CHAPTER VIII
DISCUSS JON
DISCUSSION
The use of para-medical workers in the west began as an extension of hospital
services, and as a support to the medical work of doctors. Local people were trained
to help as dressers, medical assistant etc. Later it \vas realized that these workers
could fulfill "a distincTive function which for many reasons, cannot be fulfilled
equally well by other members of health team" (Hardie, 1978 & Elliot, 1978). A long
trail of para-medical workers thus evolved to support the work of doctors, such as the
physiotherapist, the pharmacist, occupational therapist, speech therapist and those
engaged with radiology, optometry etc. The evolution of support persomtel in those
countries that were stmggling with their economics and welfare service~; was quite
different. These countries conceived of an auxiliary health worker as reflected by the
Sokhey committee report in India (National Planning Committee, 1948). This took
place under the influence of international cff011s to rebuild their services. or, nation
states themselves striving to improve the conditions of health. While the para-medical
workers are defined as trained personnel who provide .\pecific clinical services under
medical supervision, the auxiliaries were trained to provide basic health .i·crvices on
their own. In the developing world, much of the doctors were interested in staying in
the urban areas, or were migrating to the developed countries, or some of these
countries suffered from severe shortages of medical professionals. As a result, their
rural population was left without medical care. From the middle of 201h century,
countries like China, Iran and India had started experimenting with personnel with
short training who could provide basic services at the village leveL
In addition to these two categories of paramedical and auxilrary health
personnel, a third tenn was also used namely, that of Community Health Worker
(CHW). Iran experimented with training illiterate people (with six montl1s training)
and those with nine years of education (v,:ith four years training) and called them
Community Health Worker or Auxiliary Health Worker. Both were trained to provide
basic services in rural Iran and were called Community Health Workers (Ronaghy et
aL, 1983). In India, the notion of community health workers arose only in the 1970s.
These CHWs had education upto class eighth and three months of training. While the
earlier paramedical/auxiliary workers such as ANM and Health Assistants were
conceived of as providing defined health services, CHW was supposed to be a
representative of the community who would apply pressure on the health service
personnel to provide services. He/she also was seen as a link between the health
186
DISCUSSION
service system and the rural population. In 2<XX), an inter country consultation of the
WHO on allied health workers coined the term 'Allied Health Workers' (WHO,
2(X)()). It was pointed out that instead of using different terminologies it was
worthwhile to use the uniform term 'allied health workers' for support staff that
provides services at the village level and thus lets the doctor use his training in a more
efficient manner. Such mixing of categories indicates that there has always been some
confusion in the difference between auxiliaries, paramedics and community health
workers. Authors like Wemer maintained that the village health worker was not a
substitute or an auxiliary to the doctor but rather a primary member of the health team
(Werner, 1978). As Lehmann and Sanders had pointed out, the role of the CHWs
underwent a shift in the 1980s from 'an advocate for social change to a predominantly
technical and community management function' (Lehman and Sanders, 2007). Their
closeness to the community gave them a greater understanding and influence. With
international pressures for standardization and uniformity, the paramedics/community
health workers were not given due importance. Only by 1970s was it accepted that
health was contextual and there could not be a uniform standard for all communities
and countries.
In practice, instead of being a representative of the community, the CHW had
been reduced to being a helping hand for the health workers. This affects tlh: working
of the CHW as well as that of the health team, especially those health personnel, who
arc trained into a hierarchical mindset. They treat the CHW as of lesser importance
and technically inferior to them. The small experiments that had succeeded in creating
a special space for CHW- as in the experiments in Maharashtra (Arole :md A role,
1975; Koblinsky, 1994) - could not provide the basis for a better programm~, as these
small im10vations could not be absorbed in state level programmes. This \vas due to
two reasons, one being the lack of resources, and other being the haste to scale up the
programme. The health administrators were also not sensitive to the impot1ance of
issues such as having a system for identification, training, support and not just
monitoring and continuous training.
