CHAPTER VIII

DISCUSS JON

DISCUSSION

The use of para-medical workers in the west began as an extension of hospital

services, and as a support to the medical work of doctors. Local people were trained

to help as dressers, medical assistant etc. Later it \vas realized that these workers

could fulfill "a distincTive function which for many reasons, cannot be fulfilled

equally well by other members of health team" (Hardie, 1978 & Elliot, 1978). A long

trail of para-medical workers thus evolved to support the work of doctors, such as the

physiotherapist, the pharmacist, occupational therapist, speech therapist and those

engaged with radiology, optometry etc. The evolution of support persomtel in those

countries that were stmggling with their economics and welfare service~; was quite

different. These countries conceived of an auxiliary health worker as reflected by the

Sokhey committee report in India (National Planning Committee, 1948). This took

place under the influence of international cff011s to rebuild their services. or, nation

states themselves striving to improve the conditions of health. While the para-medical

workers are defined as trained personnel who provide .\pecific clinical services under

medical supervision, the auxiliaries were trained to provide basic health .i·crvices on

their own. In the developing world, much of the doctors were interested in staying in

the urban areas, or were migrating to the developed countries, or some of these

countries suffered from severe shortages of medical professionals. As a result, their

rural population was left without medical care. From the middle of 201h century,

countries like China, Iran and India had started experimenting with personnel with

short training who could provide basic services at the village leveL

In addition to these two categories of paramedical and auxilrary health

personnel, a third tenn was also used namely, that of Community Health Worker

(CHW). Iran experimented with training illiterate people (with six montl1s training)

and those with nine years of education (v,:ith four years training) and called them

Community Health Worker or Auxiliary Health Worker. Both were trained to provide

basic services in rural Iran and were called Community Health Workers (Ronaghy et

aL, 1983). In India, the notion of community health workers arose only in the 1970s.

These CHWs had education upto class eighth and three months of training. While the

earlier paramedical/auxiliary workers such as ANM and Health Assistants were

conceived of as providing defined health services, CHW was supposed to be a

representative of the community who would apply pressure on the health service

personnel to provide services. He/she also was seen as a link between the health

186

DISCUSSION

service system and the rural population. In 2<XX), an inter country consultation of the

WHO on allied health workers coined the term 'Allied Health Workers' (WHO,

2(X)()). It was pointed out that instead of using different terminologies it was

worthwhile to use the uniform term 'allied health workers' for support staff that

provides services at the village level and thus lets the doctor use his training in a more

efficient manner. Such mixing of categories indicates that there has always been some

confusion in the difference between auxiliaries, paramedics and community health

workers. Authors like Wemer maintained that the village health worker was not a

substitute or an auxiliary to the doctor but rather a primary member of the health team

(Werner, 1978). As Lehmann and Sanders had pointed out, the role of the CHWs

underwent a shift in the 1980s from 'an advocate for social change to a predominantly

technical and community management function' (Lehman and Sanders, 2007). Their

closeness to the community gave them a greater understanding and influence. With

international pressures for standardization and uniformity, the paramedics/community

health workers were not given due importance. Only by 1970s was it accepted that

health was contextual and there could not be a uniform standard for all communities

and countries.

In practice, instead of being a representative of the community, the CHW had

been reduced to being a helping hand for the health workers. This affects tlh: working

of the CHW as well as that of the health team, especially those health personnel, who

arc trained into a hierarchical mindset. They treat the CHW as of lesser importance

and technically inferior to them. The small experiments that had succeeded in creating

a special space for CHW- as in the experiments in Maharashtra (Arole :md A role,

1975; Koblinsky, 1994) - could not provide the basis for a better programm~, as these

small im10vations could not be absorbed in state level programmes. This \vas due to

two reasons, one being the lack of resources, and other being the haste to scale up the

programme. The health administrators were also not sensitive to the impot1ance of

issues such as having a system for identification, training, support and not just

monitoring and continuous training.

