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Politics of Pro- poor Reform in the Health Sector

The focus of this article is the "chain of referral" from community health workers upwards, in one particular primary health centre in Visakhapatnam, Andhra Pradesh. The study considers how the local political dynamics - shaped by competition between parties and between authorities representing tribals, the state development administration and health officials - affects the primary health centresâ?? capacity to treat poor tribal patients.

Politics of Pro-poor Reform in the Health Sector

Primary Healthcare in Tribal Areas of Visakhapatnam

The focus of this article is the “chain of referral” from community health workers upwards, in one particular primary health centre in Visakhapatnam, Andhra Pradesh. The study considers how the local political dynamics – shaped by competition between parties and between authorities representing tribals, the state development administration and health officials – affects the primary health centres’ capacity to treat poor tribal patients.

M GOPINATHREDDY, K JAYALAKSHMI, ANNE-MARIE GOETZ

P
oor people are often disadvantaged when it comes to influencing policy and are therefore poorly placed to influence the ways in which states allocates rights and resources within the society. This disadvantage encountered by the poorer sections in influencing the public policy often results in states tilting towards adopting pro-rich policy instruments. This has been case in most of the third world countries where poor people’s bargaining strength in influencing policy-making is weak and inadequate. Potentially pro-poor policies provide a means of redressing the above-mentioned imbalances by mobilising resources from one part of society to another for the purpose of planned and strategic development [Johnson 2001].

Background

Health indicators in Andhra Pradesh (AP) are slightly better than the national average but lag considerably behind those of other south Indian states such as Kerala and Karnataka. The health sector in AP faces typical problems: serious resource shortages, a failure to use existing resources efficiently, competition with a largely unregulated private sector in which moonlighting public sector medical staff spend a great deal of time (in spite of this being illegal in AP for those appointed after 1987), and a general lack of responsiveness to patient needs. AP state also faces tremendous logistical problems in reaching its most disadvantaged citizens: tribal groups living in remote and inaccessible areas. In these areas the public health infrastructure is barely present. Such rural health facilities as do exist are characterised by phenomenal levels of doctor and nurse absenteeism, an absence of drugs and equipment in primary health centres (PHCs), a weak referral system, and an absence of an orientation in the rural health system to preventive care instead of curative care. As a consequence, health indicators for tribal populations in AP are considerably worse than those for the rest of the population.

In AP’s health sector, management and planning has been decentralised through various means. Arrangements have been made to substantially increase local participation in the management of health facilities. Hospital Advisory Committees (HAC) exist for every health facility, including the PHCs in rural towns. AP has invested in versions of the “barefoot doctor” – or the para-professional rural medical worker – approach to improve the outreach of their health services in rural and impoverished areas. There are a range of such schemes, and our study concentrates on one of these, the revived Community Health Workers (CHW) scheme for extending basic healthcare to tribal areas.1 The CHW scheme in AP is integrated with the management of the PHCs and ultimately the department of health and family planning as well as the local tribal development agency.

Responsiveness to Poor in Health Sector: Key Problems

In this study we concentrate on the healthcare provided through continuous professional services (the referral system from the CHW up to the PHC). The analysis of the present study is guided by the following questions about the particular health system reform under investigation: (i) Has this reform affected the accountability system (recruitment, transfers and promotions, performance appraisals) in the public health service? (ii) Has this reform created or enhanced incentives for medical personnel to address the healthcare needs of the poor more effectively and with greater integrity? (iii) How far are new benefits for poor patients captured by better-off groups? (iv) What is the engagement of politicians and elite interest groups in this process? Specifically, where and how does the health system and this particular reform fit into the pattern of local competition for resources and for influence? (v) What is the engagement of local government bodies in healthcare planning, and are these bodies able to represent patients’ needs? and (vi) Has this reform prompted or enabled new forms of collective action around healthcare problems, particularly the health problems of the poor?

Main Findings of the Study

Vision 2020 – Health Sector Reforms

The government of Andhra Pradesh [GoAP 1999] Vision 2020 document identifies a seven-point set of priorities for health sector reform: providing universal access to primary healthcare; encouraging private investment in tertiary healthcare; focusing on specific programmes to promote family planning; focusing on improving health levels in disadvantaged groups and backward regions; ensuring a strong prevention focus; enhancing the performance of the public health system; and formulating a state information education and communication (IEC) programme to broadcast information on preventive healthcare. One important new initiative proposed in the Vision 2020 document was to expand the deployment of CHWs in tribal areas and in urban slums. CHWs are seen as particularly appropriate for AP given that some of its poorest people – its large tribal population – are physically remote from health facilities and culturally hostile to the modern health system. At the time this research began (2001) there were 8,500 CHWs in the state. They are seen as the starting point of the health referral system – in principle, the bedrock of the AP First Referrals Project (financed by the World Bank as part of the AP Economic Restructuring Programme), which has been strengthening primary and secondary health facilities since the mid-1990s.

