ISSN (Print) - 0012-9976 | ISSN (Online) - 2349-8846
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Public Health System Is Failing the Women Farmers

Nitin Jadhav (docnitinjadhav@gmail.com), Bhausaheb Aher (bhausahebaher@gmail.com) and Deepali Sudhindra (deepasy@gmail.com) are associated with Mahila Kisan Adhikar Manch network in Maharashtra.

Maharashtra, with its drought-prone areas, is one of the states with the largest number of male farmer suicides. In the aftermath of these suicides, women farmers struggle on multiple fronts. A poor public health system further fails them and aggravates their plight.

This article has been written on behalf of the MAKAAM network. The authors would like to acknowledge the valuable inputs given by the anonymous reviewer.
 

Maharashtra is counted amongst the states with the largest number of farmer suicides in the country. As per the statistical data of the National Crime Records Bureau, about 65,000 farmers killed themselves in Maharashtra between 1995 and 2015. Around 20% of the total farmer suicides in the country have taken place in Maharashtra. Fourteen districts from Vidarbha and Marathwada have been declared as suicide-afflicted districts. About 90% of the farmers who committed suicide were male. A large number of suicides by the male farmers in Maharashtra also implicate an increase in number of women farmers from suicide-affected households.

After suicide by her husband, a woman faces problems at three levels. Getting over the trauma of her husband’s death, repaying the debt, and single-handedly taking over the responsibility of running her household. In addition to this, she faces the stigma of widowhood, leading to discrimination in family as well as in larger society. Suicide by a male farmer changes the social relations within the family. As widows, women are left fending for the children and the elderly of the family, and have to deal with the harassment of debt collectors. Additionally, they are also trying to cope with drought, crop failures and the burden of expenses of education of their children, marriages of their daughters and also face the catastrophic expenses of medical care of the family.

Tale of Two Suicides

The struggle becomes more difficult, as in most cases women have no land in their name, and generally have an unsupportive family that denies them access to the relief measures offered by the government, and in addition, they become easy prey to violence and sexual harassment. Let us consider the personal experience of two of such women.

Fed up with mounting debt, the farmer son of Vilayatibai from Bijora (Pardhi Tanda) of Darwa block in Yavatmal district, in a fit of depression, attempted suicide by ingesting pesticide. Before she could even understand properly what treatment her son was being administered in the government hospital of Yavatmal, the son died. Besides, her mentally challenged daughter who was not treated well at the hospital, ran away from the home. After two days when the police handed over the daughter to Vilayatbai, the daughter had been sexually exploited and she died within the next two days. Subsequently, her father-in-law also succumbed in shock. All these incidents occurred in 2014.

Later, a knot was identified in the head of her younger son, who was mentally challenged. Due to this knot, he fell sick frequently. He had to be admitted to the sub-district hospital (SDH) in an emergency situation, for which Vilayatibai had to shell out `1,200. She questions the utility of the toll-free ambulance service with number 108 advertised by the government, as despite multiple calls, the ambulance did not turn up as promised. Her struggle continues, as she needed to take her son to Nagpur and Mumbai for further treatment. So far she has spent `11,000 for her son’s treatment, borrowing it from her relatives. She cannot afford the cost for further treatment, and she also does not have the insurance smart card under Mahatma Phule Jan Arogya Yojana (MPJAY). She is in dilemma as to how much further loan she has to take for medical treatment. Coming from a poor farming family belonging to a marginalised community, she should have received free health services on a priority, but due to the apathetic approach of the system, she lost her son, daughter, and father-in-law within quick succession. Besides, she has an ever-increasing loan on her head for expenses incurred on medical treatment.

Well known in his area as a progressive and experimental farmer, Deepak Rao from Vai village of Khandeshwar block in Amravati district became depressed due to a series of mishaps. Ultimately he chose to commit suicide. His older son’s autorickshaw met with a severe accident in 2011, and the `40,000 which were put aside for farming, had to be spent on hospital expenses. Next year, Rao himself met with an accident and the hospital bill crossed `2 lakh. The family borrowed money from relatives to pay the bill. Barely were they coping with all this, when Rao met with an accident again, and this time they had to foot a `35,000 hospital bill. In the meantime, Rao’s daughter delivered a baby, which involved an expenditure of `20,000. The combined tab of hospital expenses for all three in 2014 was `3.5 lakh, which was paid off by taking loans. The money set aside for farming activities already spent in this process, Rao chose the path of suicide in August 2014 to “resolve” this difficult situation. Though he was taken in time to a public hospital, he did not get necessary emergency treatment, and he died while being transported to a private hospital. The entire family is suffering due to Rao’s death, while his wife Chitratai is trying her best to support the family. But the one question hounding Chitratai is why would such a brave farmer like Rao choose the option of suicide? Is the collapsing healthcare system responsible for worsening of Rao’s mental state, inducing a feeling of hopelessness? And if it is, does the government have the courage to admit so?