While we recognize the historical ongms and significance of these terms

(where paramedics were those who provided specific clinical services under medical

supervision and auxiliaries were those workers v.·ho provided simple and ·dementary

187

DISCUSSION

medical care with limited education to relieve the doctors for the more complicated

tasks), we look upon the community health worker as a cadre apart from the other

categories. Although they may share ce1tain common features with the auxiliary and

paramedical workers such as the closeness with communities and their hmited sphere

of knowledge, their distinctive feature is the fact that they are villagers who are

selected for their social awareness and strengths to represent the inkrests of the

communities. The original CHW scheme emphasized this and since then there has

been a tussle between health services and those who conceptualized CHW as a

representative of the community. The fonner wants to appropriate this category of

worker as a subordinate, while the latter visualize CHWs as a controlling influence on

the health system. In this conflict, very often the community's need for medical care

and the policy maker's hurry to show adequate coverage of the population by some

kind of health worker, leads to CHW becoming a hand maiden of the health services

system.

Our review of the numerous experiments with the concept and implementation

of CHW has highlighted issues and problems in it that arc still alive. Issues such as

proper selection of the CHW, their training. supervision, support from the health

services, lack of infrastructure, have all cropped up in the various programmes. Our

study shows that these arc still relevant for the Mitanin programme.

The Mitanin programme in Chhattisgarh, arising out of the experiences of the

Community Health Workers schemes, was conceptualized after discussions with

community health practitioners from within as well as outside the state. It was a state­

civil society partnership which brought in innovations by claiming to incorporate

learnings from the previous experiments in the much older concept of Community

Health Worker. Some of these innovations were

• Unlike the other community health worker schemes, there was w be

community mobilization before the actual selection of the Mitanins and the

selection process itself was quite elaborate.

• Instead of a stipulated population or a village, the community was to lx~ the

hamlets.

188

DISCUSSION -------------------------------------------------------------------------

• Education was not supposed to be a criterion, thus it did not exclude the

uneducated but active women in the community.

• Curative training was to be given much later, after the Mitanin had est:1blishcd

rapport with the community.

• During the time of selection, the Mitanins were told that they would not be

receiving any kind of payment (though the programme had envisaged some

kind of compensation later). This enabled the enthusiastic women to voluntter

to be Mitanins and did not leave room for the power lobbies in the village to

intervene in the process.

• The most important point stressed by the group was that the Mita11in alone

could not succeed unless she had the backing of the health services. Hence, the

health services needed to be strengthened. So, the Mitanin programme was to

be started in parallel with the strengthening of the health services.

• Another innovative approach was to start the programme in few pilot blocks

and then later, based on the learning from the different approache~-. the best

practices were to be expanded in the entire state.

• Continuous suppo11 to the Mitanins and their superv1s1on was envisaged

through on-the-field as well as periodic camp based training. 1\ specially

trained cadre of trainers was created for the on-going supp011 and supervision.

This was unlike the previous community health worker schemes, where

government health workers provided the training. The training manuals were

well written with a lot of pictures; there was one book based exclusively on

pictures.

Despite such improved conceptualization and the best of intention~;, two kinds

of problems emerged from our study- conceptual problems and implementation

problems.

IQO

DISCUSSION

CONCEPTUAL PROBLEMS

Structural issues

For better monitoring and support a separate structure was created exclusively for the

Mitanin programme. The staff of this structure would be devoted entirely to the

Mitanin programme. Thus, at the district level, there were two Field Coordinators, at

the block level, three District Resource Persons, and on an average twenty Block

Resource Persons. Our study reveals that the FC was stretched out, looking into the

activities in four to five blocks. During the training times, especially, she was not able

to give time to the other blocks and supp01t the BRPs and DRPs. This ,Tcated a

distance as the BRP, DRP could not get the requisite support from their FC and

therefore had to rely on the government health workers for day to day support and

guidance. This dependence upon government health workers further molded the

functionaries of the Mitanin programme as per the needs of the health system. The

FCs are left on their own in the district, they do not have a good support structure, the

Programme Coordinator in the state capital is too far away. The FCs also did not have

much avenues for further career growth.

The government DRP had to look into the Mitanin work apart from her regular

work, due to which she was not able to support the BRPs in the field, and her work

was restricted to the office. The non-government DRP had two chains of command,

from the govemment as well as from the FC. This kind of duality did not help in the

smooth running of the programme. The non-government DRPs were not able to

support the BRPs and were largely restricted to the task of data organization, and to

being a communication channel between the government DRP/ BMO and the BRPs.