While we recognize the historical ongms and significance of these terms
(where paramedics were those who provided specific clinical services under medical
supervision and auxiliaries were those workers v.·ho provided simple and ·dementary
187
DISCUSSION
medical care with limited education to relieve the doctors for the more complicated
tasks), we look upon the community health worker as a cadre apart from the other
categories. Although they may share ce1tain common features with the auxiliary and
paramedical workers such as the closeness with communities and their hmited sphere
of knowledge, their distinctive feature is the fact that they are villagers who are
selected for their social awareness and strengths to represent the inkrests of the
communities. The original CHW scheme emphasized this and since then there has
been a tussle between health services and those who conceptualized CHW as a
representative of the community. The fonner wants to appropriate this category of
worker as a subordinate, while the latter visualize CHWs as a controlling influence on
the health system. In this conflict, very often the community's need for medical care
and the policy maker's hurry to show adequate coverage of the population by some
kind of health worker, leads to CHW becoming a hand maiden of the health services
system.
Our review of the numerous experiments with the concept and implementation
of CHW has highlighted issues and problems in it that arc still alive. Issues such as
proper selection of the CHW, their training. supervision, support from the health
services, lack of infrastructure, have all cropped up in the various programmes. Our
study shows that these arc still relevant for the Mitanin programme.
The Mitanin programme in Chhattisgarh, arising out of the experiences of the
Community Health Workers schemes, was conceptualized after discussions with
community health practitioners from within as well as outside the state. It was a state
civil society partnership which brought in innovations by claiming to incorporate
learnings from the previous experiments in the much older concept of Community
Health Worker. Some of these innovations were
• Unlike the other community health worker schemes, there was w be
community mobilization before the actual selection of the Mitanins and the
selection process itself was quite elaborate.
• Instead of a stipulated population or a village, the community was to lx~ the
hamlets.
188
DISCUSSION -------------------------------------------------------------------------
• Education was not supposed to be a criterion, thus it did not exclude the
uneducated but active women in the community.
• Curative training was to be given much later, after the Mitanin had est:1blishcd
rapport with the community.
• During the time of selection, the Mitanins were told that they would not be
receiving any kind of payment (though the programme had envisaged some
kind of compensation later). This enabled the enthusiastic women to voluntter
to be Mitanins and did not leave room for the power lobbies in the village to
intervene in the process.
• The most important point stressed by the group was that the Mita11in alone
could not succeed unless she had the backing of the health services. Hence, the
health services needed to be strengthened. So, the Mitanin programme was to
be started in parallel with the strengthening of the health services.
• Another innovative approach was to start the programme in few pilot blocks
and then later, based on the learning from the different approache~-. the best
practices were to be expanded in the entire state.
• Continuous suppo11 to the Mitanins and their superv1s1on was envisaged
through on-the-field as well as periodic camp based training. 1\ specially
trained cadre of trainers was created for the on-going supp011 and supervision.
This was unlike the previous community health worker schemes, where
government health workers provided the training. The training manuals were
well written with a lot of pictures; there was one book based exclusively on
pictures.
Despite such improved conceptualization and the best of intention~;, two kinds
of problems emerged from our study- conceptual problems and implementation
problems.
IQO
DISCUSSION
CONCEPTUAL PROBLEMS
Structural issues
For better monitoring and support a separate structure was created exclusively for the
Mitanin programme. The staff of this structure would be devoted entirely to the
Mitanin programme. Thus, at the district level, there were two Field Coordinators, at
the block level, three District Resource Persons, and on an average twenty Block
Resource Persons. Our study reveals that the FC was stretched out, looking into the
activities in four to five blocks. During the training times, especially, she was not able
to give time to the other blocks and supp01t the BRPs and DRPs. This ,Tcated a
distance as the BRP, DRP could not get the requisite support from their FC and
therefore had to rely on the government health workers for day to day support and
guidance. This dependence upon government health workers further molded the
functionaries of the Mitanin programme as per the needs of the health system. The
FCs are left on their own in the district, they do not have a good support structure, the
Programme Coordinator in the state capital is too far away. The FCs also did not have
much avenues for further career growth.
The government DRP had to look into the Mitanin work apart from her regular
work, due to which she was not able to support the BRPs in the field, and her work
was restricted to the office. The non-government DRP had two chains of command,
from the govemment as well as from the FC. This kind of duality did not help in the
smooth running of the programme. The non-government DRPs were not able to
support the BRPs and were largely restricted to the task of data organization, and to
being a communication channel between the government DRP/ BMO and the BRPs.
