Details for Reform Option "Mobile Hospitals in Tribal Bazaars, Chhattisgarh"
The minerals-rich state of Chhattisgarh is divided into plains in the north and plateau in the south. The terrain is difficult and it is challenging task for health service providers to reach out to remote villages, particularly the 6 predominantly tribal districts of the state.
Maternal mortality rate here is much higher than the national average. The health department has to battle not only against inaccessible terrain, traditional beliefs and superstition create further obstacles preventing it from reaching care to pregnant and lactating women.
Weekly haat bazaars, or local open-air markets are a centuries-old feature of India’s rural economy. This is also true for tribal areas, where on a fixed day, people come to a particular haat to sell and buy essential items such as agriculture produce, equipment, jewellery, utensils, salt and spices, among other things. These haat bazaars are usually located in the vicinity of large villages and are well connected with the outside world.
The district health department considered such haats an ideal place to station mobile health clinics whereby a large population of underserved population could be reached and provided basic healthcare facilities, including first aid. The district health department has been using this strategy in Chhattisgarh more or less on an ad hoc basis. However, the state government decided to reinforce the strategy to generate awareness among the tribal population on health issues and also provide basic curative services.
Two independent high level bodies were constituted to oversee the course of development in 6 tribal districts of Chhattisgarh in 2003: (a) Bastar Vikas Pradhikaran (Bastar Development Authority) was responsible for three districts located in the southern part of Chhattisgarh, namely Jagdalpur, Kanker and Dantewada and (b) Surguja Vikas Pradhikaran (Surguja Development Authority) was responsible for districts located in the northeast of the state, namely Surjuga, Rajnandgaon and Koriya. (For Role and Powers of the committees please see the reference section.)
Funds were provided for the purchase of 10 ambulances, salaries of the doctor, the nurse and the driver so as to make mobile clinics a regular feature of the markets. So far, the progress has been reviewed quarterly by the two committees (see Reference for excerpts of meeting minutes).
The doctors recruited under Bastar and Surguja Vikas Pradhikaran (B&SVK) have been attached to Primary Health Centres (PHC). The B&SVK mobile clinics serve the tribal population living in 6 most inaccessible blocks spread across 6 districts (62 blocks) of Chhattisgarh. Eighteen ambulances have been procured from funds provided by B&SVK. Besides, the district health department also sends its ambulances to those haat bazaars, which have not been covered by B&SVK mobile hospitals. The haats to be covered by B&SVK mobile clinics were identified by district and block officials based on weekly turnover of tribal population.
The visit schedule of mobile clinics was shared with panchayats as well as district health machinery (details in the Reference section). At the grassroots level, it was the health workers’ responsibility to publicise mobile hospitals and persuade tribals to go there during their visit to haat bazaars. There were a spurt in visits during immunisation campaigns and school health programmes, especially when done with a lot of fanfare and involvement of Aanganwadi workers and the school administration.
In the remaining 10 districts, the mobile hospital project is to be implemented by Non-Government Organisations (NGOs). Ten NGOs have been selected and memorandum of understanding (MoU) signed. The MoU clearly states that NGOs will provide ambulance service free of cost to patients below poverty line (BPL). The user fee is to be decided in consultation with the district administration. Medicines will be provided by the district administration and the NGOs will distribute them free of cost to people coming to haat bazaar clinics; free medicines are for malaria, leprosy, tuberculosis and contraceptives (list attached).
Posting the 18 mobile clinics at tribal haat bazaars has shown encouraging results. In the last one year (31 March 2005 to 30 April 2006), the B&SVP mobile clinics have provided curative services to 31,524 persons from three blocks of Kanker district. Statistics available show that during the same period, the Kanker district administration, through its own ambulances, was able to serve 38,380 patients; 45 % of them were women and children and comprised 14% of the total attendees (see Reference).
Cost of 18 B&SVP mobile hospitals (see Reference): INR 78 lakh Cost of 10 Mobile ambulances for NGOs (see Reference): INR 41, 28,700 lakh.
The ongoing operational cost of running the mobile clinic was not available.
Understanding the local epidemics: The administration can get an indication of the type of health problems currently faced by tribal population living in remote corners of the state.
Emergency Care: At times, mobile hospitals stationed at Haat Bazaars could immediately transport a critical patient to the referral hospital.
Coverage: The doctors may not be able to serve all sections of the tribal population, such as sick persons.
Follow-up services: Healthcare workers on a regular basis need to follow up with those who have sought services from mobile clinic.
Continuity: Non-availability of funds for fuel can bring the reform to a halt.
Mobile Van equipped with necessary facilities.
Nurse and Male health workers.
Convergence of Mitanin (village level community health worker), traditional healers, aanganwadi workers.
Understanding the tribal culture.
Who needs to be consulted
Directorate of Health Services.
Chief Medical Health Officer.
Doctor attached to mobile hospitals.
Depends on the government’s commitment.
Chances of Replication
Many states have adopted this strategy to reach out to people living in inaccessible and difficult terrains.
On non-haat days, the doctors were involved in other activities such as overseeing school health programmes, organising health camps, participating in gram panchayat meetings and also teaching traditional healers the benefits of modern medicine.
Political support is essential for the progress of such hospitals as also convergence of grassroots health workers, aanganwadi workers, mitanin, traditional healers. The doctors believe their active involvement, combined with proficiency in tribal dialects will popularise mobile clinics.
Dr. Nandini Roy, Research Consultant, National Institute of Medical Statistics, June 2006.