Health Status and Public Healthcare in Tribal Areas

The tribal sub-plan area is spread over nine districts and consists of about 33 tribes and 22 lakh of the total 42 lakh ST population in the state. Poverty is the prime cause for ill health, persistent morbidity and early death. Lack of access to the right foods: iron, protein and micro-nutrients such as iodine and vitamins, causes a very high incidence of nutritional deficiency diseases: anaemia, diarrhoea, night blindness, goitre, etc. These factors combined with lack of access to basic healthcare services is the main reason for the marked gap in health indicators between tribal areas and the more developed parts of the state: maternal mortality is eight per 1,000 (going up to 25 among some tribal groups) as against four per 1000 for the state; infant mortality rate is 120-150 per 1,000 compared to 72 per 1,000; and while the crude death rate is nine per 1,000, close to the state average, the mortality rate for under-fives is a shocking 30 per cent. Amongst some of the major tribal groups such as Savaras, Gadabas and Jatapus, the death rate is as high as 15-20 per 1000, with over 50 per cent deaths in children under five. Life expectancy is lower, and there has been a rapid deterioration of the sex ratio during the decade 1981-91, and an extremely high level of about 75 per cent stunting/wastage among children. Tribals suffer disproportionately to their population from communicable diseases – the rate of incidence of TB among tribals is estimated to be double the rate elsewhere in the state, and the case incidence of malaria is estimated to be over 18 per 1,000, mostly of the P Falciparum variety (cerebral malaria), accounting for 75 per cent of the state’s total malaria deaths.

On paper, the healthcare infrastructure for tribal areas appears to offer a reasonable level of coverage for this remote and physically scattered population. In reality this impressive infrastructure either does not exist in places, or else is defeated by the highly dispersed nature of the tribal populations. The PHCs and sub-centres have been so located that the distances to be covered (in these areas this means by foot) by patients seeking treatment average about 272 kms and 37 kms with the highest going up to 465 kms and 50 kms respectively. Similarly, the average number of villages/habitations that have to be covered by a PHC and a sub-centre are about 73 and 10, with a high of 1,461 and 379 respectively. Evidence that there is significant underutilisation of such facilities as do exist comes from a 2001 beneficiary assessment study carried out for the AP Economic Restructuring Project (Health Component). This World Bankfunded project supports the AP First Referrals Project, designed to strengthen rural primary healthcare. In the portion of the sample that included scheduled tribes and the PHC serving them, it was shown that the monthly caseload of a tribal PHC was just 1,281 outpatients compared to 2,085 in non-tribal areas. These tribal PHCs appeared to reach only patients in a radius of just 5 kms of the centre, which meant that the vast majority of the tribal population was not using PHCs [Taylor Nelson Sofres Mode 2001].

A survey conducted by the department of family welfare during 1994-95 showed that none of the 29 mobile medical units are functioning, 66 per cent of the PHCs require repairs to make them usable, 30 per cent have no electricity (affecting vaccine potency), 62 per cent have no labour rooms or water supply (making institutional deliveries impossible), and 19 per cent are located in thatched huts, one-roomed buildings, sheds, etc, forcing a large number of the staff members to stay at home. Eighty per cent of PHCs have no BP apparatus, and virtually none have any weighing machines or blood testing equipment, making antenatal check-ups only notional. Fifty-three per cent of PHCs have no operating theatre and in 22 per cent of the others the theatres have no equipment and therefore are unutilised.

In the case of sub-centres, which are a 100 per cent centrally funded programme, 87 per cent are in rented accommodation, which in tribal areas would only mean a portion of a thatched hut. Even in the remaining 13 per cent of sub-centres, 50 per cent require major repairs and are unoccupied. While 8 per cent of the rest have some facilities such as examination tables, etc, only 1 per cent have water connections and 6 per cent have electricity. It is safe to assume that by and large the sub-centres are non-functioning, save for those that are located in roadside villages or market centres.

The poor infrastructure is undermined further by large-scale absenteeism and vacancies, and poor training and a lack of motivation in the staff who do show up. The vacancy rate for doctors averages nearly 30 per cent, and the same is true for the auxilliary nurse midwives, while it is 20 per cent for the male health workers [Rao 1998].

Tribal Health Plan

In 1997 a tribal health project (THP) was launched by the department of tribal welfare, funded by the World Bank and the International Fund for Agriculture Development for Rs 14.06 crore (a “crore” is 10 million). This was a vast increase on the estimated Rs 3 crore available for tribal health through the state’s budget. The THP was implemented in the four districts of East Godavari, Srikakulam, Visakhapatnam and Vizianagaram, covering 7.87 lakh people.

With regard to the health component, evaluations suggest this was one of the least successful parts of the project. One evaluation notes: “in most places the health committee often did not operate at all, and its intended functions were being carried out by the community health worker” [IFAD]. But there is evidence that the CHWs did in fact make some difference to their communities. Since 1997 the Paderu division in Visakhapatnam – our research site – has seen improvements in key indicators of maternal and child health: ante- and post-natal care has improved, as has the immunisation rate for children. The local observers insist that the CHW scheme in the district is the reason for this improvement. The district medical and health officer credits the CHWs with creating an early warning system to alert district medical staff of outbreaks of disease, particularly malaria, and with bringing a larger number of patients to the PHC for treatment.2 In the Paderu division, a survey in 2001 showed that in contrast to a nearby area with no CHWs, the areas in which CHWs operated had seen a drop in the rate of pre-puberty marriage, an improvement in the numbers of women coming for ante-natal checks (94 per cent of pregnant women had three check-ups compared to 67 per cent in the control area), and there was generally a higher uptake of information on basic sanitation, as well as observation of basic nutritional improvements during pregnancy and use of iron and folic acid tablets [CPDS 2001].