Of the 16 BRPs in the block, ten were working as Mitanins (during data
collection), and seven of these had no supervisors. The reluctance to step down as
Mitanin was due to the incentives they could get as Mitanins from JSY and
immunization which they would not get as BRPs. This defeated the very purpose of
supervision which was totally lacking in these cases as DRPs rarely came to the
viJiages for house visits.
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DISCUSSION
Training issues
• The non-government DRPs were not sufficiently trained in management and
clinical care, and were largely left to manage by themselves.
• There was no provision for those DRPs or BRPs who were new to the
programme to undergo all the previous rounds of training. In the study block
the DRP who was new, did not have a complete grasp of the programme. This
affected the progranune as the Mitanins look upto the BRP and the DRP for
suppo11 and guidance and these personnel were often found lacking.
• The training of the BRP trainings was not very different in content from that
of the Mitanin' s. There were no extra reference books on technical knowledge
for these trainers. As a result, the trainers were only equal to the Mitanins, and
in some cases even worse off than the Mitanins in terms of technical
knowledge to be able to assert their superiority over the Mitanin. They were at
the mercy of the health services providers. The trainers need more inputs
because these women did not have a background in health. As our data shows,
the Mitanins relied more on the ANM for technical knowledge, even in those
case where the BRP was good. These findings match with ~he findings of the
evaluation of the Mitanin programme by Community Health Cell in 2005,
where they had stated that the trainers were often enthusiastic but lacked the
experience, expertise and skill required for the training (CHC, 2005).
• While the Mitanin training was to begin with exposition of the social
dimensions of health and disease, and the importance of environmental
factors, the training of the Mitnins was not fully equipped to demonstrate this
in day to day work. Their competence being no better, they could neither show
Mitanins the links between health and environment, nor could they answer
their queries effectively.
IMPLEMENTATION ISSUES
The BRPs and DRPs
Initially, the selection of the BRPs and DRPs did not have stringent criteria and
norms, but over time and with experience, a formal method of recruiting the BRPs
and DRPs started coming into place - in the case of DRPs, they have to undergo a
191
DISCUSSION
written examination followed by the interviews. Only then, they are seleded and
trained.
The BRP was conceptualized to be a support for the Mitanin, and to provide
the latter with on-the-field training. However, our data (in chapter V) shows that the
BRPs were primarily engaged in collecting information from the Mitanins to
complete their records, and they provided support to only few of the components of
the programme as and when pushed by the DRPs or Government officials. For
example, the very good BRPs could at best revise the trainings and provide support to
Mitanins and pass on information that they received from the DRPs. The not-so-good
BRPs were restricted to collection of data for themselves and passmg on of
information. The reports that the BRPs submitted for the sake of submittif'.g were the
only proof of their work. They were hardly ever using or referring to it and were often
even making it up. The reporting was more for the sake of displaying to ,, isitors than
for improving the work. The significance and utility of such data never gels known to
those who collect it (Mitanin), as there was no planning process in which the data
from the grass roots were used. The BRPs in turn did not get the support from the
DRPs, as the latter themselves were laden with reporting and with CHC work. They
could not give much attention and time to the field work and left it at entirely to the
BRPs.
In the beginning of the programme, there were unjustified deduct tons from the
payment of the BRPs along with long delays in payment. Later, by 2007 the issue of
deductions was corrected but the BRPs kept getting payment after gaps of three to
four months. These lacunae in the programme lessened the enthusiasm of the BRPs.
Selection of Mitanins
Our literature review has shown that the selection of the CHWs from the community
and by the community has always been a problematic issue that has be,~n consistently
highlighted. Yet there have always been problems in selection of the CHWs. In the
Mitanin programme, the selection was given due attention. A detailed procedure of
community mobilization followed by selection by the community was laid down as
described in chapter-IV. Even then, our data shows, the selection of d1e Mitanins, in
those blocks where the programme was implemented by the governmc~nt was done by
192
DISCUSSION
the health staff who did not able follow the procedure bid down. Firstly, they were
familiar with the villages and had their own idea of t:he suitable candidate, and
secondly, due to their workload they could not devote much time to this process as
had been recommended. Thus, only 53 percent of Mitanins were selected in the
village meetings which are considered to be the best form of selection. In case of
another 13 percent the Mitanin herself was not present in the meetings. In another five
percent, the Mitanin was selected from the SHG group•;_ Sixteen percent of the
Mitanins were selected by the Sarpanch or the health worker, ten percent of the
Mitanins had themselves approached the trainer and in three percent, the mother-in
law was the Mitanin who handed over the responsibility of the Mitanin programme to
the daughter-in-law (Table- 4.2). This data matches the JSA findings which report the
selection of the Mitanins in meetings to be 53 percent (JSA, 2008) and the SHRC
internal evaluation data puts this figure at 61 percent (SHRC, undated). This is still far
better than the selection of the ASHAs. The JSA has reported only eight percent of
ASHA being selected in village meetings (JSA, 2008).
