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Rural Karnataka: Dependence on small time clinics, quacks; lack of trust in govt hospitals


By IMPRI Team

To discuss the impact of  the spread of the second wave in rural areas, the Centre for Habitat, Urban and Regional Studies (CHURS) and Impact and Policy Research Institute (IMPRI), New Delhi, organized a panel discussion on Rural Realities: Karnataka Practitioners’ Experiences in Tackling the Second Wave in Indian Villages.
The panelists were Dr Basavaraju R Shreshta, Executive Director, Grassroots Research And Advocacy Movement (GRAAM), Mysore; Dr Priya Shanmugam, Faculty, Department of Economics, Mount Carmel College Autonomous, Bengaluru; Leo Saldanha, Founding Trustee and Coordinator, Environment Support Group, Bengaluru; Nitesh Kumar Jangir, Co-Founder, Coeo Labs Pvt. Ltd (An InnAccel Division), Bengaluru; Dr Purnima Madhivanan, Associate Professor, Public Health, Mel and Enid Zuckerman College, The University of Arizona; Dr Nazrul Haque, Assistant Professor, Azim Premji University, Bengaluru; Dr M R Seetharam, consultant orthopedic surgeon, Vivekananda Memorial Hospital; nd Dr Jyotsna Jha, Director, Centre for Budget and Policy Studies (CBPS), Bengaluru as the discussant.
The moderator of the session was Prof Krishna Raj, Professor, Institute for Social and Economic Change (ISEC), Bangalore. He initiated the discussion by asserting that India is facing an unprecedented health and livelihood crisis. Coronavirus spread in rural and urban areas and subsequently India reported highest death rate in the world. Health and infrastructure system are inadequate. Due to focus on election campaigning and religious congregations, the Government neglected the second wave, thus it’s a man-made disaster.
As Nobel laureate Amartya Sen has mentioned, during the famine of 1942-43 the major reason for deaths was not availability of food but lack of supply to the needy people at the right time; the same situation is repeating now in 2021. Mismanagement is a huge issue. Availability of life saving medicines and beds are less. Children with malnutrition in rural areas is another grave concern, Dr Raj said, adding, frassroots NGOs can play a vital role in rural areas in creating awareness as there are layers of health issues.
Prof Krishna Raj presented the following questions before the panelists:
  • Whether government took timely initiative or prevented the outbreak of Covid to the extent it was in its hands?
  • Question of reverse migration and food infra in rural areas
  • Role of institutions like NGOs. Is theory of survival of the fittest coming true? And how to bring institutions together?

Human-centric approach

Dr MR Seetharam, who has three-decade community connect as a doctor, said that health is not just absence of infirmity or disease but a positive state of well- being. The objective is to ensure that person is stable and is productive physically, economically and socially and leads a happy life. A human-centric approach is crucial.
It is important that health security reaches the right people. We have to build resilience for the long- term future. “Covid is more of a behavioral issue. We need to focus more on lifestyle and strengthen the system”, he said.
In rural areas, there is reliance on traditional home remedies. There is collective response to illness in the family. People in rural areas have a culture of doing things together and have calendarized public events, like festivals and temple fairs which are unavoidable according to them.
The major issues in rural areas are dependence on quacks, preference on small time clinics, lack of trust in Government hospitals, gossips and rumours, incomplete disclosure of information. There is a ladder to disaster in rural areas and the conception that it will not happen to me. There is widespread stigma.
There is a need for an epidemiological approach and not just a medical or clinical approach. Health determinants need to be addressed adequately. We have to reach rural communities on their terms and keep it simple. A holistic multi- pronged approach is the need of the hour. Capacity building programs for the local people can go a long way. We have to network and work together.
There has to be an ABCD Model: A -attitude change, B- behavioral change, C- control spread, and D- Disease management. Equitable and inclusive approach is needed. Community institutions embedded in the health system like ARS and ASHA workers and institutions embedded in other departments can be really helpful. There has to be collaborative initiative, he said.

Systemic collapse

Leo Saldanha pointed out that suicide is an indicator of public health. The quality of governance needs our attention. Corporate sector taking over major sectors like food and health is an issue of concern. Panchayati raj system’s role is of vital importance. No attention to primary health centers in rural areas needs our attention. It is a systemic collapse which has happened over the time.
A culture of specialized services being concentrated in urban areas has led to systemic subversion of public health outreach in rural areas. For example, in Thailand, there is compulsory two-year service rendered by doctors in rural areas to promote the doctors to serve in rural areas, similar models can also be adopted by India, he said.
Lockdown is leading to malnourishment in rural areas as some people have hand to mouth situation. Investment in health sector is the need of the hour. Migration is due to lack of opportunities in rural areas. There is a distress cycle. “Fundamental structural change is the solution,” he added.
Investment in infrastructure is an indicator of political class building a legacy. Wasteful investments have to be stopped and there has to be a public outcry. Civil society organizations have to come together for the betterment of India.

