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People’s Health Care Initiatives in Chhattisgarh.
Binayak Sen
P.O.Box 130, Raipur- 492 001, Chhatisgarh.
A History of the Rupantar health programme
Most of the attempts to address the problem of health care within the context of globalization seem to take the legitimacy of the state as an agent of welfare for granted. Such attempts mostly have either an analytical or an exhortatory character. In other words, they either tell us where we are, or where we should be but very little about how to get there. This is only natural because, in our view, there are insurmountable structural constraints to state intervention in health. On the other hand, we certainly do not advocate any form of privatization as a solution.
Community based approaches which are linked to peoples’ movements to control livelihoods/access to natural resources open up important cultural and political issues and provide an alternative approach by which this problem can be addressed.
A series of health care initiatives have been effected over the last fifteen years in the context of the Chhattisgarh Peoples’ movement. This is the most significant example of sustained activity in the field of health that has been initiated and carried out by a peoples’ organization. As such it holds important lessons for the future of a community based health care approach.
The Dalli Rajhara experience.
In 1977, the Chhattisgarh Mines Shramik Sangh (CMSS) was formed in Dalli Rajhara among the mine workers working in a very large iron ore mine in Durg district in eastern Madya Pradesh. This area is also called Chhattisgarh, and its people are Chhattisgarhis. These people have a long history of oppression and resistance. The workers in the CMSS carried out a long and heroic struggle against social and cultural oppression that affected them in the workplace, in the existing trade unions, as well as in their homes. Their just demands for fair wages and working conditions were met with severe repression, including police firing. Their leader in the struggle was Shankar Guha Niyogi.
Niyogi was a political worker with a long experience of participation in the peoples’ struggles in Chhattisgarh. In the course of his work he had formed certain definite ideas about the mutually supportive interaction between peoples’ struggles and community based development activity. The objective conditions in Dalli Rajhara also favoured such a conjunction. The Chhattisgarhi workers lived in distinct colonies called dafais which had no infrastructural or health facilities. This was in marked contrast to the infinitely better favoured colonies of the regular workers of the Bhilai Steel Plant (BSP) which owned the mines. The struggles of the workplace found their logical extension in organized efforts to improve life in the dafais. These efforts included campaigns against alcohol, primary education, and a health programme.
The direct impetus for the health programme was the death in childbirth of Kusinbai, one of the important leaders of the movement. Public sentiment was therefore committed to building up an appropriate clinical facility that people would find accessible and friendly. The Shaheed hospital began to take shape around 1981, and today has 80 beds, with a lab, operation theatre, and X ray machine. The entire unit has been financed by the organization.
In the first few years, hospital assets were built up out of funds contributed by the mine workers. Even though the fee structure was kept extremely modest to enable poor people to access its services, there was nevertheless enough money left over to finance a steady train of asset acquisition.
Since many of the activites that could be classified under preventive and promotive health care (such as the struggle for safe drinking water, the campaign against liquour sales and alcohol abuse) were being directly undertaken by the organization, my medical colleagues and I were able to concentrate on building up a culturally acceptable alternative paradigm of clinical care.
The operative details of this paradigm were:
1. An overall emphasis on rational practices in health care with special efforts directed at making the rational basis of our practice accessible to all users.
2. Demystification of technology with the maximum possible decentralization of all technical procedures.
3. Constant attempts to minimize the distinction between mental and manual labour.
4. Democratization of all decision-making processes.
These points can now be elaborated below.
1. Accessible rationality.
We tried very hard to subject all our practices to rational scrutiny. Moreover, we tried our best to involve patients and their relatives in sharing our perceptions of the scientific and rational content of our efforts. Significant amounts of time were devoted to explaining procedures and therapies. This was an attempt to rid health technology of its magical trappings, but it was more than that. Proletarians need dignity before they need bread, and this was an attempt to bring about an atmosphere in which people could become the subjects and not the objects of healing enterprise.
2. Decentralization of technology
From the beginning, the Shaheed Hospital was fortunate to have a group of health volunteers from among the mine workers, who while continuing their work in the mines, devoted three to four hours every evening to help in the work of the hospital and to participate in its management. While initially, they were themselves very apprehensive about their capabilities, over time they became highly skilled at nursing, dressings, and operation theatre work. Gradually, they also took over the entire range of management functions in the hospital including accounts. All the premedical and nursing workers of this approximately hundred bed hospital have been trained in the hospital itself. Some of them had very little formal education.