There was no mechanism in place to select in a democratic way new Mitanins
in place of the drop outs. This was all the more needed because after having a Mitanin
in the village the people knew about the Mitanin programnte and the incentives
attached to it. Seeking to grab opportunities, the influential people in the village
would recommend their relatives as was evident from the fact that the new Mitanins
belonged to a better off class. Our literature review has shown that in the earlier CHW
schemes in India and in various other countries, the CHW selected through the
powerful and influential in the village- such as the Sarpanch- is not necessarily the
best candidate for this job and is not motivated enough to perform.
Training
The initial trainings had been on the concept of health and disease, and understanding
of the programme and the health services. The idea was not to introduce curative care
in the beginning, and to impart an understanding of the social determinants of health.
This was then followed by training on use of medicines. The medicines became the
most important aspect of the work of the Mitanins since both, the trainers and medical
supervisors, emphasized it. The Mitanins also gained respect once they could give
medicines. As a consequence, gradually the emphasis on the social role was replaced
193
DISCUSSION
by developing their curative skills. This was so because, as with medicines, there was
no demonstration in the field of effectiveness of social interventions, given an inactive
Panchayat and a weak sanitation committee.
The trainings of the Mitanins were held at irregular intervals. After a couple of
trainings, enough time was not given for the Mitanins to statt utilizing the trainings in
the villages. This was particularly so for the eighth and ninth round of trainings.
There was no provision for the new Mitanins to go through the earlier
trainings. They were dependent on the books (of which they never got the complete
set), and the trainer who was not able to devote the time needed to train the new
Mitanins. The new Mitanin therefore missed out on the initial rounds of trainings.
Continuing field education was a good concept but as we have seen, due to the
various limitations of the technical competence of BRP as well as her workload, the
Mitanins did not get much support. However, this was still better than the earlier
CHW programme in India, where the CHWs were left to themsclvc~; with totally no
support.
Even though it was said that the Mitanin should not be burdt~ned with report
writing, as she was not expected to give this much time, and also as many were
illiterate, ultimately the burden fell on her to regularly update the registers. The
trainers too had been emphasizing regular updates as this was seen to be the proof that
the Mitanin and the trainer were working. This was also an easier and surer way to
assert that they worked, than assessing their work in the community.
Health committee
Though institutional support in the form of health committees was envisaged, in
practice, this did not work out. As our data shows (in chapter- VII), the committee
existed on paper, as the Mitanin was seen largely to be a represental11Ve of the health
services and the others were not too enthusiastic to join. The Mitanins used the SHG
meetings as a forum. Half of the Mitanins studied had passed on information, such as
availability of medicines or about health camp, and 16 percent of the Mitanins
reported that they talked about health issues in the SHG meetings. The committee
lOA
DISCUSSION
members were never trained or orientated to understand the linkages of health. The
committees were expected to support the Mitanins but these were themselves the poor
women in the village, the influential ones were absent. These women were expected
to help the Mitanin in tackling the issues of water and sanitation which are mostly
political issues. So it was inevitable that they would not be able to perform and added
to this was the fact of their own lack of training in understanding the social roots of
disease.