Approach to the Study

The focus of this study is the “chain of referral” from CHWs upwards in one particular PHC area in Visakhapatnam. The study considers how the local political dynamics – shaped by competition between parties, and between authorities representing tribals, the state development administration, and health officials

– affects the PHC’s capacity to treat poor tribal patients. There is a particular interest in understanding the way the lowest level worker in this system – the CHW – is affected by these political relationships, but we also consider the incentives affecting other health workers such as the ANMs, multipurpose male health workers, nurses and doctors. We also consider the way local government institutions interact with the health system, particularly through the health advisory committees formed by local panchayats to participate in local health planning and to raise money for and direct maintenance work in local health facilities. Local level political chiefs are expected to play an important role in the advisory committee functioning.

Two villages, each with different dominant political parties and tribal groups, but both served by the Minumuluru PHC, were selected for an in-depth comparison. The researchers sought to discover whether there were any differences in the delivery of healthcare to the villagers that could be attributed to local politics or power relations in the contrasting areas. These two village panchayats represent two political formations i e, one dominated

Table 1: Party and Clan Identifications of Panchayat Chairpersons in Paderu Mandal

S Name of the Name of the Party Name of the Clan S e x No Panchayat

1 Paderu Congress Bagatha 2 Badimala BSP Konda Dora Woman 3 Gondili TDP Bagatha 4 Kensuru BSP Konda Dora 5 Keyjile BSP Konda Dora 6 Vantla mamidi TDP Gadaba (PTG) 7 Vanjangi TDP Nooka Dora 8 Salugu Congress (shifted to

TDP after the elections) Bagatha 9 Vonugu palli Congress Konda Dora 10 Lagiri palli TDP Bagatha 11 Dopur luru BSP Konda Dora 12 Vanthadapalli BSP (shifted to TDP

after the elections) Nooka Dora 13 Barisengi BSP Konda Dora 14 Chinthala vadi TDP PTG 15 Devapuram Congress Bagatha Woman 16 Enadapalli BJP Bagatha Woman 17 Gablangi BJP Konda Dora 18 D Goondhuru Independent Konda Dora Woman 19 Guttulu puttu TDP Bagatha 20 Einada Congress Bagatha 21 Kadali TDP Konda Dora Woman 22 Kindangi TDP Valmiki Woman 23 Modhopalli TDP Valmiki Woman 24 Minumulu TDP Bagatha Woman 25 Munchinguputtu BSP Valmiki Woman 26 Thumpada BSP Konda Dora Woman

by Telugu Desam Party (TDP) and the other by the Bahujan Samaj Party (BSP).

Qualitative methods were used to elicit information on the perceptions of locals on the quality of health delivery as well as politics of health delivery. Key informant interviews were conducted with political chiefs, PHC doctors and health staff including ANMs, multipurpose health workers (MHWs), and CHWs, and other important stakeholders involved in the programme. Secondary data on health services provided by PHC was used in the analysis. The research had a survey element: in both field sites a random sample of households – 41 in total – was taken and a questionnaire applied to produce data on the morbidity profile of households, on their use patterns of public and private health facilities, and on the costs of health treatment. The principal research staff visited the field sites periodically (at least four times) until the completion of field survey and conducted major key informant interviews.

Description of Field Sites

Minumuluru PHC, built in 1998, is situated 9 km away from the seat of the integrated tribal development agency (ITDA) (there are 9 ITDAs in total across the tribal agency areas in the state) in Paderu mandal. It caters to 26 gram panchayats representing a total of 287 hamlets or villages and extends medical services through 14 sub-centres. One of the first things to note about this PHC is that it is badly located. It is very close to Paderu town, which has a community health centre (CHC), yet it is very far from the majority of the villages that it serves. Just three gram panchayats are nearby, another 10 are accessible by 20 kms of metalled road, and the rest, up to 30 kms away, face at least 10 kms of rough terrain before they reach a road.

Twelve panchayats are held by the TDP (two having switched to the TDP after the elections), seven by the BSP, three by the Congress, two by the BJP and one by an independent candidate. Bagathas account for nine panchayats; Konda Doras hold 10 panchayats; Nooka Doras and Valmikis (a trader group) account for two panchayats each and two panchayats are controlled by persons belonging to primitive tribal groups. Gender-wise, there are 10 panchayats that have women chairpersons in the mandal.

Two gram panchayats served by the Minumuluru PHC were selected for study: the Minumuluru gram panchayat itself, and the nearby Thumpada gram panchayat. The first is dominated by the TDP and the latter by the BSP. In each gram panchayat the main village and seat of the gram panchayat was studied, and in addition one of the smaller hamlets under the authority of the panchayat was studied. In Minumuluru this was the Kodigulu hamlet, and in Thumpada this was the Gaddamputtu hamlet. Minumuluru has been a TDP area since 1988 (prior to that it was Congress-dominated). In Thumpada, the recent elections saw a shift from long-standing TDP affiliations to an all-BSP panchayat – something that is unusual for the area.

Table 2 outlines the population and dominant tribal group in each field study area. Minumuluru and Thumpada gram panchayats are at equivalent levels of development. Thumpada has a higher rate of landlessness, with about one-third of household having to work as agricultural labourers. In Minumuluru most of the landless households are immigrant non-tribal families from the plains, “Kapus”, who work on coffee plantations or the steel plant on the coast. They bring substantial trading activity to the area, as this group may not purchase land (Tribal Act 1/70 forbids the transfer of land by sale from tribals to non-tribals).