The above two stories are representative of many such incidents in the suicide-prone areas in Maharashtra. Various studies indicate that complex factors contribute to farmer suicide. It has been identified as a symptom of larger socio-economic malaise—the rural agrarian crisis and rural indebtedness. Two factors have transformed the economy of agriculture into a negative economy—the rising costs of production and the falling prices of farm commodities. Both these factors are rooted in the policies of trade liberalisation and corporate globalisation. Inaccessibility to proper healthcare adds to this situation of helplessness.

Collapsing Health System

In the last 20 years, major relief packages and debt waiver schemes were declared and implemented by the central as well as the state governments. However, along with financial intervention, there is
an urgent need to address some of the critical and yet ignored (especially by the government) precipitating factors which are directly linked with unavoidable and out-of-pocket expenditure by the farmers. Some of these key and protuberant precipitating factors are expenditure on marriage, unexpected and catastrophic healthcare expenditure, expenditure on education, especially higher education and routine expenditure on food items. Indeed, out of these factors, expenditure on healthcare is evolving as a crucial major burden factor, due to the almost collapsed healthcare system which forces patients to go to private hospitals.

According to a press release of Jan Arogya Abhiyan dated 14 February 2018, while other less developed states like Rajasthan spend much higher amounts on public health per capita (`1,672), Maharashtra planned to spend just `1,001 per capita in 2018–19, which remains far below the national average of `1,560 per capita. The National Health Mission (NHM) appears to be one of the worst affected programmes due to these budget cuts. From allocation of `3,473 crore in 2017–18 (revised estimate), the budget for 2018–19 shows reduction to `2,629 crore. NHM has been reduced by `844 crore this year compared to last year’s budget.

Even these low allocations are not adequately spent. During 2017–18 till the end of January 2018, only 56% of total public health expenditure has been utilised by the state government, and for medicines, the expenditure was only 27% of allocations. In relation to the NHM programme, in 2017–18, only 59% of the budget was spent till the end of January 2018. And in the financial year 2016–17, total expenditure under NHM programme was 56% till 31 March 2017. In 2017–18, the budget for medicine procurement was `471 crore. In 2018–19, the state has reduced it by `104 crore, bringing it to `367 crore.

In addition, as per the rural health statistics of 2016–17 by the Ministry of Health and Family Affairs, 6,188 posts of ANM (auxiliary nurse midwife) reserved for SCs (Scheduled Castes) and 6,501 posts at primary health centres (PHCs) were vacant, while 432 PHCs were working with only one medical officer and there was a shortfall of 81.2% in the number of specialists at the community health centres (CHCs) level, with respect to the required number. As per World Health Organization guidelines, the doctor–population ratio should be 1:1000. However, in Maharashtra, according to the Census 2011, the rural population of Maharashtra is 6,15,56,074, whereas the medical officers in position in PHCs are around 2,929 in number, as of March 2017. This means that there is a major imbalance in doctor–population ratio, as it comes out to be 1:21,016. This is also true for ANM–population ratio, standing at 1:5,800 in rural areas. In the case of specialists, especially surgeons, obstetricians, gynaecologists, physicians and pediatricians, the specialists–population ratio in rural areas is 1:1,21,173.

Failed Schemes

It is clear that Maharashtra needs major reform and restructuring in the public health system. In order to address the healthcare services issues in the 14 suicide-prone districts, two schemes—the “Prerna” project and MPJAY were started. However, according to a survey conducted by the Mahila Kisan Adhikar Manch (MAKAAM; Forum for Rights of Women Farmers),1 among 505 farmer women of 20 blocks from these 14 districts, there are huge gaps in the implementation of these schemes.

To safeguard the mental and physical well-being of the farmers, in 2015, the public health department took the initiative to start a special programme called “Prerna Prakalp” in the 14 districts. The main objective of the Prerna project is an assessment of farmers and their family members for mental illnesses, providing counselling services, and referral services to the district and sub-district hospitals for further treatment by mental health specialists. For this purpose, a helpline by the name of Manobal was also started and could be accessed by dialling 104. The psychotherapy cell was expanded in the district hospitals of nine districts. In addition, services such as counselling and medication were to be made available free of charge. Under this project, provisions were also made to provide for training of accredited social health activists (ASHAs) to help them identify cases of mental disorders and to encourage the patients to seek treatment.

