| City-based doctors have much to relearn while taking healthcare to remote and impoverished regions
Six years ago, a group of young doctors from the All India Institute of Medical Sciences (AIIMS), New Delhi, rejected the lure of private practice and the comforts of the capital to provide cheap and effective community health services in the remote regions of Chhattisgarh’s Bilaspur district. They decided to combine their professional skills and academic excellence to take modern healthcare to tribals and dalits, who were already plagued with poverty and malnutrition.
The core team of eight doctors ' specialists in gynaecology, paediatrics, epidemiology, medicine, surgery and microbiology ' set up an organisation called Jan Swasthya Sahayog for this purpose. They also converted an abandoned and dilapidated building into a 15-bed hospital. The Ganiyari Health Centre, which is 20 km from Bilaspur town, now boasts of a small out-patient ward, a surgery complex and a pharmacy dispensing cheap but effective drugs to the impoverished people of the district.
With communicable diseases like tuberculosis and malaria rampant in the area, the pride of Ganiyari is a well-equipped pathological laboratory; the only one in Chhattisgarh with facilities for tuberculosis (TB) culture. TB is the single largest killer disease in our country and claims more than 450,000 lives every year. In Bilaspur alone, about 2,500 cases are detected every year. Dr Biswaroop Chatterjee, who single-handedly transformed a ramshackle godown into the modern laboratory, says each week at least three patients with skin lesions visit Ganiyari. This figure, he adds, belies policy makers’ claims that leprosy is on the wane in India.
The city doctors had a great deal to relearn in the field, as they were unprepared for the lack of connection between their academic grooming and the diseases of the poor. Says Dr Anurag Bhargava, one of the doctors involved with the project, “Initially, we thought that the poor suffered from simple health problems. We were, however, shocked to find the severity of some diseases prevalent among them.” Apart from the diversity of health problems including “rich man’s diseases” like hypertension and diabetes, the doctors discovered that poverty and malnutrition were making the situation worse. They saw that social factors like caste, literacy, gender and poverty aggravated health problems associated with pneumonia, pregnancy or TB.
In all the 35 villages where JSS began work, the villagers were trapped between an overburdened and dysfunctional public healthcare system and private doctors. This made it very difficult for them to seek treatment, which is, considering their economic status, very expensive. Many of these villagers were forced to take loans for treatment, but the high interest rates (between 60 and 120 per cent) added to the burden. This forced many people to mortgage their land; some even committed suicide.
The JSS, therefore, has kept its registration fees low. It charges a new patient Rs 6 and Rs 3 for successive visits. To lower the burden on poor patients, the doctors only prescribe essential diagnostic tests and drugs.
In 1999, when JSS began work at Ganiyari, doctors drew up a three-tier approach for spreading healthcare in the region. First, they trained local women to become village health workers (VHWs) to provide the first-contact healthcare to villagers. These women acquired skills to diagnose and treat common diseases, take blood pressure, sputum for TB and internally examine women. “Our biggest challenge was to evolve a comprehensive community health programme with the participation of local villagers,” says Dr Rachana Jain, another doctor associated with JSS.
The team made a breakthrough when VHWs learnt to take blood specimens from malaria patients and transported blood samples to Ganiyari for testing. This is done through an innovative but simple network, with everyone from the community participating in the process. The VHWs hand over blood samples to students who drop them at the village bus stop on their way to school. The conductors of the buses going to Bilaspur take these samples and hand them over to the watchman at Ganiyari for testing at the health centre. On their return journeys in the evenings, the buses pick up the blood reports that are in a simple format so that even an illiterate villager can understand them. These reports are then given to the VHWs. The success of this system is borne out by the impressive statistics. With a 20 per cent positive rate (almost always falciparum) in the 8,000 patients tested over the past six years, the process has helped immediate diagnosis of malaria and treatment for patients, who earlier had to wait sometimes for weeks with fatal consequences.
While the second-tier comprises three mobile clinics equipped with doctors, medicines and a laboratory, the third is the referral at Ganiyari, which is the most trusted in the entire region for children’s surgery. Since 2001, more than 3,000 surgeries have been performed for diverse ailments of the chest and throat and for gynaecological problems. And this has certainly brought a new hope for these poor villagers. For example, one-year-old Shravan was suffering from Hirchsprung’s disease, a malformation of the large intestine requiring sophisticated surgery, which the patient’s parents could hardly afford. Today, they thank Dr Raman Kataria who operated the child three times and “brought back hope” to their lives.
Ganiyari has developed into a one-stop clinic, where patients can consult doctors as well as have facilities for diagnostic tests. This approach was important so as to minimise the loss of poor patients in terms of a day's earning and bus fare and also maximise the value of effective treatment.