Infrastructure woes

To fix India’s flailing public health system, health sub-centres need to be improved first

Health sub-centres are the first points of contact between people and the public health system. But many sub-centres need to do much better.

In Dongargaon Khurd, a remote village in Bicchua block of Chhindwara, Madhya Pradesh, the newly constructed building of the sub-centre is open only twice a month. Once for the monthly immunisation day and then for completing paperwork. About 90 kilometres away, the sub-centre in Ghoghri village of Amarwara block has not been open for over a year. The building has been illegally occupied by a retired staff nurse who refuses to let anyone in. And in Panara village in Jamai block, which has an opencast coal mine, no one knows when, and if, the sub-centre opens.

These micro findings from a survey done by local students in a district in Madhya Pradesh, as part of an assessment of the state of public health facilities, necessitate a macro look at the way India’s sub-centres are functioning. Sub-centres play a crucial role in rural healthcare delivery. Being the first tier of the primary healthcare structure, they serve as the initial point of contact between people and health services. Each sub-centre is designed to cover a population of 5,000 in rural plains and 3,000 in hilly or desert or tribal areas through a staff of at least one female health worker or Auxillary Nurse Midwife and one male health worker. Sub-centres perform vital tasks that include providing health services related to immunisation, maternal and child health, and disease control, along with health education and motivation. In many ways, they form the foundation on which the goals of India’s public health are built.

But is this foundation as strong as it should be?

Problems at the bottom

The Rural Health Statistics of 2015-’16, brought out by the Ministry of Health and Family Welfare, reports that out of total 1,55,069 sub-centres in India, 86% do not meet the Indian Public Health Standards set up by the government. As on March 2016, 28% of sub-centres did not have regular water supply and one-fourth did not have electricity supply.

Although all sub-centres in Andhra Pradesh and Telangana, Tamil Nadu and Goa had regular water supply and electricity, much fewer sub-centres in Arunachal Pradesh, Manipur, Jharkhand, Jammu and Kashmir and Bihar had this essential infrastructure.

Along with functional infrastructure, primary healthcare requires adequate and skilled health personnel. Government data reveals an alarming shortage of male health workers, which may seriously affect the implementation of many important national health programmes like the National Vector Borne Disease Programme. More than 90% of sub-centres in Uttaranchal and Rajasthan, 88% in Jharkhand, 87% in Bihar and 84% Uttar Pradesh did not have a male health worker. Nationally, the shortfall of male health workers is as much as 65%. The only state with a surplus is Mizoram. The situation is far better in terms of female health workers or ANMs, with national shortage being only 3% percent of the requirement, and most states having a surplus.

As found by the survey in Chhindwara, the challenge for India’s health workforce is not only of shortage but also of high absenteeism. A nationally representative study in 2011 found that absence rates of medical workers were as high as 39%. Another study of 100 public health facilities (with 68 sub-centres) of four northern states reported that, on average, only 3.6 out of 10.5 appointed staff were found to be present at the time of a surprise visit. The authors argue that high absenteeism contributes to underutilisation of public health facilities.

Why sub-centres matter

If overall underutilisation of public health facilities is to be tackled, more attention needs to be given to sub-centres, where people first interact with the health services system. A badly functioning sub-centre reinforces public opinion of inefficient government health services. This contributes to the popularity of private practitioners, most of them untrained. It also exposes people to unsafe practices of medicine, and increases out of pocket expenditure on health, while undermining the public provisioning of healthcare.

Underperforming sub-centres are also partly responsible for the unmanageable patient load at the higher tiers of healthcare, which themselves are understaffed and deficient in infrastructure. Instead of going through a referral system where a patient first goes to primary levels and if needed is referred to secondary and tertiary levels, most patients go directly to higher levels without any referral. A 2008 study of three referral hospitals in Lucknow found that only one-tenth of all patients had been referred from the lower levels while all others were self-referred. This puts immense burden on secondary and tertiary care facilities, whereas primary levels of healthcare remain poorly utilised.

Fixing the foundation

For all the levels of healthcare to function well, it is necessary to strengthen the foundation. Recently, the government announced in its financial budget a plan to transform 1.25 lakh sub-centres into health and wellness centres in a phased manner. But a parliamentary panel on budget allocation noted that there was no solid roadmap to ensure the financial resources for such an initiative.

Any kind of roadmap for making sub-centres functional and effective needs to go beyond changing the nomenclature or financial allocation alone. It will have to tackle the overarching issues of infrastructure and human resources, especially the acute shortage of male health workers. Much can be learnt from the improvements in states like Tamil Nadu and Himachal Pradesh. There is also a need to check absenteeism and work ethics of medical workers. For this, action oriented methods like community based monitoring, social audits, and jan sunwayis or public hearings should be supported and strengthened. Finally, such a roadmap must be grounded in the ideals of public health and the primary health care approach, so that the health of those at the peripheries does not become peripheral.

The writer is pursuing her MPhil at the Centre of Social Medicine and Community Health, Jawaharlal Nehru University.

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Swara Bhasker: Sharp objects has to be on the radar of every woman who is tired of being “nice”

The actress weighs in on what she loves about the show.

This article has been written by award-winning actor Swara Bhasker.