Prevention, Treatment and Referrals in Minumuluru PHC Area

As noted above, officially the Minumuluru PHC covers a population of over 54,000 people, but in practice, because of its inaccessibility to the majority of the 287 habitations it serves, it caters to at the most, 25 villages. The PHC treats between 30 and 40 patients a day, but considerably more on the weekly market day that brings many people from the hilltops down to the village. The low patient load at the PHC itself means that its outreach systems are all the more important. Outreach – consisting of preventive health training of villagers, the application of simple remedies on the spot, early warning data collection to prepare for or prevent epidemics, and sensible referrals to appropriate health facilities – depends upon the network of auxiliary nurse midwives and MHWs servicing the PHC’s 14 sub-centres in its catchment area, and upon the 234 CHWs and 102 traditional midwives living in its villages.

The formal vacancy rate at the PHC is not as dramatic as it is in other PHCs in the region – and nothing close to as bad as the situation in the nearby Paderu CHC, where just two out of eight doctors’ posts have been filled, and each doctor only attends for 15 days a month. The 30-bed CHC at Paderu, ITDA headquarters of Visakhapatnam district, had a zero occupancy rate for the first five years since its construction, for lack of staff. But the formal vacancy rate gives little indication about absenteeism rates. Villagers complained that doctors – particularly the female doctor – were frequently absent from the PHC, and that the ANMs only infrequently visit villages, and are an even more rare a sight in the hilltop hamlets. Particularly weak in this PHC is the endowment of field supervisors. The formal allotment of seven public health supervisors who are supposed to monitor the field work of ANMs and the public health assistants in the 14 sub-centres; only four supervisors were appointed in this PHC,

Table 2: Demographic Profile of Field Site Villages

Name of the Village or Hamlet Population Main Tribe or Clan

1 Minumuluru Gram panchayat

(a)Minumuluru 368 Bagathas

  • (b) Veragandhi (hamlet) 54 Primitive tribal group
  • (c) Kodigudlu (h) 102 PTG
  • (d)Sangodi (h) 378 Konda Dora

    (e) S V Nagar (h) 242 Mixed (Coffee board employees

    from the plains) Total 1144 2 Thumpada gram panchayat

    (a)Thumpada 496 Bagathas

  • (b) Gaddamputtu (h) 321 Konda Dora
  • (c) G Kothuru (h) 104 Konda Dora and PTGs
  • (d) Bayiluveedhi (h) 42 Konda Dora and PTGs Total 963

    Table 3: Staff at Minumuluru PHC on January 30, 2003

    Staff Position Posts Sanctioned Posts Filled Posts Vacant

    Medical officers* 2 2 -MPHEO 1 01 Senior assistant 1 1 -Pharmacist 1 1 -Staff nurse 1 -1 Lab technician 1 1 -Medical public health supervisor 7 4 3 MPH assistant (male) 14 10 4 Auxilliary nurse midwives 14 14 -

    Note: * One male and female doctor. The lady doctor was appointed very recently on contract basis with a remuneration of Rs 15,000 per month and additional allowance of Rs 2000.

    and were unable to cover the 14 notional sub-centres. These supervisors, like most of the professional medical staff of the PHC, live in Paderu town or even in the district capital, Visakhapatnam. This meant that daily attendance at the PHC was a rarity for the more senior medical staff.

    ANMs are simply unable to conduct the number of village visits they are mandated to do. In our study, the hilltop hamlets of primitive tribal groups said they almost never received visits from the ANM. In both Gaddamputtu and Khodigudlu not one of the referrals to the PHC in the period under study was made by the ANM – all were made by the CHW. Systems for performance monitoring and controlling of ANMs are weak. The public health supervisor is supposed to write her annual report, but the high vacancy rate at this level means this task is left to the medical officer (doctor) at the PHC, who is not directly exposed to her work. The PHC doctor can sanction and even suspend ANMs for poor performance, but in this they are often undermined by the DM and HO or other district-level line ministry officials who can be bribed to effect a transfer of the ANM. In one case in our study area, neglect by an ANM had resulted in three deaths in Devapuram village. A complaint was made by villagers, who also pointed out that the ANM had forced the CHW to provide her with cooked food on the occasion of her visits. The PHC doctor’s report on this was ignored after the ANM paid a Rs 30,000 bribe to be transferred out of the area. Besides complaints about the failure of ANMs to make visits, doctors complain that they file false reports on disease incidence and treatment histories. The villagers complain that they impose informal charges for medicines or extract payments for treatment.