Of the 16 BRPs in the block, ten were working as Mitanins (during data

collection), and seven of these had no supervisors. The reluctance to step down as

Mitanin was due to the incentives they could get as Mitanins from JSY and

immunization which they would not get as BRPs. This defeated the very purpose of

supervision which was totally lacking in these cases as DRPs rarely came to the

viJiages for house visits.

190

DISCUSSION

Training issues

• The non-government DRPs were not sufficiently trained in management and

clinical care, and were largely left to manage by themselves.

• There was no provision for those DRPs or BRPs who were new to the

programme to undergo all the previous rounds of training. In the study block

the DRP who was new, did not have a complete grasp of the programme. This

affected the progranune as the Mitanins look upto the BRP and the DRP for

suppo11 and guidance and these personnel were often found lacking.

• The training of the BRP trainings was not very different in content from that

of the Mitanin' s. There were no extra reference books on technical knowledge

for these trainers. As a result, the trainers were only equal to the Mitanins, and

in some cases even worse off than the Mitanins in terms of technical

knowledge to be able to assert their superiority over the Mitanin. They were at

the mercy of the health services providers. The trainers need more inputs

because these women did not have a background in health. As our data shows,

the Mitanins relied more on the ANM for technical knowledge, even in those

case where the BRP was good. These findings match with ~he findings of the

evaluation of the Mitanin programme by Community Health Cell in 2005,

where they had stated that the trainers were often enthusiastic but lacked the

experience, expertise and skill required for the training (CHC, 2005).

• While the Mitanin training was to begin with exposition of the social

dimensions of health and disease, and the importance of environmental

factors, the training of the Mitnins was not fully equipped to demonstrate this

in day to day work. Their competence being no better, they could neither show

Mitanins the links between health and environment, nor could they answer

their queries effectively.

IMPLEMENTATION ISSUES

The BRPs and DRPs

Initially, the selection of the BRPs and DRPs did not have stringent criteria and

norms, but over time and with experience, a formal method of recruiting the BRPs

and DRPs started coming into place - in the case of DRPs, they have to undergo a

191

DISCUSSION

written examination followed by the interviews. Only then, they are seleded and

trained.

The BRP was conceptualized to be a support for the Mitanin, and to provide

the latter with on-the-field training. However, our data (in chapter V) shows that the

BRPs were primarily engaged in collecting information from the Mitanins to

complete their records, and they provided support to only few of the components of

the programme as and when pushed by the DRPs or Government officials. For

example, the very good BRPs could at best revise the trainings and provide support to

Mitanins and pass on information that they received from the DRPs. The not-so-good

BRPs were restricted to collection of data for themselves and passmg on of

information. The reports that the BRPs submitted for the sake of submittif'.g were the

only proof of their work. They were hardly ever using or referring to it and were often

even making it up. The reporting was more for the sake of displaying to ,, isitors than

for improving the work. The significance and utility of such data never gels known to

those who collect it (Mitanin), as there was no planning process in which the data

from the grass roots were used. The BRPs in turn did not get the support from the

DRPs, as the latter themselves were laden with reporting and with CHC work. They

could not give much attention and time to the field work and left it at entirely to the

BRPs.

In the beginning of the programme, there were unjustified deduct tons from the

payment of the BRPs along with long delays in payment. Later, by 2007 the issue of

deductions was corrected but the BRPs kept getting payment after gaps of three to

four months. These lacunae in the programme lessened the enthusiasm of the BRPs.

Selection of Mitanins

Our literature review has shown that the selection of the CHWs from the community

and by the community has always been a problematic issue that has be,~n consistently

highlighted. Yet there have always been problems in selection of the CHWs. In the

