The death of at least 15 women during a tubectomy operation in Chhattisgarh has sent shock waves across the country. The State government claimed in a report that the deaths occurred as the medicines given to the women were laced with rat poison. But this was no isolated incident. As was recently narrated by victims at a workshop held in the State capital Raipur, people in the State continue to fall prey to systematic medical incongruities.
Two women from Abhanpur Block, Sharda and Ramkali (names changed), spoke about the hysterectomy operations they were made to undergo. They narrated how the doctors in one of the private hospitals in Raipur prescribed that their uterus be removed in order to relieve stomach pain.
Sharda was made to pay an extra Rs. 20,000 despite using the Rashtriya Swasthya Bima Yojna (RSBY) card, which offers cashless hospitalisation for up to Rs. 30,000. “We had to sell land to arrange for the money,” she said. More than 20 women in her village had undergone hysterectomies.
When the issue of forced hysterectomies to make insurance claims came to the fore earlier in 2012, it was found that nearly 7,000 women had got their uterus removed under the RSBY over a period of 30 months.
Chhattisgarh Health Minister Amar Agarwal had promised “stringent steps” against the guilty in 2013 and much like this time, an inquiry was ordered by the State Health Department. After the report came out, the licences of seven doctors were suspended. The doctors went to the High Court and acquired a stay order. Meanwhile, the government constituted a ‘high-level’ inquiry that went on to exonerate the doctors. The High Court then ruled in favour of the doctors and they went back to their jobs. The women were not paid any compensation. “Now, we routinely take injections from the village quack to reduce pain, while the doctors have gone unpunished,” Ramkali said in the workshop.Who is responsible?
While the Chhattisgarh Health Department is solely responsible for the tragedy, the incident raises several questions regarding India’s family planning programme. Every State is given a target to boost women’s sterilisation. The pressure to sterilise women rises towards the end of the year and the Health Department starts checking the number of tubectomies performed.
So, the District’s Chief Medical officer calls up the Block Medical Officers for “targets” who in turn question the Auxiliary Nurse and Midwives (ANM) and the ANM pulls up the mitanins (volunteer community health workers). The mitanins , who get a few hundred rupees for performing the operations, encourage the women to visit the camp set up in their area on a particular day.
As the “targets” increase, the guidelines set up by the Ministry of Health and the Supreme Court are flouted. “In this case, for example, we do not know why more than 80 women were getting operated, when the Supreme Court permitted 30 operations in one clinic,” said Sulakshana Nandi of Jan Swasthya Abhiyan (JSA), the Indian circle of the People’s Health Movement. “We are also unable to understand why the operation was conducted in a makeshift temporary camp when it has to be performed in a public health facility,” she said.
Moreover, health activists across Chhattisgarh said that operations go wrong often and the women develop new ailments after tubectomy as antibiotics are randomly used flouting norms. The cases come to light only when deaths occur such as in the recent episode.
The gender bias involved in the implementation of such schemes cannot be ignored either, especially when the family planning programme is almost entirely focussed on women. Both in Community Health Centres (CHCs) and in district hospitals, the rate of women’s sterilisation or Laparoscopic Tubectomy (LTT) is alarmingly higher than Vasectomy (VT).
This year, between April and November 21, in Raigarh district alone, 1,070 LTTs were conducted in CHCs, whereas in the same period, only one VT was performed in the same district. In Bilaspur, the ratio is 1039:23. In Janjgir, there were no VTs against 1091 LTTs. The data underscore similar stories across the State, except in the tribal districts of the south.
The project to provide health insurance using taxpayer’s money was started by the Central government in 2008. While it was meant for the people Below Poverty Line (BPL), in many States such as Chhattisgarh, it was introduced for people Above Poverty Line (APL). The scheme has hugely benefitted the private health sector.
Let us sample a testimony from the insurance awareness programme in Raipur. One of the participants, a Gond tribal from Pandariya, broke down while sharing how a private hospital in Raipur refused to treat her husband under RSBY and made her pay Rs. 2.4 lakh. After 10 days of hospitalisation and the death of her husband, the hospital asked for an additional Rs. 23,000 to release the body. She could pay only Rs. 10,000 and the hospital deducted Rs. 13,000 from her card and released the body. These are not exceptions but have become the norm.
The public-funded insurance scheme has made the private sector aware that there is no point in keeping the money unutilised in the health cards of beneficiaries. A report by the Public Health Resource Network, a voluntary network of public health professionals, has found that private hospitals “cherry pick” RSBY/MSBY packages that are profitable while refusing to treat patients with general illnesses such as jaundice, malaria, in Chhattisgarh. “Private clinics are only interested in performing operations,” says a health department official. So, hysterectomies are often advised.Poorly staffed
Thus, while the private health sector is growing rapidly, there is a severe lack of trained medical staff. The problem is particularly acute in Chhattisgarh where public education is also in a shambles resulting in a huge proliferation of private training centres for paramedics and support staff. Students trained in anaesthesia from such centres can be found participating in the performance of complicated surgeries in hospitals.
Moreover, the ratio of doctors in the cities compared to district towns is skewed. Reports put out by the Heath Department show that while the public facilities have more “medical officers” than those sanctioned in the big cities, the rural or semi-rural areas have hardly any and specialists are even fewer. Moreover, “private hospitals do not operate in the far-flung remote corners” says a JSA study. In fact, many of the government’s ambitious public-private partnership over the last few years collapsed as the private sector refused to go to remote villages.
The process of buying and distributing medicines is complicated as well, and there have been times when the entire State was left more or less without any essential drug supply in 2012 and 2013. There are many testimonies to establish the occurrence of acute malnourishment, malaria, tuberculosis and dysentery-related deaths in Chhattisgarh and how data related to these are fudged by the State’s Health Department. But narrating them will call for a separate story altogether.