    The CHW system fills an obvious gap in the primary healthcare outreach provided by ANMs. CHWs are married women selected at the village level by the sarpanch. They must be married in order to increase the chances that they will stay in the area, and also to enable them to discuss matters of family planning with other women. They are supposed to be literate, but few in this study were. They receive about 20 days training in the basics of sanitation, nutrition, maternal and post-natal care, and general preventive healthcare. CHWs are supposed to meet up at the PHC once a month to restock their medicines, confer with ANMs and the PHC doctor, and to receive their honorarium of Rs 300. No funds are provided for their travel to the PHC, nor any for the cost of travel with sick patients to the nearest health facility, a duty that they are expected to fulfil in serious cases. The most common complaint raised by CHWs is that their honorarium is never paid on time, and has in the past sometimes been as much as 12 months in arrears. They never know who or what authority will be paying their honorarium – in the 12 months between 2001 and 2002 the CHWs in the study area were paid once by the PHC, twice by the bank, and once in a Janmabhoomi exercise. Drugs, which are in desperately short supply at the PHC3, are never available in sufficient quantities for the CHW, and this undermines her credibility as a health worker in the village. Though the villagers interviewed for this study were generally very positive about the impact of CHWs, particularly in the area of ante-natal and post-natal care, they all observed that the CHW rarely had any drugs to dispense, or that when she did, she made them available only at a price.

    High rates of absenteeism and the uneven supply of drugs means that the credibility of the PHC and its outreach system is relatively low amongst villagers. When the costs of transport, bribes, and contemptuous attitudes of health professionals are added to the uncertainties about whether medical staff and drugs will be available, there is little to make the public health system seem more attractive, reliable, or cheaper than private providers. Nevertheless, in tribal areas there is greater use of public health facilities than in other poor areas in AP because the relatively greater poverty of tribal people means they have fewer resources to purchase private care. In addition, there are fewer private providers servicing tribal areas. In the 14 household illness case histories taken for this study, we found that sick people in the study area routinely sought treatment first from public health providers, and when and if that failed, men would pay for treatment from private providers, while women and children either sought traditional remedies or continued to deteriorate without further assistance.

    Since the late 1990s a HACC has been set up for every health facility to represent patients’ concerns, but these simply do not function at the PHC level. These committees are set up by the mandal panchayat and are supposed to embrace representatives of relevant public services at the local level such as the PWD, the education service, the police, as well as the local development administration and the local MLA. These committees have the powers to raise funds by levying user charges for medical services and have taken over the basic maintenance budget from the local PWD. When this system was introduced in the late 1990s the health secretary at the ministry of health hoped to endow these committees with administrative authority over health facilities and to monitor doctors’ attendance, and to recommend salary cuts to punish absenteeism. In response, the AP Government Doctors’ Association threatened a strike, so this idea was dropped. In our study area the HAC for the Minumuluru PHC met rarely. Chaired by the mandal president, it took no role in monitoring the performance of the PHC. However, it has insisted that some PHC contingency funds be spent on a cleaner centre and a female ayah for the labour ward – and brought attention to the fact that the PHC has no budget at all for cleaning. There is no sense, however, in which medical professionals at the PHC level report to locally elected representatives or are under pressure to respond to their needs.

    Family Planning in the Primary Health System

    The association of the primary healthcare system with family planning has some obviously worrying implications for the credibility of the system and for its effectiveness, while the preoccupation of providers with meeting family planning targets may have negative implications for their ability to address other public health concerns in the area. Health service providers from the grassroot level to the district health and medical officer to state-level officials in the Department of Public Health and Family Welfare insist that they do not have official sterilisation targets to meet. This insistence here and in the rest of the state is belied by a glut of sterilisation operations every February, just before the end of the financial year, to meet local sterilisation targets. Official records of the Paderu division’s healthcare performance highlight show steadily improving rate

    Table 4: Performance Indicators of Minumuluru PHC 2001-02

    Activity Target Achievement
    Antenatal care 1333 1209
    Tetanus injections 1333 1316
    Attended deliveries (including institutional) 1193 887
    Sterilisations 577 583
    Full immunisation 1157 851
    Measles vaccine 1203 1203
    TB 65 cases identified

    of sterilisation over the years, clearly indicating targets and achievements. In 1997-98, for instance, the health facilities in the Paderu division performed 2,522 sterilisations, or 61.52 per cent of the target for that year, but by 2000-01 they performed 11,653 sterilisations, or 225.92 per cent of the target for that year [GoAP 2002].

    Minumuluru PHC is one of the better-performing PHCs in this respect, with its doctors receiving letters and certificates of appreciation from the government for overreaching sterilisation targets and for achievements in encouraging contraceptive use. As it happens, the main type of performance for which doctors in PHCs can be given official, formal recognition and approval is for high rates of sterilisations. As noted in a recent study of accountability mechanisms in the health system in AP: “Although there are targets for many different things, the prime interest of the DM and HO is the achievement in the area of family welfare (and then, primarily the number of sterilisations) because this is what the DM and HO is made responsible for, and because this is also the main health performance indicator for the district and the district collector [Mooij et al 2003].

    Minumuluru PHC had received a certificate five times since it opened in 1998 for its family planning performance. The performance indicators for the Minumuluru PHC show the importance of family planning achievements to the medical staff. Achievements against some of these measures in the year 2001-02 are shown in Table 4.

    As the table shows, targets were met or exceeded in the case of sterilisations and application of the measles vaccine. The sterilisation rate was on the increase – 634 operations had already been conducted before the 2002-03 year ended. On the other hand, as Table 5 shows, the number of institutional deliveries at the PHC has remained very low.

    The delivery facilities in the Minumuluru only opened in 2000, though facilities for sterilisations were opened in 1998. The figures show that fewer than 10 per cent of local deliveries are conducted in the PHC. Sterilisations, on the other hand, bring rewards beyond the non-monetary official approvals and recognition. There are financial incentives – CHWs, for instance, are paid Rs 15 for every case they bring to the PHC for sterilisation, and often press the patient for an additional payment, drawn from the Rs 500-1,000 that the government gives to those who accept sterilisation.