Panchayat
There was no mechanism to bring the Mitanin and Panchayat closer until VHSC was
launched. In the study area the VHSC was formed in a hurTy as the block wanted to
dispose off the money sanctioned to the VHSC accounts before the end of the
financial year. As a result the Mitanins could not be oriented and the BRPs could not
be given a half day orientation of the VHSC. For the formation itself, the BRPs could
be present only in 50 percent of the Panchayats leaving the other Panchayats at the
hands of the Sarpanch and Sachiv. Thus the foundation was weak as the Mitanins
were not clear about the VHSC, and their role in it, and use of the allotted money. The
VHSC calls for a greater role of the Mitanin in the village affairs. The Mitanin would
be expected to take decisions along \Vith the others in the VHSC on health matters
relating to the village. The process of village health planning is now to be initiated,
and that will call for an even greater role of the Mitanin. But the question is whether
the ground is ready for the Mitanin to take on these larger roles. She has not been
adequately trained, and most of the Mitanins do not have experience of getting
involved in village matters. There arc chances of her being manipulated by the
PanchayaL For Mitanins to be effective, she needs to be politically and socially aware
of the functioning of Panchayats and the vested interest it represents. Raising issues of
sanitation, water supply and roads, means asking for change in the power structure.
Assigning this responsibility to the weakest link- the three women Al'l"M, A WW and
Mitanin- means that the programme is on! y making a gesture, not a concerted
intervention.
195
DISCUSSION
SUPPORT FROM HEALTH SERVICES
The need for better and more supportive health services was emphasized from the
very beginning of the Mitanin programme. Our study shows that even five years after
the initiation of the Mitanin programme, there are severe shortcomings in the health
ServiCeS.
There was shortage of manpower, especially of specialists at the CHC,
Medical Officers, RHOs and Male supervisors as seen in Table- 3.2 (chapter III). Om
data in chapter III shows that although new PHCs have been opened, they were
functioning under severe shortage of staff. In Aasara PHC where there is a doctor and
other staff available, the utilization is better; according to the staff in Tappa, when the
doctor was present the number of patients increased by one and half times.
There had been an increase in the supply of equipmcnts according to the staff
of the PHC and CHC. However, sufficient trained staff was not available to usc them.
The supply of medicines to the PHC is also not based on their requirement and usage.
None of the PHCs had residential quarters for the staff. In two of the PHCs, a
doctor and an ANM had occupied one of the rooms in their respective PHCs
indicating how much they needed the residential quarters. At the sub-centre level, of
the 29 SCs, fifteen were run from rented premises. In the study villages, of the 16 SCs
the ANM did not stay in seven sub-centres and preferred to commute thereby
affecting the quality of work. Such lack of infrastructure and the personnel in the state
ha<; been pointed out by the second Common Review Mission of the NRHM (GOI,
2008a).
The health personnel did not get support from the supervisor:-; as the latter
busied themselves with preparing records, and rarely came to supervise the personnel
in the field. The assessment was done through the reports and thus a huge emphasis
was placed on reports. The personnel were given targets to be met under the national
programmes, and the backlog was discussed every month in the Sector and CHC
meetings of health staff. With nine of the 16 sub-centres in the study area, having only
one personnel, the entire work load including preparing elaborate reports, fell on this
single personnel and he/she was able to deliver only the minimum services like
196
DISCUSSION
immunization, family planning and slides (making slides of people with no fever
coming to immunization sessions was widely reported) as discussed in chapter- III.
The Mitanins were then roped in to help the ANM in completion of her targets,
especially in making blood slides, looking for sterilization cases and cases of cataract
operation. As the Mitanins themselves look up to the health serviocs for technical and
referral support and are not in a position to refuse, the ANMs can usc the Mitanins for
such purposes. The CHC data on the national programmes as seen in Table- 3.7 and
3.8 in chapter III is quite erratic which raises doubts about the reliability of the data
reported.
The huge amount of bribes (as reported by the health workers) demanded by
officials for the contractual positions and their renewal dampens the morale of the
health workers. Such personnel also have bribed their way in, then take money from
the people, such as in delivery cases.
Our findings in chapter VII have shown that 96 percent of the villagers in the
study villages did not prefer government services and within the poor, none wanted to
go to govemment health services. Yet 51 percent of the studied population and 61
percent of the poor end up utilizing it as they did not have other opt ions.
The health services lack a forn1al chain of refcnal, whereby the patient
referred from the PHC or the CHC can get transport and direct access in the higher
institutions, instead of having to wait in a queue. When the Mitanin rcfcn·ed cases,
only those doctors who knew about the programme and were interested in it
acknowledged the Mitanins, and gave importance to the patients they had refen·ed.