Mitanin programme, the selection was given due attention. A detailed procedure of

community mobilization followed by selection by the community was laid down as

described in chapter-IV. Even then, our data shows, the selection of d1e Mitanins, in

those blocks where the programme was implemented by the governmc~nt was done by

192

DISCUSSION

the health staff who did not able follow the procedure bid down. Firstly, they were

familiar with the villages and had their own idea of t:he suitable candidate, and

secondly, due to their workload they could not devote much time to this process as

had been recommended. Thus, only 53 percent of Mitanins were selected in the

village meetings which are considered to be the best form of selection. In case of

another 13 percent the Mitanin herself was not present in the meetings. In another five

percent, the Mitanin was selected from the SHG group•;_ Sixteen percent of the

Mitanins were selected by the Sarpanch or the health worker, ten percent of the

Mitanins had themselves approached the trainer and in three percent, the mother-in­

law was the Mitanin who handed over the responsibility of the Mitanin programme to

the daughter-in-law (Table- 4.2). This data matches the JSA findings which report the

selection of the Mitanins in meetings to be 53 percent (JSA, 2008) and the SHRC

internal evaluation data puts this figure at 61 percent (SHRC, undated). This is still far

better than the selection of the ASHAs. The JSA has reported only eight percent of

ASHA being selected in village meetings (JSA, 2008).

There was no mechanism in place to select in a democratic way new Mitanins

in place of the drop outs. This was all the more needed because after having a Mitanin

in the village the people knew about the Mitanin programnte and the incentives

attached to it. Seeking to grab opportunities, the influential people in the village

would recommend their relatives as was evident from the fact that the new Mitanins

belonged to a better off class. Our literature review has shown that in the earlier CHW

schemes in India and in various other countries, the CHW selected through the

powerful and influential in the village- such as the Sarpanch- is not necessarily the

best candidate for this job and is not motivated enough to perform.

Training

The initial trainings had been on the concept of health and disease, and understanding

of the programme and the health services. The idea was not to introduce curative care

in the beginning, and to impart an understanding of the social determinants of health.

This was then followed by training on use of medicines. The medicines became the

most important aspect of the work of the Mitanins since both, the trainers and medical

supervisors, emphasized it. The Mitanins also gained respect once they could give

medicines. As a consequence, gradually the emphasis on the social role was replaced

193

DISCUSSION

by developing their curative skills. This was so because, as with medicines, there was

no demonstration in the field of effectiveness of social interventions, given an inactive

Panchayat and a weak sanitation committee.

The trainings of the Mitanins were held at irregular intervals. After a couple of

trainings, enough time was not given for the Mitanins to statt utilizing the trainings in

the villages. This was particularly so for the eighth and ninth round of trainings.

There was no provision for the new Mitanins to go through the earlier

trainings. They were dependent on the books (of which they never got the complete

set), and the trainer who was not able to devote the time needed to train the new

Mitanins. The new Mitanin therefore missed out on the initial rounds of trainings.

Continuing field education was a good concept but as we have seen, due to the

various limitations of the technical competence of BRP as well as her workload, the

Mitanins did not get much support. However, this was still better than the earlier

CHW programme in India, where the CHWs were left to themsclvc~; with totally no

support.

Even though it was said that the Mitanin should not be burdt~ned with report

writing, as she was not expected to give this much time, and also as many were

illiterate, ultimately the burden fell on her to regularly update the registers. The

trainers too had been emphasizing regular updates as this was seen to be the proof that

the Mitanin and the trainer were working. This was also an easier and surer way to

assert that they worked, than assessing their work in the community.

Health committee

Though institutional support in the form of health committees was envisaged, in

practice, this did not work out. As our data shows (in chapter- VII), the committee

existed on paper, as the Mitanin was seen largely to be a represental11Ve of the health

services and the others were not too enthusiastic to join. The Mitanins used the SHG

meetings as a forum. Half of the Mitanins studied had passed on information, such as

availability of medicines or about health camp, and 16 percent of the Mitanins

reported that they talked about health issues in the SHG meetings. The committee

lOA

DISCUSSION

members were never trained or orientated to understand the linkages of health. The

committees were expected to support the Mitanins but these were themselves the poor

women in the village, the influential ones were absent. These women were expected

to help the Mitanin in tackling the issues of water and sanitation which are mostly

political issues. So it was inevitable that they would not be able to perform and added

to this was the fact of their own lack of training in understanding the social roots of

disease.