    Historically CHW schemes in India have been intimately connected to family planning goals. After the sharp fall in sterilisations after Sanjay Gandhi’s overzealous, not to say coercive, vasectomy campaign of the mid-1970s, India’s government announced “an entirely new scheme” for the strengthening of rural healthcare services. Inaugurated in 1977, a national family planning policy highlighted the role of CHWs as a means of putting “people’s health in people’s hands” and was simultaneously seen as a means of putting the problem of population control “on a war footing”. A terminology change accompanied the new policy focus on using women health workers to encourage women to accept sterilisation or contraceptives: “targets” became “expected levels of achievements” [Rao 1999].

    This preoccupation with family planning and sterilisation takes on insidious features in the contexts of tribal populations. Some of the tribal groups in the agency areas are considered “endangered” – their numbers have collapsed and just a few thousand remain. Medical practitioners are supposed to ease off family planning targets in their cases. But the opposite seems to be happening, with numbers of sterilisations very high in tribal areas. Because of the availability of financial incentives for sterilisations, and the ban on sterilisation across the border in tribal areas of MP, tribals from MP are crossing the border for sterilisations [The Indian Express 2003]. Tribal populations in the AP agency areas are already suspicious about the state government’s motives in the region, and this is an area where there has been, for years, organised violent protest through the People’s War Group, also known as Naxalites. The strong interest shown by health officials in sterilisations tends to stoke local concerns about the coercive measures used to control tribal populations, and does nothing to build local trust in health service providers.

    Politics of Primary Care and Health Outreach Services

    As noted earlier, CHWs and link volunteers are funded under the World Bank’s APERP (AP economic recovery project) as the key means of reaching poor patients who are remote from health facilities by virtue of physical isolation (tribal communities in border areas) or because of social exclusion (women and children in low-income households). In the tribal area studied here, the CHWs were financed and managed through an additional scheme – the World Bank and IFAD-funded AP Tribal Development Project, which had come to an end at the very time of our fieldwork in 2002, and had been transferred to the authority of the panchayat system, not the health system, given a budget crisis and low capacity of the health system.

    This means that at the time of our research the CHW programme was in a moment of transition, with an uncertain budget, confusion over appropriate authorities for supervision, and an uncertain future. In most areas the immediate concern of the sarpanch was to assert authority over the CHW by appointing a new one to replace the one appointed by the village tribal development agency (VTDA)

    – unless, of course, the sarpanch was from the same village clan group or faction as the young man heading the VTDA.

    In the local tussles over access to resources, the health sector is of minor interest compared to resources available via contracts for construction on watersheds, irrigation systems and rural roads. The appalling state of healthcare in the region is barely raised in local election campaigns. The BSP, which has gained a toe-hold in six mandals (G Madugula, Munchingputtu, Peddabayulu, Paderu, Hukumpeta and Dumriguda), where it has 54 sarpanches and a lone mandal president (in G Madugula) campaigned largely using identity politics arguments. As a Dalitbased party it projected itself as the defender of the rights of socially excluded people, and played on tribal resentments about immigrants from the plains.

    The only party to take up health issues in tribal areas has been the CPI (M), which also mobilises and supports many front-line development workers, particularly in the Paderu area. It began working in tribal pockets in 1992, in the nearby Araku valley, by mobilising and unionising Anganwadi workers, construction workers and coffee plantation workers. It has three reasonably well-organised wings functioning in the area: the Student Federation of India, the Centre for Trade Unions and the Andhra Pradesh Girijana Sangham (APGS). The latter is an association devoted to defence of the rights of tribals, and it has been active at the district and state levels in protesting injustices suffered by tribals – including healthcare so negligent that it fails to prevent killer epidemics of malaria and diarrhoea. In January 2003, the APGS registered a union of CHWs, and enjoyed two immediate successes: it demanded that the honorarium of the CHWs be paid by the medical officer at the PHC, and that CHWs be issued with identity cards. In the wake of epidemics of malaria and viral fever that had embarrassed the district and state government, both measures were agreed and implemented for CHWs in all agency areas in a gesture to show a response to the health crisis in the region.

    If the primary healthcare system offers little to political parties in terms of commissions to be gleaned from mediating access to funds or to construction contracts, access to healthcare and to lower-level jobs in the system is still something that can be auctioned locally or used to reward supporters. As discussed earlier, the decision over the location of the Minumuluru PHC was political – though unfavourable for most of the villages in its radius, it was located in a stronghold of TDP support. Our village household sample survey showed that Minumuluru residents overwhelmingly chose to use the PHC, whereas in the BSPidentified Thumpada village, sick people who could chose either the PHC or the CHC – which were the same distance away – almost always chose to go to the CHC, even though it was not as well staffed and equipped as the PHC.