The referral slips were also not accepted by most of the doctors in the district hospital,
thw; letting down the eff01ts of the Mitanin. The Mitanins are asked by the villagers to
accompany to their private doctors, which indicates support to the Mitanins, but
failure of the public system. Thirty one percent of Mitanins in our study reported that
they had accompanied patients with serious illnesses to the government health
services. The assistance of Mitanins was sought also for gynecological cases like
hysterectomy and menstrual problems. The CHC had better facilities and staff, and
the doctors, especially the BMO were more responsive to the Mitanins. Our data in
chapter VI, shows that in one sub-centre area, which is close to the CHC and where
197
me Lramcr was very gooo, ::>::> percent ot M1tanms accompamed patients to the health
SerVICeS.
STRENGTHS AND LIMITATIONS OF THE MITANIN
The role of the ANMs had been supportive as far as giving medicines was concemed.
They also gave additional medicines to those Mitanin whom they considered 'active'.
As the stock for the Mitanin medicine kit was not regular, the AN.\1s, on orders from
the block, gave medicines from their kit. The irregular supply of drugs has been
highlighted in several other reports (GOI, 2007, 2007a; CHSJ, 2006; CHC, 2005). In
spite of the irregular supply of medicines, the data (in chapter VII) shows that 78
percent of the people have used the Mitanin' s medicines at some point of time. People
approached her for the basic medicines which they otherwise bought from shops or
obtained from the unqualified practitioners. This has made a difference and has made
the Mitanin respectable in the village. With a regular supply of medicines, the
utilization of these medicines will increase and go a long way m establishing the
Mitanins as the first contact person for small ailments, in place of the unqualified
pract itioncr.
The Mitanins were to be all women. This would ensure that the women are
reached more so that the MCH and RCH programmes can be their focus. This has
limited the programme, and even women's health issues were not being adequately
addressed. While diseases like Tuberculosis, Malaria were prevalent, these did not
receive adequate attention within the Mitanin programme. In case of blood slides for
malaria, as the Mitanins did not get the reports (which according to the CHC could be
negative while the private lab could be positive), people who had fever and other
symptoms preferred going to the private labs for faster delivery of report. On the other
hand, the Mitanin had to make slides of people without fever according to our data. In
the case of DOTS, the Mitanins were not utilized even though they were trained and
knew about the symptoms and disease. There were only eight Mitanins giving DOTS
out of the 52 (13 percent). The money for this programme was also not regular and
got delayed by a couple of years. The findings of CRM have also shown that the
Mitanins did not get the reports of the slides that they made (GOI, 2007a).
198
DISCUSSU)N
That the Mitanin's presence had increased the immunization coverage has
been widely accepted by the health workers and the officials. The Mitanins
pressurized the people to get their children immunized by going to their houses, if
needed, more than once. They also helped the ANM in small ways like administering
Vitamin A drops to the children. In the case of sterilization operations, earlier there
was coordination between the ANMs and Mitanins. The introduction of money w the
motivator has led to a situation of conflict between the two, which can have serious
repercussions in the other areas too. With the launch of JSY, the Mitanins take
delivery cases to the sub-centres and PHC or CHC. In the rented sub-centres, the
facilities are minimal, still women arc taken to complete the formality. The literature
review has highlighted that the health infrastructure is not prepared to handle the
increase in cases (CHSJ, 2006; GOI, 2007a). The Mitanin did not play much of a role
in the general health of the women apai1 from giving iron tablets for anemia. In
Chhattisgarh, 46 percent of women have mild to severe anemia (liPS and ORC,
2000).
Health education which was greatly stressed in the initial rounds has declined
over time. Fifty seven percent of the Mitanins interviewed after the seventh round of
training said that they talk about health education to the village women, this dropped
to 32 percent of the Mitanins after the end of tenth round of training (Chapter- VII).
The training on the poverty-under nutrition- disease training had not found much
relevance. The seventh round training which was on health planning oC Panchayats
has also not been much appreciated. The emphasis of the Mitanin programme has
moved away from the social role of the Mitanin. 111e Mitanins were mainly involved
in giving medicines and helping in the ANM's work. They sec themselves more as
provider of health services and six percent of the Mitanins said they wanted to learn
giving injections, as they had seen the ANM and the private practitioner giving
injections. They feel that giving injections would give them the desired status. Thus
there is an increasing trend to shift towards curative care. The Mitanins are excited
about the tenth round of training as they get to learn certain skills in those trainings.