Panchayat

There was no mechanism to bring the Mitanin and Panchayat closer until VHSC was

launched. In the study area the VHSC was formed in a hurTy as the block wanted to

dispose off the money sanctioned to the VHSC accounts before the end of the

financial year. As a result the Mitanins could not be oriented and the BRPs could not

be given a half day orientation of the VHSC. For the formation itself, the BRPs could

be present only in 50 percent of the Panchayats leaving the other Panchayats at the

hands of the Sarpanch and Sachiv. Thus the foundation was weak as the Mitanins

were not clear about the VHSC, and their role in it, and use of the allotted money. The

VHSC calls for a greater role of the Mitanin in the village affairs. The Mitanin would

be expected to take decisions along \Vith the others in the VHSC on health matters

relating to the village. The process of village health planning is now to be initiated,

and that will call for an even greater role of the Mitanin. But the question is whether

the ground is ready for the Mitanin to take on these larger roles. She has not been

adequately trained, and most of the Mitanins do not have experience of getting

involved in village matters. There arc chances of her being manipulated by the

PanchayaL For Mitanins to be effective, she needs to be politically and socially aware

of the functioning of Panchayats and the vested interest it represents. Raising issues of

sanitation, water supply and roads, means asking for change in the power structure.

Assigning this responsibility to the weakest link- the three women Al'l"M, A WW and

Mitanin- means that the programme is on! y making a gesture, not a concerted

intervention.

195

DISCUSSION

SUPPORT FROM HEALTH SERVICES

The need for better and more supportive health services was emphasized from the

very beginning of the Mitanin programme. Our study shows that even five years after

the initiation of the Mitanin programme, there are severe shortcomings in the health

ServiCeS.

There was shortage of manpower, especially of specialists at the CHC,

Medical Officers, RHOs and Male supervisors as seen in Table- 3.2 (chapter III). Om

data in chapter III shows that although new PHCs have been opened, they were

functioning under severe shortage of staff. In Aasara PHC where there is a doctor and

other staff available, the utilization is better; according to the staff in Tappa, when the

doctor was present the number of patients increased by one and half times.

There had been an increase in the supply of equipmcnts according to the staff

of the PHC and CHC. However, sufficient trained staff was not available to usc them.

The supply of medicines to the PHC is also not based on their requirement and usage.

None of the PHCs had residential quarters for the staff. In two of the PHCs, a

doctor and an ANM had occupied one of the rooms in their respective PHCs

indicating how much they needed the residential quarters. At the sub-centre level, of

the 29 SCs, fifteen were run from rented premises. In the study villages, of the 16 SCs

the ANM did not stay in seven sub-centres and preferred to commute thereby

affecting the quality of work. Such lack of infrastructure and the personnel in the state

ha<; been pointed out by the second Common Review Mission of the NRHM (GOI,

2008a).

The health personnel did not get support from the supervisor:-; as the latter

busied themselves with preparing records, and rarely came to supervise the personnel

in the field. The assessment was done through the reports and thus a huge emphasis

was placed on reports. The personnel were given targets to be met under the national

programmes, and the backlog was discussed every month in the Sector and CHC

meetings of health staff. With nine of the 16 sub-centres in the study area, having only

one personnel, the entire work load including preparing elaborate reports, fell on this

single personnel and he/she was able to deliver only the minimum services like

196

DISCUSSION

immunization, family planning and slides (making slides of people with no fever

coming to immunization sessions was widely reported) as discussed in chapter- III.

The Mitanins were then roped in to help the ANM in completion of her targets,

especially in making blood slides, looking for sterilization cases and cases of cataract

operation. As the Mitanins themselves look up to the health serviocs for technical and

referral support and are not in a position to refuse, the ANMs can usc the Mitanins for

such purposes. The CHC data on the national programmes as seen in Table- 3.7 and

3.8 in chapter III is quite erratic which raises doubts about the reliability of the data

reported.

The huge amount of bribes (as reported by the health workers) demanded by

officials for the contractual positions and their renewal dampens the morale of the

health workers. Such personnel also have bribed their way in, then take money from

the people, such as in delivery cases.

Our findings in chapter VII have shown that 96 percent of the villagers in the

study villages did not prefer government services and within the poor, none wanted to

go to govemment health services. Yet 51 percent of the studied population and 61

percent of the poor end up utilizing it as they did not have other opt ions.

The health services lack a forn1al chain of refcnal, whereby the patient

referred from the PHC or the CHC can get transport and direct access in the higher

institutions, instead of having to wait in a queue. When the Mitanin rcfcn·ed cases,

only those doctors who knew about the programme and were interested in it

acknowledged the Mitanins, and gave importance to the patients they had refen·ed.

