Reproduction | Family Planning | Health Policy
Mithi is the capital of district Tharparkar, one of the poorest districts in the province of Sindh, Pakistan. I wrote this on-the-ground report shortly after the release of a widely publicized assessment of the gains made through the Lady Health Worker’s Program. From what it seemed, the government initiative on family health had created a mixed bag of half-failures, half-achievements.
It is 8:00 p.m. in Mithi and passers-by move at a leisurely pace through streets illuminated infrequently by the headlight of an odd motorcycle. The lanes of this small town in eastern Sindh’s Tharparkar district, around 300 kilometres from Karachi, are so narrow that buses cannot enter them. These streets remain uncannily empty even during the day as the extremely hot and dry environment of the town keeps people indoors almost throughout the year.
“Most people in Tharparkar have nothing but their hands to work with,” says Dr Shankar Lohano who runs a private clinic along with his brother from a room in their house just off one of these streets. There is no agriculture here because it is an arid region; rearing animals is not viable and local people do not have educational, technical or other skills to earn livelihood, he adds.
But inhospitable living conditions are not the only problem the area suffers from. Out of the many unresolved issues that people in Mithi have to contend with, reproductive health remains perhaps the most neglected one. “For locals sheer survival is an issue,” says Dr Lohano, who during the day works at the city’s only government hospital and is also the district trainer for the Lady Health Workers’ Programme. “Getting them to understand the details of primary health care is a tough task.”
For a district headquarters, Mithi has only recently seen some development and modernisation. Room for improvement remains vast but plans and projects to fill this room are either few or ineffective. As far as reproductive health goes, “we have not achieved drastic reductions in infant and maternal mortality,” Dr Lohano says.
No government programme has been as important as roads and cellular communication. Now people of the district can make a phone call for a taxi and reach the hospital in 2 hours. Earlier, they would spend hours just travelling to a hospital and by the time they reached there, the pregnant woman would be already in critical condition or even dead.Dr Drupati, a medical officer posted at the district headquarters hospital since 1996
This is in contrast with the picture some official reports paint about the success of initiatives of the health workers’ programme. “I may sound cynical,” Dr Lohano observes, “but ground realities remain different [from what these reports say].” He then qualifies his statement. “There have been other changes which are subtle but very important.” As a result of those changes, “health care for women has improved.”
Lady health workers were first appointed under the National Programme for Family Planning and Primary Health Care launched in 1994 by the Benazir Bhutto regime. They were meant to fill in the gaps – resulting from the lack of trained medical practitioners in small towns and rural areas – in providing essential preventive health care. For every 1,000 persons, one matriculate girl is trained under the programme as a lady health worker for three months at a local hospital. The training includes nutrition, mother and child care, vaccination, hygiene, record-keeping and family planning. After three months, she establishes a clinic in a room in her house in her village or town. Every month she comes to the nearby government hospital with demographic data that includes population, number of households, number of marriages, health profile of the village, the state of water supplies and toilet facilities.
In this day-long trip to Mithi and interviews with doctors, midwives, lady health workers and patients there is evidence that there has been some improvement in women’s health in the town and that lady health workers have played an important role in it. But there is also some scepticism about the effectiveness of the programme and loud murmurs about shortcomings in its execution.
I cater to 629 people and 109 households. Earlier, women did not listen to me at all. Now even their men go to the hospital with us for the women to get injections and people come [to the hospital] on the second or third day of delivery to have their children vaccinated.
Chandrakanta, a 30-something mother of three, has been working as a lady health worker for over a decade.
The town’s only government hospital, Civil Hospital Mithi, showcases both sides of the argument. Its corridors are wide and rooms spacious and, unlike the common perception of government hospitals being filthy, it is clean. There are no sanitation problems and no overflowing gutters because there is little water available to flow through them. But some other scarce resources do not have a similarly benign impact. For one, it is the only hospital to cater to Mithi town as well as rural areas within a radius of 200-300 kilometres. Then there is an obvious lack of trained staff for specialised treatment like gynaecology and obstetrics.
