity of visits by health workers

Ar peranlsge of lata! bmnbol.d: whirh rQorlut! reeiued any uis't

Village wise data sheets and observations further indicate that the delivery ofhealth services is not only different in the respective districts but there are also con-siderable ntra district variations. Nfe found a sharp dividing line between the villageswith positive and negative respoflses.While the positive responseswere found onlyin a few villages, the negative responses were distributed over a large number of vil-lages. Our observatibns also support the above findings. The relatively better func-tioning of some sub cefltres was due primarily to the dedication of their workers, notbecauseof any policy or structure. In most of the cases he sub cenftes were left to

Birbhum Dumka::B;r*..n one and *o .on,h, I4 I

A

Three months - l2 months74

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A 4 i . , F . \ ' r ' ' : f ' . , , ? : . r ' ' , I

the mercy of the individual health v/orkers, some of whom - out of humanitariancommitment - tried to keep the system running in spite of many difficulties.Q U / : , L | T YO F t f ? , ' . l l { i S A 1 t i A f l , t

Similady, when asked about the quality of services extended by the health work-ers during their visits, most of the respondents expressed satisfaction. This againshows that a small section of health workers who visited the villages had tried to doiustice to their iobs.

Eghty six percent of the respondents of Birbhum (visited by health workers)said that the health workers talked nicely with them. In Dumka, the figure was lower- 45 petcent. Seventy eight percent of such respondents in Birbhum responded thathealth workers spent sufficient time with them. The Dumka figure was much lower- 55 percent

As to what type of serviceswere delivered at home, vaccination ranked first. (fhelist included supply of pills, condoms, follow-up after ster't\zation, counselling for fam-ily planning and othet related services,awareness-generation n prevention of diseases,treatment of general ailments, etc.). The other services provided were negligible (seeAppendix table E 7.b for details).A female health worker in Dumka said that she felthelpless fot she was seldom provided u.ith the required pills and other medicines.Besides, she complained, she found very little time to visit the households as the areaassigned o her was large and there was no communicatton available.Another female

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health worker reported that het area was under thick forest cover and villages werescattered.To add to her probiems, the area s prone to elephant attacks. I

\[hi]e there wete practical difficulties faced by some health workers, some ofthem, as we have seen,neglected their duties simply because of the perceived diffi-culties. Many of them were found to live in urban or semi-urbart are \ from where itwas vefy difficult for them to cornmute to their areas of operation. In addition, theirdifference from the villagers they are supposed to serv- both in terms of status andmentality - perhaps leads to the development of inhibitions towards villagers and rurallife. Some of the health workers in both the districts, echoing the doctors, officials, andother middle classpersons, held the villagers responsible for their ailments. "Villagersarc ft7tht'', "they are lliterate", "they dont care for their health," "th.y don't want touse modern medicins", were a few of the comments made by healrh workers.

C r l l n P R L t r l l \ T r t / fM h A l u ' ? h 5Measures to prevent Diarrhoea: In both the districts, diarrhoeal diseaseswerereported to be among the most common. Difficulty in accessingpotable water is oneof the major causesbehind the increase in diarrhoeal diseases. n almost all the vil-lagesstudied in Dumka there is scarcity of drinking wateq which becomes acute p^r-ticularly during the summer. In addition, despite the installation of many hand-pumps in the villages most of them were out of order during the survey. Villagersreported having lodged many complaints but to no avail. Some villagers alleged thatthe block office askedfor money to repair the hand-pumps, which villagers could notafford. Thus, many of the villages, particularly those located in the hilly areas,depend upon streams or open dug wells for drinking water. In none of the study vil-lageswas the distribution of purifying agents @leachingpowder, etc.) recollected bythe respondents. In some of the villages, the quality of water was found to beextremely dirty and unhygienic - paticles of diffetent kinds of organic and inor-ganic matter were quite visible, in the water.

The situatiotr in Bitbho- was relatively better, but the district is not completelyfree from problems regarding potable water. At least in two of the 12 villages sur-veyed, the situation was very similar to that of Dumka. The other villages were alsonot completely free of drinking water pollution. As reported by some of the PHCauthorities in Birbhum, programmes related to water purification were carried outonly in specific areasrvhere diarrhoe:a ook an epidemic turn.

It worth a mention here that the Panchayat nd Rural Development departmentof the Government of West Bengal has launched a programme of sanitation,"Gramin Swastha Vidhan" in 1991, which has been very successful n some districts(for example, Medinipur East and Hoog$. The progtamme became operational in1993-4.Tbe number of low cost toilets built in the state has increased more than ahundred-fold (froin 19,565 in 1993-94 to 2,079 493 in 2002-3).12 In an interview, anofficial of the department sard that Nandigram II of East Medinipur district hasbecome the first fullv sanitized Community Development Block in the country and

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they were expecting orre or two districts to be fulty sanitized very soon. The achieve-ment of the sanitation pfogfamme, as mentioned by the official, has had a directimpact in reducing the occurrencesof water borne diseases, articulady diarrhoea.However, the programme has yet to achieve significant success n Birbhum district'

Though the importance of sanitation has been acknowledged in pubhc policyllin Dumka district no tface of such a pfogfamme was found. Neady 100 percent ofthe people were reportedly using open grounds as toilets, r.vhich ncreasesthe possi-bilit-v of the occurrence of diarrhoea.Measures to pfevent rnalaia: Although we found very few malaria cases n ourstudy areas n Birbhum, it has remained a menacing killet disease n the district, asu,e have mentioned earlier. In 2001-2, the reported casesof malarta in Birbhumlawere 4L2 of which 35 percent were of Plasmodiamfalciparatn.

Dumka is known to be a malaria-prone disttict. In our study area malariaparients formed 24 percent of the population that suffered from any ailment duringthe year preceding the study. As mentioned eariiet, malaita is afl acute problem formany parts of the country, and takes a healry annual toll. The Cenffal Govetnmenthas launched the National Anti-Malaria Ptogramme, which compfises pteventive,curative and other measures o eradicate he disease.Sprayingof pesticides s one ofthe important pfeventive measufes. However, none of our respondents in Dumka(including the residents of the malaria-prone villages of Gopikandar block) con-firmed any such spraying.

The National Anti-Malaria Programme 2002 tn the district claimed to have dis-tributed mosquito nets. It also claimed that distribution of mosquito nets was doneamong 100 percent of the households in Gopikandar block, 40 percent of thehouseholds in Jatmundi block and 20 percent of the households in Sikaripara biock.Gopikandar is a highly malaria-prone block - the incidence of malaria was so enor-mous that it took 35 lives from a single village in our study area n the year prior toour visit. However, contrary to the claim of the health officials, noneof the espondentswasfound to haue eceiuednlt mosquitonets n the block.

As part of the preventive programmes, mass communication (mainly wall writing)has been carried out both in Bubhum and Dumka. But the effectivenessof such pro-grammes cannot extend beyond the boundaries of the literate population. The mostessentialmode of generating awareness, irect contact, was found to be largely absent.

Part II- d v n 1 : ' , fY 1 : l ) , ! L I : 1

When the much-focussed and heralded pubhc health services for prevention ofdiseasessuffer from such gross deformities, the stateof the curative services can wellbe imagrned. We har,'eseen n section 5 that only a smali fraction of the patients vis-ited the public health centres for healthcare. An absolute majority of the suffering