The referral slips were also not accepted by most of the doctors in the district hospital,

thw; letting down the eff01ts of the Mitanin. The Mitanins are asked by the villagers to

accompany to their private doctors, which indicates support to the Mitanins, but

failure of the public system. Thirty one percent of Mitanins in our study reported that

they had accompanied patients with serious illnesses to the government health

services. The assistance of Mitanins was sought also for gynecological cases like

hysterectomy and menstrual problems. The CHC had better facilities and staff, and

the doctors, especially the BMO were more responsive to the Mitanins. Our data in

chapter VI, shows that in one sub-centre area, which is close to the CHC and where

197

me Lramcr was very gooo, ::>::> percent ot M1tanms accompamed patients to the health

SerVICeS.

STRENGTHS AND LIMITATIONS OF THE MITANIN

The role of the ANMs had been supportive as far as giving medicines was concemed.

They also gave additional medicines to those Mitanin whom they considered 'active'.

As the stock for the Mitanin medicine kit was not regular, the AN.\1s, on orders from

the block, gave medicines from their kit. The irregular supply of drugs has been

highlighted in several other reports (GOI, 2007, 2007a; CHSJ, 2006; CHC, 2005). In

spite of the irregular supply of medicines, the data (in chapter VII) shows that 78

percent of the people have used the Mitanin' s medicines at some point of time. People

approached her for the basic medicines which they otherwise bought from shops or

obtained from the unqualified practitioners. This has made a difference and has made

the Mitanin respectable in the village. With a regular supply of medicines, the

utilization of these medicines will increase and go a long way m establishing the

Mitanins as the first contact person for small ailments, in place of the unqualified

pract itioncr.

The Mitanins were to be all women. This would ensure that the women are

reached more so that the MCH and RCH programmes can be their focus. This has

limited the programme, and even women's health issues were not being adequately

addressed. While diseases like Tuberculosis, Malaria were prevalent, these did not

receive adequate attention within the Mitanin programme. In case of blood slides for

malaria, as the Mitanins did not get the reports (which according to the CHC could be

negative while the private lab could be positive), people who had fever and other

symptoms preferred going to the private labs for faster delivery of report. On the other

hand, the Mitanin had to make slides of people without fever according to our data. In

the case of DOTS, the Mitanins were not utilized even though they were trained and

knew about the symptoms and disease. There were only eight Mitanins giving DOTS

out of the 52 (13 percent). The money for this programme was also not regular and

got delayed by a couple of years. The findings of CRM have also shown that the

Mitanins did not get the reports of the slides that they made (GOI, 2007a).

198

DISCUSSU)N

That the Mitanin's presence had increased the immunization coverage has

been widely accepted by the health workers and the officials. The Mitanins

pressurized the people to get their children immunized by going to their houses, if

needed, more than once. They also helped the ANM in small ways like administering

Vitamin A drops to the children. In the case of sterilization operations, earlier there

was coordination between the ANMs and Mitanins. The introduction of money w the

motivator has led to a situation of conflict between the two, which can have serious

repercussions in the other areas too. With the launch of JSY, the Mitanins take

delivery cases to the sub-centres and PHC or CHC. In the rented sub-centres, the

facilities are minimal, still women arc taken to complete the formality. The literature

review has highlighted that the health infrastructure is not prepared to handle the

increase in cases (CHSJ, 2006; GOI, 2007a). The Mitanin did not play much of a role

in the general health of the women apai1 from giving iron tablets for anemia. In

Chhattisgarh, 46 percent of women have mild to severe anemia (liPS and ORC,

2000).

Health education which was greatly stressed in the initial rounds has declined

over time. Fifty seven percent of the Mitanins interviewed after the seventh round of

training said that they talk about health education to the village women, this dropped

to 32 percent of the Mitanins after the end of tenth round of training (Chapter- VII).