All women growing up in India, South Asia, or anywhere in the world frankly; will remember in some form or the other that gentle girlhood admonishing, “Nice girls don’t do that.” I kept recalling that gently reasoned reproach as I watched Sharp Objects (you can catch it on Hotstar Premium). Adapted from the author of Gone Girl, Gillian Flynn’s debut novel Sharp Objects has been directed by Jean-Marc Vallée, who has my heart since he gave us Big Little Lies. It stars the multiple-Oscar nominee Amy Adams, who delivers a searing performance as Camille Preaker; and Patricia Clarkson, who is magnetic as the dominating and dark Adora Crellin. As an actress myself, it felt great to watch a show driven by its female performers.

The series is woven around a troubled, alcohol-dependent, self-harming, female journalist Camille (single and in her thirties incidentally) who returns to the small town of her birth and childhood, Wind Gap, Missouri, to report on two similarly gruesome murders of teenage girls. While the series is a murder mystery, it equally delves into the psychology, not just of the principal characters, but also of the town, and thus a culture as a whole.

There is a lot that impresses in Sharp Objects — the manner in which the storytelling gently unwraps a plot that is dark, disturbing and shocking, the stellar and crafty control that Jean-Marc Vallée exercises on his narrative, the cinematography that is fluid and still manages to suggest that something sinister lurks within Wind Gap, the editing which keeps this narrative languid yet sharp and consistently evokes a haunting sensation.

Sharp Objects is also liberating (apart from its positive performance on Bechdel parameters) as content — for female actors and for audiences in giving us female centric and female driven shows that do not bear the burden of providing either role-models or even uplifting messages. 

Instead, it presents a world where women are dangerous and dysfunctional but very real — a world where women are neither pure victims, nor pure aggressors. A world where they occupy the grey areas, complex and contradictory as agents in a power play, in which they control some reigns too.

But to me personally, and perhaps to many young women viewers across the world, what makes Sharp Objects particularly impactful, perhaps almost poignant, is the manner in which it unravels the whole idea, the culture, the entire psychology of that childhood admonishment “Nice girls don’t do that.” Sharp Objects explores the sinister and dark possibilities of what the corollary of that thinking could be.

“Nice girls don’t do that.”

“Who does?”

“Bad girls.”

“So I’m a bad girl.”

“You shouldn’t be a bad girl.”

“Why not?”

“Bad girls get in trouble.”

“What trouble? What happens to bad girls?”

“Bad things.”

“What bad things?”

“Very bad things.”

“How bad?”

“Terrible!!!”

“Like what?”

“Like….”

A point the show makes early on is that both the victims of the introductory brutal murders were not your typically nice girly-girls. Camille, the traumatised protagonist carrying a burden from her past was herself not a nice girl. Amma, her deceptive half-sister manipulates the nice girl act to defy her controlling mother. But perhaps the most incisive critique on the whole ‘Be a nice girl’ culture, in fact the whole ‘nice’ culture — nice folks, nice manners, nice homes, nice towns — comes in the form of Adora’s character and the manner in which beneath the whole veneer of nice, a whole town is complicit in damning secrets and not-so-nice acts. At one point early on in the show, Adora tells her firstborn Camille, with whom she has a strained relationship (to put it mildly), “I just want things to be nice with us but maybe I don’t know how..” Interestingly it is this very notion of ‘nice’ that becomes the most oppressive and deceptive experience of young Camille, and later Amma’s growing years.

This ‘Culture of Nice’ is in fact the pervasive ‘Culture of Silence’ that women all over the world, particularly in India, are all too familiar with. 

It takes different forms, but always towards the same goal — to silence the not-so-nice details of what the experiences; sometimes intimate experiences of women might be. This Culture of Silence is propagated from the child’s earliest experience of being parented by society in general. Amongst the values that girls receive in our early years — apart from those of being obedient, dutiful, respectful, homely — we also receive the twin headed Chimera in the form of shame and guilt.

“Have some shame!”

“Oh for shame!”

“Shameless!”

“Shameful!”

“Ashamed.”

“Do not bring shame upon…”

Different phrases in different languages, but always with the same implication. Shameful things happen to girls who are not nice and that brings ‘shame’ on the family or everyone associated with the girl. And nice folks do not talk about these things. Nice folks go on as if nothing has happened.

It is this culture of silence that women across the world today, are calling out in many different ways. Whether it is the #MeToo movement or a show like Sharp Objects; or on a lighter and happier note, even a film like Veere Di Wedding punctures this culture of silence, quite simply by refusing to be silenced and saying the not-nice things, or depicting the so called ‘unspeakable’ things that could happen to girls. By talking about the unspeakable, you rob it of the power to shame you; you disallow the ‘Culture of Nice’ to erase your experience. You stand up for yourself and you build your own identity.

And this to me is the most liberating aspect of being an actor, and even just a girl at a time when shows like Sharp Objects and Big Little Lies (another great show on Hotstar Premium), and films like Veere Di Wedding and Anaarkali Of Aarah are being made.

The next time I hear someone say, “Nice girls don’t do that!”, I know what I’m going to say — I don’t give a shit about nice. I’m just a girl! And that’s okay!

Swara is a an award winning actor of the Hindi film industry. Her last few films, including Veere Di Wedding, Anaarkali of Aaraah and Nil Battey Sannata have earned her both critical and commercial success. Swara is an occasional writer of articles and opinion pieces. The occasions are frequent :).

Watch the trailer of Sharp Objects here:

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This article was published by the Scroll marketing team with Swara Bhasker on behalf of Hotstar Premium and not by the Scroll editorial team.