The fifth round of training where the Mitanins were introduced to the medicines and
drug-kit was the round of training which was eagerly awaited by them.
199
DISCUSSION
The Mitanins get incentives for certain activities like takiilg cases for
institutional delivery, sterilization, immunization, administering TB medicines, and
our study has shown that the Mitanins who were not very active in the field limited
their work to these activities. For example, in the case of motivating women for
institutional delivery, the good Mitanins had counseled the women on food, rest and
precautions before and after delivery along with the benefits of institutional delivery
but the average and not so good Mitanins mainly focused on the money aspect while
motivating the women for delivery. Our data showed (chapter VI), that eight percent
of the Mitanins who were not otherwise active had also taken cases for institutional
delivery. The study on ASHA by JSA has also shown this trend (JSA, 2008). Thus
this system of payment through Mitanins gives imp011ance to certain activities only
and it is largely RCH related. This does not take into consideration all the key needs
of the villagers.
The trainers also emphasized these as these arc activities that get rep011ed, and
the block was graded accordingly. This was not in tune with the earlit.~r vision of the
Mitanin programme where she was to secure all the services from the state
government and to address the social causes of ill-health. The incentiv·c also puts two
people working on health in the same village as competitors for the same money
where there should be coordination between the two. This has led to discord and non
cooperation.
One thing that is common to most Mitanins, is that it has given the women an
opportunity to come out of their houses, interact with officials and accompany other
women to the health services. This exposure for the women is in itself a positive input
in their self realization. They have also been able to usc their knowledge and contacts
for their self fulfillment even though at times it ends up with doing things for their
own families. The vast mobilization of these women has also seen the effect in some
other spheres as 500 Mitanins in Chhattisgarh of the 60,000 had contested for the
Panchayat elections and many of them now got to SHGs and learn about Panchayat
activities. Being given responsibility by the VHSC and also in the A W to help ANMs
and A WW gives them self confidence. These women are today learning to cope and
deal with family pressures on the one hand. and social responsibilities, on the other
hand. In many cases, families have realized the value of the work that they do and are
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DISCUSSION
beginning to support tt,eir activities. This in itself is nothing short of significant social
change.
The people in the villages knew the Mitanins in their village, and also knew
that they have medicines for some basic ailments. The information sharing in the
SHG, house visits or at the meeting points like pond or hand pump was also usefuL
However little it may b·~, it had made health a topic of discussion.
The reduction o~ IMR in Chhattisgarh is generally projected as an effect of the
Mitanin programme. Special care was given to the pregnant woman and the new born
as the Mitanins were e:cpected to meet the pregnant woman and new born babies at
regular intervals. This -~nsured that any high risk cases or where the child was not
well, were referred to the health centre. But this cannot be said about the other health
problems in the village as other things did not get as much importance. After the
formation of new state, as the health staff has reported, supply of medicines and drugs
have relatively improved and yet remained less than required. Hand pumps were
installed in all villages, which provided the people with clean drinking water. So how
much can the reduction in IMR be ascribed solely to th·~ Mitanin programme is
debatable. However, the Mitanin progr<~mme, <~long with th~~ other welfare measures
brought in after the formation of the new state, has had an impact.
There is immense potential in the Mitanins. With good selection, training <Jnd
supervision, they could v;ork even better. In the limited sphere of women's health, the
Mitanins have been able to help. The system is not being able to tap their potential
fully because of its own limitations. These arc primarily infrastructural inadequacy
and using Mitanins onl) for one targeted programme- reproductive health without
actually building a conve.~gence with other development programmes.
IMPLICATIONS OF NRHM
Mitanin programme started off as a state programme with the state govemment m
2002 giving it the status of a flagship programme. With the coming of NRHM m
2005, two things have happened. One, the state got the funds from the centre for
strengthening the infrastiUcture. Second. the already existing Mitanin programme
became a part of NRHM. The state continued the ownership of the Mitanin
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DISCUSSION
programme and did not modify it according to the universal principles of the NRHM.