The training on the poverty-under nutrition- disease training had not found much

relevance. The seventh round training which was on health planning oC Panchayats

has also not been much appreciated. The emphasis of the Mitanin programme has

moved away from the social role of the Mitanin. 111e Mitanins were mainly involved

in giving medicines and helping in the ANM's work. They sec themselves more as

provider of health services and six percent of the Mitanins said they wanted to learn

giving injections, as they had seen the ANM and the private practitioner giving

injections. They feel that giving injections would give them the desired status. Thus

there is an increasing trend to shift towards curative care. The Mitanins are excited

about the tenth round of training as they get to learn certain skills in those trainings.

The fifth round of training where the Mitanins were introduced to the medicines and

drug-kit was the round of training which was eagerly awaited by them.

199

DISCUSSION

The Mitanins get incentives for certain activities like takiilg cases for

institutional delivery, sterilization, immunization, administering TB medicines, and

our study has shown that the Mitanins who were not very active in the field limited

their work to these activities. For example, in the case of motivating women for

institutional delivery, the good Mitanins had counseled the women on food, rest and

precautions before and after delivery along with the benefits of institutional delivery

but the average and not so good Mitanins mainly focused on the money aspect while

motivating the women for delivery. Our data showed (chapter VI), that eight percent

of the Mitanins who were not otherwise active had also taken cases for institutional

delivery. The study on ASHA by JSA has also shown this trend (JSA, 2008). Thus

this system of payment through Mitanins gives imp011ance to certain activities only

and it is largely RCH related. This does not take into consideration all the key needs

of the villagers.

The trainers also emphasized these as these arc activities that get rep011ed, and

the block was graded accordingly. This was not in tune with the earlit.~r vision of the

Mitanin programme where she was to secure all the services from the state

government and to address the social causes of ill-health. The incentiv·c also puts two

people working on health in the same village as competitors for the same money

where there should be coordination between the two. This has led to discord and non­

cooperation.

One thing that is common to most Mitanins, is that it has given the women an

opportunity to come out of their houses, interact with officials and accompany other

women to the health services. This exposure for the women is in itself a positive input

in their self realization. They have also been able to usc their knowledge and contacts

for their self fulfillment even though at times it ends up with doing things for their

own families. The vast mobilization of these women has also seen the effect in some

other spheres as 500 Mitanins in Chhattisgarh of the 60,000 had contested for the

Panchayat elections and many of them now got to SHGs and learn about Panchayat

activities. Being given responsibility by the VHSC and also in the A W to help ANMs

and A WW gives them self confidence. These women are today learning to cope and

deal with family pressures on the one hand. and social responsibilities, on the other

hand. In many cases, families have realized the value of the work that they do and are

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DISCUSSION

beginning to support tt,eir activities. This in itself is nothing short of significant social

change.

The people in the villages knew the Mitanins in their village, and also knew

that they have medicines for some basic ailments. The information sharing in the

SHG, house visits or at the meeting points like pond or hand pump was also usefuL

However little it may b·~, it had made health a topic of discussion.

The reduction o~ IMR in Chhattisgarh is generally projected as an effect of the

Mitanin programme. Special care was given to the pregnant woman and the new born

as the Mitanins were e:cpected to meet the pregnant woman and new born babies at

regular intervals. This -~nsured that any high risk cases or where the child was not

well, were referred to the health centre. But this cannot be said about the other health

problems in the village as other things did not get as much importance. After the

formation of new state, as the health staff has reported, supply of medicines and drugs

have relatively improved and yet remained less than required. Hand pumps were

installed in all villages, which provided the people with clean drinking water. So how

much can the reduction in IMR be ascribed solely to th·~ Mitanin programme is

debatable. However, the Mitanin progr<~mme, <~long with th~~ other welfare measures

brought in after the formation of the new state, has had an impact.

There is immense potential in the Mitanins. With good selection, training <Jnd

supervision, they could v;ork even better. In the limited sphere of women's health, the

Mitanins have been able to help. The system is not being able to tap their potential

fully because of its own limitations. These arc primarily infrastructural inadequacy

and using Mitanins onl) for one targeted programme- reproductive health without

actually building a conve.~gence with other development programmes.

IMPLICATIONS OF NRHM

Mitanin programme started off as a state programme with the state govemment m

2002 giving it the status of a flagship programme. With the coming of NRHM m

2005, two things have happened. One, the state got the funds from the centre for

strengthening the infrastiUcture. Second. the already existing Mitanin programme

became a part of NRHM. The state continued the ownership of the Mitanin

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programme and did not modify it according to the universal principles of the NRHM.