    The selection of the CHW is also affected by local power relations. Whether the VTDA selects the CHW or the sarpanch, this is part of a set of decisions they make about rewarding support groups, or palliating the resentments of excluded groups. The CHW position is hardly the most desirable prebend on offer – it involves a lot of work with little reward – and therefore is low down on any list of benefits to be distributed by a powerholder. Nevertheless, it involves a certain amount of social status, access to saleable drugs, knowledge, travel and training. In interviews, most CHWs said that their selection, whether by the VTDA or the sarpanch, had been made in consultation with caste leaders and the village administrative officer. However, it was evident from interviews with village women that prominent women in the village took considerable interest in the selection process, and had no small degree of influence over it. What is noticeable is that women seem to have conspired to keep the status associated with being a CHW relatively modest. Once it was understood that the CHW would have access to no significant honorarium or drugs supply, better-off women lost interest in this position for themselves. Instead, according to some observers, they took care to ensure that the woman selected for the CHW position represented no threat to their interests in the village4. This has not infrequently meant selecting an under-qualified woman, sometimes from a minority tribe or clan, and often quite young, who will know her place in relation to more senior women in the village.

    These power relations between women have at times undermined the role and effectiveness of the CHW. Thus, for instance, when ANMs visit villages they may often interact with and show more respect for the anganwadi than the CHW, who is made

    Table 5: Deliveries at the Minumuluru PHC

    Year Deliveries Sukhibava*
    November 1999- March 2000 1 4 1 4
    April 2000-March 2001 April 2001-March 2002 9 2 108 1 7 6 9
    April 2002-August 2002 4 7 3 3

    Note: * Sukhibava is a central government-sponsored scheme to promote institutional deliveries. Mothers in the below poverty line category are paid Rs 300 for each of their first two deliveries to cover transport costs to the PHC or hospital.

    a junior partner in these exchanges. There are cases where a family planning accepter identified by a CHW will be taken over by an ANM and anganwadi worker, who will get the credit (and maybe a small pay-off) for arranging sterilisation.

    Incentive Systems and Power Relationsin Health Sector

    As evident in the forgoing analysis, the primary healthcare system in tribal areas is not just poorly funded, it suffers greatly from dysfunctional accountability systems that are ineffective in dealing with absenteeism and corruption. Systems of negative sanctions are undermined because of political interference. Systems of positive rewards for performance are undermined by the excessive importance given to sterilisations, and the lack of performance monitoring systems for achievements and behaviours that would produce better responsiveness to the poor – for insistence, rewards for evidence of greater time spent in villages by health professionals.

    It is ironic that so little attention has been paid to incentives systems for the outreach health staff given that the CHW system has been inspired by the Brazilian success story – the Basic Community Health Programme. In the Brazilian case, particular attention was paid to creating and incentives and sanctions system that motivated the new corps of street-level women health workers. They were supplied with simple uniforms enabling them to be easily identified, regular awards ceremonies acknowledged hard work, and constant scrutiny by those who had been refused entry to the programme provided free monitoring of their activities. In addition, they were closely supervised by qualified nurses. In the Paderu case, there has been little investment in building up an esprit de corps amongst the CHWs. Only their one-off 20 days of training brings them together; attendance at monthly meetings is sporadic because they cannot afford the travel costs. There are unclear lines of supervisory authority over CHWs, and their relationship to their most direct supervisors – the ANMs – is ambivalent, as they are often exploited by the ANMs.

    Incentives systems for the ANMs are likewise inadequate. They, like the women doctors, get additional cash incentive or working in rural areas, over and above the extra increment given to all health professionals working in tribal areas. But they get no support for the considerable distances they must travel, nor recognition of the childcare problems this poses for women who have children, or the physical risks that lone travel by women brings in these areas. Worse, the ANM position is something of a career dead-end. ANMs have nowhere to go in terms of promotions. There are 11,000 in the state and they can aspire to just 2,500 higher positions – namely, the public health supervisor position (which involves an even greater mobility requirement) or the district health worker position. PHC doctors in our study, sympathetic to the problems of ANMs, proposed a reduction of the number of people to which they must attend from 6,000 to 4,000. But district officials instead proposed harsher controls on their movements in order to incite better performance

    – for instance, the introduction of a biometric card system in sub-centres to record the ANM’s visit, with failures to visit field sites punished through salary cuts.5

    The high rate of absenteeism and private moonlighting by doctors signal the effect of low salaries and poor conditions upon their incentives to perform well. Only the chance of a favourable transfer motivates better performance, and this is easiest demonstrated by performing large numbers of sterilisations. Even recognised achievements in rural health service can be wiped out by a high bribe given by a rival for a transfer. As a senior bureaucrat in the health ministry lamented in an interview6, every day the health minister receives up to 200 chits from MLAs requesting that a particular medical professional receive a favourable or a punishment transfer. Prior to 1999 the health secretary introduced a “counselling system” to regularise transfers and appointments. The system graded PHCs from A to C

    – doctors in PHCs with a good grade would get preferential postings. A government order was produced that proposed that these performance assessments be conducted through a committee on which the district collector, DM and HO, and directors of other public services in the district would sit. Resistance from doctors’ associations to this was ferocious – it took two years to get the government order past the AP Government Doctors’ Association. And the system was abandoned before it got underway when the health secretary clashed with the health minister and was suspended in 2001.