The slate has retained the major components of the Mitanin Programme and remained
committed towards the principles of running the programme as it was conceptualized.
The number of Mitanins and the support structure was left untoucb ed and continued
as it had under the Mitanin prog;·amme.
Nonetheless, NRHM has influenced the Mitanin programme 111 a big way. The
introduction of JSY under NRHM has had a big impact on the programme. As the
Mitanins started getting incentives, they paid more attention to motivating pregnant
woman for deliveries. The focus of house visits underwent a change as our data has
shown in chapter VII. The earlier concept of visiting all houses had been replaced by
visiting houses of only pregnalit woman and children. While 75 percent of the
Mitanins had claimed that they gc. for house visits. only 32 percent have rep01ted that
they go to houses for general health problems and only four percent said they visit all
the houses. The shift is from general health to more focused RCH. Similarly, there is a
change in the work of the Mitanins as we have already seen the percent of Mitanins
giving health education has dropped. Thus their role has undergone a shift from focus
on social determinants to a more medical one. The VHSC was introduced during the
latter part of the researcher's field vvork, so its impact could not be asses sed.
Difference between ASHA and Mftanin
Though the ASHA programme has come after the Mitanin programme, and ASHA
programme was also conceptualized after discussions with public health experts, there
were few basic difference between tr.e two.
The Mitanin programme has acknowledged that the population density is very
varied in the state and therefore inste<td of a certain population, it has taken the hamlet
as a unit for one Mitanin. ASHA has .1 stipulated population nonn and it is very likely
that if the population is spread across more than one hamlet, then ASHA will not he
able to deliver her services effectively to the other hamlet.
The CRM report mentions that the support structure at the district level were
not formed in most of the states (GOL 2009). In Chhattisgarh, the support stmctures
J>ISCUSSION
were in place from the beginning of t1e Mitanin programme. The regular contact with
the BRPs and DRPs helped the Mitanins keep the enthusiasm alive.
At the time of selection the Mitanins were told that they would not be paid
anything for their services and this work was to serve the people of their village. This
enabled the influential people of the village to stay out. The Mitanins ~ere not paid
any money except for the compensation in trainings in the first few years In the case
of the ASHA, she is selected from tht~ village knowing that her work ha~, got ce11ain
incentives attached to it and therefore there were inegularities in the selection
process.
The Mitanins in the first few rcunds were taught about the social determinants
of health and disease. They were also encouraged to visit all the families to emphasize
her social role. This was followed by medicines and JSY followed later. In the case of
ASHA, they have started directly with JSY and as the literature review has pointed
out, their work had been restricted to activities which have incentives attacl1ed to it.
Our findings thus, on one hand. indicate the potential of the Mitanins if they
are given the right support from their own supervisors and the health services. On the
other hand it also reveals that the innovations of the scheme arc being unde-rmined by
the implementation of JSY and neglect of principles inherent in Mitanin •;chcme as
well. Such as, selection through participative process, emphasis Dll social
determinants in the training process re-emphasized by practical training, voluntary
nature of their work without introducing selective incentives and better training to
their supervisors along with not only a promise of improving primary health care
infrastructural support but actually invening in it. Unless these are taken c1re of, the
Mitanin programme will only depend upon accidental selection of committed worker.
Our data shows that as yet very few of these issues have been adequate! y dealt with.
The second CRM rep011 dearly shows the inadequacies of NRHM with respect to
improving the infrastructure (GOI, 2009). Similarly, while initially the NGOs were
involved to generate a range of options from which the government programme could
select, in reality scaling up of the programme happened without any consideration of
the positive practices. This was due to political pressure and this led to the difference
of opinion bct\veen the implementing body and the advisory body. On the insistence
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DISCUSSION
of the implementing body, the programme was expanded too fast and with a uniform
approach.
Whether the Chhattisgarh state '.viii succumb to the attraction of central
financing of NRHM or it would be abk to strengthen the Mitanin programme by
consolidating the strengths of the scheme is something that time will show. If it does
not, then Mitanin too will be one of the very many experiments in CHWs that were
washed away by the overpowering interests of the medical care provisioning system,
without an emphasis on prevention, health education and people's participation in
primary health care.
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