On an average day there are 80 women – most of them dressed in heavily-embroidered, colourful traditional ghaghras – in the outpatient department of gynaecology and obstetrics section. But they are usually examined by two or three general physicians because it is hard to find female gynaecology and obstetrics specialists willing to live in such a remote area. Dr Mohini, also the resident medical officer at the hospital, is the only doctor here who is qualified to perform a gynaecology and obstetrics surgery for this town of 50,000 people and other areas such as Nagar, Chachro, Diplo and Umerkot. That she plays a pivotal role is clear: no one except her can perform a Caesarean section here. This, however, may soon change for the worse because Mohini is trying to have her transferred to a larger town.
But Dr Drupati, a medical officer posted at the hospital since 1996 and already well-settled in her job, says some good things have already taken place in the area and these might stay that way in the foreseeable future. “When I first joined the hospital I was the only doctor here and the first patients were the ward boys’ wives. But now there is awareness among people that they need to go to a hospital for births.” This, according to her, has become possible because lady health workers and non-governmental organisations have gone to every home in every town and village in the area to raise awareness about reproductive health. “Now women listen to us about breastfeeding and even family planning. It is so much better now. They have a lot of knowledge, they are more motivated and they take measures to reduce morbidity risk,” says Drupati.
She explains how the development of physical infrastructure has been crucial for such positive developments. “No government programme has been as vital as roads and cellular communication,” she says. “Now people of the district can make a phone call to call a taxi and within two hours they can reach a hospital,” she adds, contrasting it with the recent past when people would spend hours just travelling to a hospital and by the time they reached there, the pregnant woman would be already in critical condition or even dead.
Dr Lohano insists such positive changes are not exclusively because of initiatives specific to health care. “The success of lady health worker programme has been a bit exaggerated. It has not been as successful as it could be because the programme developers sitting in Islamabad do not take into account the ground realities,” he explains. “Door to door campaigning and visiting [people’s homes] sounds perfect but there are social barriers that prevent lady health workers from fulfilling their role.” For instance, he points out, lady health worker from one caste cannot visit the homes of women belonging to another caste and some of them who are appointed on political grounds feel no compulsion to do their job well.
Dr Lohano is also frustrated with the administration of the programme. “There are no checks to see if lady health workers are selling essential medicine that are meant to be given free.” Also, he claims, a lot of lady health workers fudge figures because they have been found filling in data while travelling to the hospital and not while they were in the field as they should have.
Dr Mohini’s experience also shows that the programme still has some ground to cover. “I don’t have a lot of antenatal care patients. Women usually come [to the hospital] when labour pains start,” she says, mildly exasperated. Most people, in fact, come to the hospital only when there are complications, she remarks. “They still don’t understand the importance of antenatal health care,” she says, implying that lady health workers have failed to induce that understanding.
All said lady health workers have not been an unqualified failure. They have at least expanded the reach of health services. Chandrakanta, a 30-something mother of three, has been working as a lady health worker for over a decade. “I cater to 629 people and 109 households,” she tells the Herald. “Earlier, women did not listen to me at all. Now even their men go to the hospital with us for the women to get injections and people come [to the hospital] on the second or third day of delivery to have their children vaccinated.”
One of the most positive changes, Chandrakanta says, has been the acceptance of spacing between children. “Even when people had six children, they would say that Bhagwan gives them [their children so they cannot do anything to stop them]. Now they have one child and they come to me for family planning.”
This raised level of awareness is leading more women to opt for permanent birth control. “At least 70 to 80 women get tubal ligation done at a monthly camp,” says Drupati. This is a routine surgery for permanent birth control and was deemed as a major and, therefore, dangerous operation until recently.
Lady health workers are also spreading the message by practising what they preach. Those the Herald spoke to have a maximum of three children. “My husband and I both have agreed not to have more than three children,” Chandrakanta says.
Such proclamation of emancipation coming from someone living in a small town in rural Sindh — certainly something has worked here.
This article was first published in the June 2010 issue of the Herald.