3. Minimizing the distinction between mental and manual labour
Form the beginning we believed that the emphasis in modern medicine on esoteric knowledge mainly serves as the ideological justification for an enormous hierarchical stratification of position and rewards both within the profession and with reference to society at large. We tried in Shaheed Hospital to incorporate a model of science in which manual and mental skills were given equal importance, and in which the entire range of workers was able to participate. Differentials in financial rewards were kept as low as possible.
4. Democratic decision making.
Management decisions were taken at the Shaheed Hospital at weekly meetings attended by all categories of staff. Decisions were taken by consensus after discussion. Policy issues were referred to the parent organization.
Extension of the Dalli work
The experience gained at Dalli Rajhara served as the basis for a series of health initiatives. Health exhibitions at local fairs and at public political meetings of the organization, which had by now evolved into the Chhattisgarh Mukti Morcha (CMM), became a regular feature. These exhibitions incorporated poster displays, an extremely attractive “magic show”designed to promote rational thinking on matters of health and disease, songs and skits. Shaheed Hospital produced a series of pamphlets on basic health issues which became extremely popular. Topics covered in this series, which were sold at a nominal price, included fevers, blood transfusions, injections versus tablets, the dangers of pitocin injections at delivery, and rational drug therapy.
With the extension of the political work of the CMM to adjacent districts, satellite units of the Shaheed hospital were established in Bhilai, Kumhari, and Urla. Initially, these were run by people from Dalli Rajhara. The Urla unit is now in the process of developing into an independent health programme. However, the largely clinic based services developed as part of the Shaheed Hospital initiative were not able to surmount an inherent limitation. A decentralized, community based and controlled primary health care programme remained unachieved due to the dominance of the clinical component of the service. For the same reason, the model was never able to overcome its dependance on a small group of highly skilled, motivated and selfless technical personnel. It remained necessary to make further efforts to broadbase and democratize the initiative. The Development experiences within the CMM gave rise to a slogan: “Sangharsh ke liye Nirman, Nirman ke liye Sangharsh” (Struggle to further Development, and Development to further the Struggle). Rupantar, an NGO which began work in Raipur in 1989, tried to extend this philosophy to areas outside the ambit of the trade union based parent organization. The health programmes of Rupantar are carried out in the Nagri Sihawa block in the southern part of Raipur district. This area has a long history of struggle among the people displaced by the dams in the upper Mahanadi catchment area. Health services of any kind were practically non existent until Rupantar began work in the area. Rupantar’s work has consisted of allying with existing organizations, training, deploying and monitoring the work of community health workers in twenty villages, and providing referral backup services for these workers Rupantar has set up a basic medical laboratory, with a full time lab technician, which can be accessed by the health workers. The senior health workers who have been with programme for about five years, function at an extremely high level of competence. Routine cases include falciparum malaria, sputum positive tuberculosis, lower respiratory tract infections in young children, diarrhoea, malnutrition, and ante natal care. Through these means, Rupantar has tried to further extend the Shaheed Hospital experience in terms of decentralized access and control and shift the locus of technological and social control from the hospital directly into the community.
There are some other dimensions to the community activities of Rupantar in this sector. The Nagri Sihawa area is covered under the 5th schedule, and the “Extension of Panchayati Raj to Scheduled Areas Act” took effect here from December, 1997. These Constitutional changes over the last few years, give decision making powers with regard to service activities and the management of certain natural resources to the general body of adult village residents, the gram sabha. Future development in health services will have to take account of structures and processes within this new dispensation. We believe that Rupantar’s approach opens up significant possibilities in this regard. Rupantar's activities so far have been mediated through external resource inputs. We are actively searching for ways whereby political decentralization can come together with economic decentralization, and this work can be financed through surpluses generated through community based production. People’s movements do not substantially alter the social metabolism of capital. However, they do create a space within which, however temporarily, the constitutive cells of a socialist hegemonic alternative can be created. Recent technological developments in health care and information technology, leading to the possibility of the application of decentralized algorithms and technical tools and skill modules make it possible to create scientifically relevant, epidemiologically sound and culturally challenging alternatives in this area.
Binayak Sen, batch of 1966, has not lost the fiery passion & idealism that set him apart during his college days. After completing his MD Paediatrics from CMC he spent several years working with the mine workers in Chattisgarh before moving to work with Rupantar a centre for social research. His wife, Ilina, who has a PhD in demography, taught in Scudder school while they were at Vellore.