Existing allopathic health services are basic, often difficult to access, and show signs of only very slow improvement. The ongoing entry of the private sector into health service provision may be a relief to those who can afford to access it, as new and better services are beginning to be available in some rural areas. But this offers little comfort to those who cannot even imagine being able to afford private care, while also taking the onus off the government sector to improve existing services. It also raises a major question about who is to be responsible for preventative health, which is clearly not in the interests of the private sector.
Government primary level care is over-stretched, under-resourced and suffers from a lack of accountability to the very poor, even though these people are increasingly the main constituency they serve. Secondary level care is relatively better off: the sub-divisional hospital, about 10 miles away, is relatively efficient and well equipped, although it suffers from the standard problems of poor medicine supplies and doctor absenteeism. In many cases, being relatively efficient and well-equipped does not amount to much: there is no functioning pediatric incubator; the blood bank is often empty; the ‘women’s ward’ where everything from abortion to sterilisation to post natal care takes place together is frequently 2 or 3 patients to a bed.
But some facilities are better than none, and even these basic services are simply not accessible to everyone. No services are entirely free: they all involve transport costs (getting a patient to the hospital by rickshaw costs about the same as a day’s wage in agricultural labour); most medicines have to be paid for; and an able-bodied family member has to stay with every patient, including at night, to provide food, buy medicines, and take back the patient’s body if he/she dies. That person – or people, since few can do 24 hour shifts for long – will not be able to earn while looking after the patient, and has to pay to get him/herself between home – for food and sleep – and the hospital regularly.
Out-patient care is also difficult to access, and time-consuming. Since primary-level care is so inadequate, referrals are very difficult to access and out-patient schedules difficult to get information about. You may have to wait many hours to be seen; you may be told to come back tomorrow. To make things worse, if you are adivasi, you stand a good chance of being treated with disrespect by medical professionals, will have to communicate in Bengali which is not your mother tongue, and probably cannot read any of the hospital signs or medicine packets.
Women suffer access difficulties acutely. Cash is less likely to be in their hands to enable a decision to seek care; many are unfamiliar with public spaces or how to organise transport, they are less likely to be able to read signs and prescriptions. Emergency treatment is particularly difficult for women: many are simply not allowed to make the decision to go to the hospital; this decision needs to be made by a man who may not be at home. If you are poor, adivasi, female, and very busy trying to make ends meet, the disincentives to getting medical treatment are enormous: it often seems more practical to hope for the best.
Health problems in the villages.
Conditions in the village are basic. No-one has a latrine; people and animals live very close together; nutrition is poor; and many children do not get fully vaccinated, despite the proximity of the diseases for which vaccines are available. There is a high incidence of chronic skin diseases, diarrhoea, worms, anaemia particularly amongst women and ‘viral fever’, especially during the monsoon, when sanitation is difficult to maintain. Ante-natal care, or medically supervised childbirth are virtually non-existent.
‘Unnecessary deaths’ are all too common: from childbirth; from post-natal problems; of neo-nates; from snakebite; from undiagnosed chronic illness often presenting as ‘diarrhoea’. Most of these deaths happen because appropriate treatment is not sought at the right time: because it is too expensive, too complicated and difficult to access. The government health system does not have a great reputation for success either: a visit to the hospital – often at acute stages, and amidst poor resources – often ends in a death. This is an understandable disincentive.
Health information and knowledge is also piecemeal and disparate, such that health decisions are complicated and challenging. Allopathic, homeopathic and traditional medicine each have different ways of conceptualising body, mind and health, and different interpretations of health solutions. Cultures also have different ways of talking about the body and health, making communication – for instance between Santal patients and hospital doctors – conceptually as well as linguistically difficult. These three systems co-exist in fairly equal proportions in this area. Sadly, co-operation between them is rare, with the result that all three sometimes use their knowledge irresponsibly. As a client, you enter one of these systems with poor information and at your own risk.
Suchana’s challenge in these circumstances is to find ways of working on preventative health, including nutrition, that make sense to and are realistic for the village populations and to improve people’s chances of making appropriate health care seeking decisions. One aspect of this is to work on solving problems of access to available services by linking people in to allopathic primary and secondary care services, so that these are at least included in their health care options.