    Summary and Conclusions

    The CHW scheme is an appropriate means of extending the outreach of primary health services in remote and impoverished areas. This case study from a tribal area in north-eastern AP shows, however, that the CHW scheme, and the primary healthcare system, fail the poor for a number of reasons attributable to power relations within the health system and at the local level:

  • The politicisation of the system of appointments and transfers within the health system means that no system of performance monitoring and accountability will be effective if practitioners can bribe their way into a better position, regardless of their performance in rural areas. Work in a remote tribal PHC is the least rewarding position for medical staff and they feel under no compulsion to perform well – except in the area of sterilisation operations, for which they receive official kudos. As a result the PHC itself and its outreach system function extremely poorly.
  • The refusal of the public health system to take ownership over the CHW programme means that there is no effective performance monitoring of these volunteers, and no means of coordinating their work to produce a coherent assault on the health problems afflicting tribals.
  • The refusal of the public health system to take charge of the CHWs puts them under the authority of local elites and creates of their position another prebend that can be awarded within patronage systems. Caste, clan and gender politics determine the appointment and control of CHWs.
  • Wherever local authorities – be they panchayats or VTDAs
  • are given control over a health system resource such as the CHW, this creates conflict with the technical line ministry staff and discourages their interest in working with people who they see to be appointed for political reasons, not merit.
  • Up until 2002 CHWs were appointed through VTDAs and purportedly monitored by community health associations. This followed a pattern in other sectors in AP where users committees attract resources directly, bypassing panchayat authorities. This has the effect of fracturing and fragmenting local political energies and focusing them upon the capture of development resources, particularly contracts for construction work. The CHW and primary health system, however, brought few such resources to the village and therefore attracted little attention from maledominated power structures. This has left it open to competition amongst the village’s female community, which has found ways to control and subordinate the CHW to more powerful female actors within and across communities.
  • Patterns of use of health facilities are shaped in part by party and political concerns, with some health facilities identified as a resource for particular support groups, to the exclusion of others.
  • Health sector reform policy is profoundly influenced by the professional doctors’ associations in the state, with the overall effect of leaving the private medical market under-regulated, and the work of public sector doctors under-monitored.
  • EPW

    Email: mgopinathreddy@cess.ac.in mgrjl@yahoo.com A.M.Goetz@ids.ac.uk

    Notes

    [This study was part of a DFID funded research project ‘State Responsiveness to Poverty: The Politics of Pro-Poor Policy-Making and Implementation’. DFID provided funds for this study but the views and opinions expressed are those of the authors alone. The authors also thank Rob Jenkins of the University of London for his valuable comments.]

    1 An example of another health provision scheme using para-professionals are the “link volunteer” schemes in Hyderabad, Mahaboobnagar and Nalgonda. These use women volunteers in urban slums to disseminate basic good practice for public health and preventive care, and have been very successful in increasing the use of urban health posts.

    2 Interview with S J Subba Rao, District Medical and Health Officer (DM and HO) Visakhapatnam, February 2002, Visakhapatnam.

    3 The PHC has a budget of Rs 30,000 per quarter, down from a budget in the late 1990s of Rs 49,000 per quarter – the standard amount for all PHCs. A standard package of drugs are ordered through a central drug store under the AP Health, Medical and Housing Infrastructure Development Corporation. Earlier, the DM and HO ordered drugs for local PHCs, but graft at this level meant that the AP government has decentralised drugs procurement. This has had the effect of eliminating responsiveness to local variation in needs, as well as introducing substantial transaction costs, as PHC staff must travel to the district capital as many as four times a quarter to collect the drugs.

    4 Interviews with district-level health officials in Visakhapatnam, February 2002.

    5 DM and HO interview with the first two authors of the study, July 4, 2002, Visakhapatnam.

    6 Name withheld, February 18, 2002, Hyderabad.

    References

    Centre for Population and Development Studies (2001): Evaluation of Community Health Workers Scheme under Tribal Health Plan in Andhra Pradesh Tribal Development Project (APTDP Area), Hyderabad.

    GoAP (1999): Vision 2020, Swarna Andhrapradesh, Hyderabad, AP, India.

    – (2002): Family Welfare Programme in Paderu Division of Visakhapatnam District,Medical and Health Department, Paderu Division, Visakhapatnam District, mimeo.

    International Fund for Agricultural Development: ‘Andhra Pradesh Tribal Development Project: Agreement at Completion Point’ (www.ifad.org/ evalaution/pulbichtml/eksyst/doc/agreement/pi/andhra.htm).

    Johnson Craig, Daniel Start (2001): ‘Rights, Claims and Capture: Understanding the Politics of Pro-poor Policy’, Working Paper 145, Overseas Development Institute, London.

    Mooij Jos, Sheela Prasad and Asha George (2003): ‘Health, Decentralisation, Decision-Making and Accountability in Andhra Pradesh, India’, Background Study for the Health Strategy and Expenditure Framework of the Government of Andhra Pradesh, India, DFID, Chapter II, London.

    Rao Mohan (ed) (1999): Disinvesting in Health: The World Bank’s Prescriptions for Health, Sage Publications.

    Rao Sujata, K (1998): ‘Health Care Services in Tribal Areas of Andhra Pradesh: A Public Policy Perspective’, Economic and Political Weekly, Vol 33, No 9, February 28-March 9:3.

    Taylor Nelson Sofres (TNS) Mode (2001): Beneficiary Assessment of AP First Referral Health System Project, Hyderabad, September.

    The Indian Express (2003): ‘Endangered Tribals Skip Ban, Sneak Into AP for Tubectomy’, February 1.

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