Map 3: Map of Nalbari district
7.2 HEALTH INFRASTRUCTURE IN THE STUDY VILLAGES IN REFERENCE TO INDIAN PUBLIC HEALTH STANDARDS (IPHS)
The village level health facilities struggle to meet the minimal levels of standard laid down by the Indian Public Health Standard.63 For instance, according to IPHS standards, a PHC should have inpatient care services with four beds. But in practice there is only one emergency bed in the Bamuni Pathar PHC. They are not equipped with the much required childbirth
63 Indian Public Health Standards are the standard norms for all public health institutions. These are set under
the NHM to improve the quality of public health institutions of the state.
delivery services, both normal and caesarean. As there is no provision of child delivery in the PHC, facilities for new born care is also not available. Moreover, pregnancy termination facilities are also not available in both the villages which is a high risk for maternal health.
Of course the PHCs of both villages provide the minimum required care to pregnant women, particularly in terms of ANC, natal care and PNC. They are also largely responsible for the increasing rates of full immunization and control of communicable diseases. The health centre has one ambulance but it is not in a working condition because of lack of funds for maintenance. There is an acute shortage of personnel in the health centre. The centre has electricity facility functional for only 16-18 hours a day and a single toilet used both by male and female patients. Water supply is available for 24 hours through a tube- well. It has one medical store which has stock of only some of the common medicines.
In Balagaon the block PHC centre is equipped with 2 beds. For child birth, only normal delivery cases are carried out in the hospital, C-section patients are referred to the civil hospital. No caesarean cases are taken up in the PHC because of lack of manpower and required equipments in the health centre. Further there are no anesthetics in the centre to handle caesarean cases. There are two medical officer (AYUSH) in the centre, 1 medical officer (contractual), 2 staff nurses, 1 pharmacist, 1 male health assistant, 2 laboratory technicians (contractual), 2 female health workers (contractual), 2 class IV employees and 2 cleaners. The normal delivery cases are dealt with by the Medical Officer. The health assistant informed me that there is crisis of medicines in the health centre. Supply of medicines from the state headquarter are irregular. Shortage of medicines is common to PHCs in both villages. However, unlike Bamuni Pathar, the centre is equipped with proper electricity facility, drinking water and toilet facility. The centre provided healthcare services for 24 hours. The medical officer from the PHC visits the sub-centre for supervision and record keeping every month. Thus the health facilities in both the villages do not possesses even some of the minimum requirements for satisfying the norms established by Indian Public Health Standard.
The role of primary health care providers in the rural set up
At the village level there are two important health care providers. These include the accredited social health activist (ASHA) and auxiliary nurse midwives (ANM).
Selection of the accredited social health activist (ASHA): The ASHA is selected on the basis of a focus group discussion (FGD). ASHA workers are women. The FGD is initiated by the
Gaonburah64 of the village. On the basis of the discussion the ASHA is selected by consensus. She is then appointed by the block authorities on the recommendation of the Gaonburah. The ASHA is entrusted with the following
1. Providing information about existing health services,
2. Creating awareness in the community on health, hygiene and nutrition.
3. Encouraging women to access antenatal care, post natal care and immunization of the children.
4. Escort pregnant women and sick children to the nearby health facility of the village.
4. Counseling on safe delivery and taking precautions during the time of delivery.
5. Providing information on new born care, breast feeding and supplementary food, use of contraceptives and family planning measures.
6. Providing statistical records on births and deaths in the villages to the sub-centre, PHC or the CHC.
Incentives to ASHA: The ASHA workers of both villages opined that the amount they are provided as incentive is not enough with respect to their work load. On an average they get Rs. 1500 per month. They are paid on the basis of the work load they have to carry on. For providing antenatal care they receive an amount of Rs. 150 under the condition that the pregnant lady have completed full antenatal checkup otherwise no incentive is paid. For a normal health checkup they are paid an amount of Rs. 100. Similarly, for post natal an amount of Rs. 250 is paid to the ASHA workers. In case of family planning measures they are paid an amount of Rs. 500 for the first two children, while an amount of Rs. 150 is paid for 3rd and 4th child. The ASHA workers opined that they are being provided with very low incentives which are not sufficient. In other words the ASHAs get a disincentive for birth orders above two.
Auxiliary Nurse Midwives (ANM): Auxiliary Nurse Midwife is the female health worker in the village working in the sub-centres, the first unit of contact between healthcare providers and the community. They are the grass root workers in the village. In both villages there is one ANM in the sub-centre. Although the National Health Mission specifies a norm of two ANM (one permanent and one contractual) for each sub-centre, in both the villages there were only one ANM each. ANMs are expected to work as multi-purpose health workers.
They are entrusted with maternal and child health activities, family planning, educational
64 Gaonburah is the head of the village.
awareness on health and nutrition, sanitation, child immunization, control of communicable diseases, treatment of minor illnesses and providing first hand aids during emergency.
ANMs are expected to motivate ASHA workers for bringing beneficiaries to the sub-centre.
They also act as resource person for training of ASHA workers. Since there was only one ANM each in both the sub centres, they have heavy work load. They opined that it is difficult for them to maintain all the official work in the sub-centre. They suggested providing additional workers to ease out the load.
7.3 FUND FLOW PATTERN AT VILLAGE LEVEL HEALTH FACILITIES