In the survey conducted by the MAKAAM, it was found that among 505 farmer families, only 74 (15%) families were aware of the Prerna project and only 36 (7%) families knew about the counselling cell. Only 28 families knew about the Manobal helpline. Only 23 women reported having seen banners/posters about the Prerna project in their villages. Only 17% of the patients availed of mental health treatment in the public sector. Forty-three percent availed mental health treatment in the private sector, while 40% preferred not to take any treatment at all. The women reported the following obstacles in accessing mental health services from the public sector:

(i) public sector hospital/government hospital distance from the home/village (29.2%);

(ii) lack of help from the front-line workers, ASHAs or ANMs in the village (25.5%);

(iii) unavailability of the psychiatrist (mental health specialist) (24%); and

(iv) unavailability of medicines (19%).

The MPJAY scheme was started by the state government as part of the 125th anniversary of Mahatma Jyotiba Phule. This scheme basically renamed an earlier scheme, namely the Rajiv Gandhi Jeevandayee Arogya Yojana (RGJAY) that was in force before 1 October 2016 and launched it a day later in new name on 2 October 2016. Under the scheme, total annual coverage of `1.5 lakh can be availed either by one individual or collectively by all members of the family, with the exception of renal transplant surgery where the upper ceiling would be `2,50,000 per operation per year per family.

Yellow cardholder under the poverty line, beneficiaries of Antyodaya Anna Yojana, Annapurna scheme ration cardholders, students from government ashram schools, women from women’s ashrams, orphanages, senior citizens from old-age homes, accredited journalists along with their dependents, and other beneficiaries can avail this scheme. Farmer families from 14 drought-prone districts having yellow, orange and white ration cards are also eligible for this scheme. Farmers are expected to get the card (smart card) for this purpose, but even if they have not received the smart card, and one of the family members has to get an operation immediately, the farmers of these 14 districts can also produce alternative documents in the form of either yellow, orange or white ration card or 7/12 document. The scheme covers around 971 surgeries along with 121 follow-up services. A call centre has also been set up for guidance and grievances redressal, which can be accessed by dialling the number 15538/18002332200. A person suffering from a pre-existing disease is also covered under this scheme. Benefits of this scheme can be availed from government/semi-government, private and charitable hospitals that have more than 30 beds, along with select hospitals that have been chosen as “Arogya Mitra.” A total of 489 hospitals in Maharashtra are covered under this scheme.

Lack of Awareness

The survey has thrown up some rather surprising results in relation to this scheme. Among the 505 suicide-affected families surveyed, only 99 (19%) were aware of the MPJAY. Although the beneficiaries of the MPJAY are supposed to receive an identification card (smart card), only 10% of the people in the survey were aware of such a card. Out of the 505 families, members of 69 families had to undergo some surgery after 1 January 2016. Out of these, 17 opted for surgery in public hospitals while 52 opted for surgery in private hospitals. Although this scheme guarantees free surgeries, all the farmer families had to undertake other expenses, including doctor’s fees, medicines, ambulance services, surgical equipment/tools, etc, and 47 families out of the 69 had to take loans to meet these expenses. Sometimes bribes had to be paid. Despite having all the paperwork, the benefits of the scheme were also denied to some people.

Given such circumstances and poor implementation of schemes, how will the women having lost their husbands/sons, cope with their loss and support the family, while dealing with sudden high expenses being incurred for healthcare? To change this situation, the out-of-pocket expenses being incurred by farmers on health services need to be reduced. Given the context of drought in the 14 districts of Maharashtra, the farmer widows and their family members should have access to good quality health services free of cost.

To achieve this, all vacant posts in these districts should be immediately filled, and the constant shortage of medicines in the public health sector needs to be urgently addressed. In these suicide-prone and drought-hit districts, any tests and investigations required by the women should be available completely free of cost. These suicide-afflicted families should be incorporated in the Ayushman Bharat Yojana, without any terms and conditions. These are also some of the demands being made by the MAKAAM. Effective implementation of schemes like Prerana and MPJAY can reduce the burden of expenditure on the women farmers. Actually, it is not so difficult for the government to accept these demands; provided they have the willpower to do it and they exercise an appropriate implementation mechanism.

Note

1 The Mahila Kisan Adhikar Manch (MAKAAM) is a network that has been working on the issues of women farmers from 2014 onwards at a national level. Various campaigns, movements, organisations, researchers, and farmers are a part of this network active in 24 states across the country. It works towards ensuring that women get recognised as farmers in their own right, along with recognising their rights to land and other natural resources. MAKAAM has been active in Maharashtra from 2016, focusing on the issues of women farmers from suicide affected households.

Updated On : 11th Mar, 2019

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