The slate has retained the major components of the Mitanin Programme and remained

committed towards the principles of running the programme as it was conceptualized.

The number of Mitanins and the support structure was left untoucb ed and continued

as it had under the Mitanin prog;·amme.

Nonetheless, NRHM has influenced the Mitanin programme 111 a big way. The

introduction of JSY under NRHM has had a big impact on the programme. As the

Mitanins started getting incentives, they paid more attention to motivating pregnant

woman for deliveries. The focus of house visits underwent a change as our data has

shown in chapter VII. The earlier concept of visiting all houses had been replaced by

visiting houses of only pregnalit woman and children. While 75 percent of the

Mitanins had claimed that they gc. for house visits. only 32 percent have rep01ted that

they go to houses for general health problems and only four percent said they visit all

the houses. The shift is from general health to more focused RCH. Similarly, there is a

change in the work of the Mitanins as we have already seen the percent of Mitanins

giving health education has dropped. Thus their role has undergone a shift from focus

on social determinants to a more medical one. The VHSC was introduced during the

latter part of the researcher's field vvork, so its impact could not be asses sed.

Difference between ASHA and Mftanin

Though the ASHA programme has come after the Mitanin programme, and ASHA

programme was also conceptualized after discussions with public health experts, there

were few basic difference between tr.e two.

The Mitanin programme has acknowledged that the population density is very

varied in the state and therefore inste<td of a certain population, it has taken the hamlet

as a unit for one Mitanin. ASHA has .1 stipulated population nonn and it is very likely

that if the population is spread across more than one hamlet, then ASHA will not he

able to deliver her services effectively to the other hamlet.

The CRM report mentions that the support structure at the district level were

not formed in most of the states (GOL 2009). In Chhattisgarh, the support stmctures

J>ISCUSSION

were in place from the beginning of t1e Mitanin programme. The regular contact with

the BRPs and DRPs helped the Mitanins keep the enthusiasm alive.

At the time of selection the Mitanins were told that they would not be paid

anything for their services and this work was to serve the people of their village. This

enabled the influential people of the village to stay out. The Mitanins ~ere not paid

any money except for the compensation in trainings in the first few years In the case

of the ASHA, she is selected from tht~ village knowing that her work ha~, got ce11ain

incentives attached to it and therefore there were inegularities in the selection

process.

The Mitanins in the first few rcunds were taught about the social determinants

of health and disease. They were also encouraged to visit all the families to emphasize

her social role. This was followed by medicines and JSY followed later. In the case of

ASHA, they have started directly with JSY and as the literature review has pointed

out, their work had been restricted to activities which have incentives attacl1ed to it.

Our findings thus, on one hand. indicate the potential of the Mitanins if they

are given the right support from their own supervisors and the health services. On the

other hand it also reveals that the innovations of the scheme arc being unde-rmined by

the implementation of JSY and neglect of principles inherent in Mitanin •;chcme as

well. Such as, selection through participative process, emphasis Dll social

determinants in the training process re-emphasized by practical training, voluntary

nature of their work without introducing selective incentives and better training to

their supervisors along with not only a promise of improving primary health care

infrastructural support but actually invening in it. Unless these are taken c1re of, the

Mitanin programme will only depend upon accidental selection of committed worker.

Our data shows that as yet very few of these issues have been adequate! y dealt with.

The second CRM rep011 dearly shows the inadequacies of NRHM with respect to

improving the infrastructure (GOI, 2009). Similarly, while initially the NGOs were

involved to generate a range of options from which the government programme could

select, in reality scaling up of the programme happened without any consideration of

the positive practices. This was due to political pressure and this led to the difference

of opinion bct\veen the implementing body and the advisory body. On the insistence

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DISCUSSION

of the implementing body, the programme was expanded too fast and with a uniform

approach.

Whether the Chhattisgarh state '.viii succumb to the attraction of central

financing of NRHM or it would be abk to strengthen the Mitanin programme by

consolidating the strengths of the scheme is something that time will show. If it does

not, then Mitanin too will be one of the very many experiments in CHWs that were

washed away by the overpowering interests of the medical care provisioning system,

without an emphasis on prevention, health education and people's participation in

primary health care.

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