Community-based approach

Dr Basavaraju R Shreshta remarked that when there is a war, everybody is a soldier; therefore his organization is working at the ground level to help people. Karnataka showed positivity rate over 25%. Testing was reduced substantially and syndromic approach to treat the cases was followed. The reality of rural areas is: “We eat well, work hard and we do not have to worry”.
The challenge of an infodemic world wherein myths and rumours spread quickly as people believe hospitals are not safe and at-least they will die at home peacefully. There are small houses and shared toilets in rural areas making home isolation difficult. There are no oximeters and thermometers at the community level and focus is more on treatment than prevention. Also, there is lack of basic safety materials to frontline workers, he said.
Lack of information about hospitals at the village level is a major challenge. The role of village panchayat is important and critical. “Coordination and cohesiveness are needed to reach the community”, he added.
He favoured Panch-Tantra Grama-Mantra: Strengthening the gram panchayat; building team of youth volunteers; engaging community- based organisations; supporting community health personnel; and mobilising civil society support.
Dr Nazrul Haque said following points are important to note: Panchayats need to form Covid task forces; disseminating information should be done in a simpler way; women panchayat heads should be encouraged, as they are more sympathetic and responsive; there should safety materials for frontline workers; there should be second line staff to support front line doctors; and vaccine hesitancy should be overcome with proactive role of panchayats.

Digitalization and communication

Dr Purnima Madhivanan highlighted that vaccine shortage is a huge issue. As many as 550 million people in India do not use smart mobile phones and therefore can’t register for vaccine slots. It will take three years to vaccinate people at the current rate of vaccination. “Entire country can’t run on apps”, she insisted.
Digitalization has added a new layer of exclusion. Policies are changing quickly reflective of flaws in the planning process. Short term perspective needs to be done away with and sustained public health policy needs to be focused upon, she added.
According to her, pandemics and epidemics are predictable, they occur within a span of 30-40 years. We should focus on evidence and science. It is a public health situation. Crisis communication has to be adopted as Government has to be accurate as it is critical for credibility. Empathy and respect towards people is very important during this unprecedented situation.
Neurological disorders in old, people with disabilities, concerns of indigenous people, Mental health, collective trauma (PTSD) etc. are the challenges before us. It is a shared tragedy. We will take time to heal. Reach out and support mechanisms need to be strengthened, she added.

Livelihood security

DrPriya Shanmugam pointed to the nexus between lives and livelihood security. Government alone can’t do it, we need to cooperate to tackle the pandemic. The role of NGOs and volunteers is of utmost importance during these hard times. Bengaluru as IT hub has used technology efficiently. Task forces have been constituted. Sought help with Infosys to revamp BBMP bed allocation software to ensure transparency.
A big rural concern is helplessness of ASHAs as they lack proper protective gears. Urban centric COVID response has added to the agony. Decentralized decision making and mental health is deteriorating more. “Door to door vaccination intensification to prioritize rural areas”, Dr Priya Shanmugam said.
Humane approach required in adhering to the norms. Gender gaps would widen post pandemic; therefore, we need to strengthen our institutional framework and policy mechanisms. Also, there should be special window borrowing programs for states to strengthen health care and fund vaccination programmes. Crime rates would increase because of livelihood concerns, she added.

Public healthcare

Dr Nitesh Kumar Jangir asserted that lack of health care knowledge is a huge problem. Proper use of devices is important. Lack of bio medical staff in hospitals needs more attention. Lack of oxygen connectors and standardization of the same adds to the existing problems. Maintenance of medical equipment is crucial at this juncture.
Dr Jyotsna Jha underlined following three characteristics of the second wave: High infection rate, prevalence in rural areas, and younger age group getting infected. According to her, it is a behavioral and cultural issue. Lack of health preparedness led to this rapid upsurge in cases.
There are critical gaps which needs our attention. Good communication is needed for reaching to the public effectively. Problems are deeper than they seem. We have poor accountability mechanisms. We can’t be apolitical now. Weak public health system is the result of corporatization. Technology is a divider. Definitely it is a federal issue. Long term horizon of decision making is needed. Strengthening public health care is the solution. We have to be better prepared. We have to hold the leadership accountable, she said.

Way forward

Prof Krishna Raj said that the Government has to be proactive. Policies have to be consistent and NGOs role is of vital importance. Jyotsna Jha concluded by saying that an open and transparent system can solve many problems. We have to allow everyone to have a role. There has to be collaborative effort which is clear, precise and consistent.
Dr Basavaraju said that it is a public health issue and we need public support. Dr Priya Shanmugam advocated on strengthening the state fiscal capacity. PURA (Provision of Urban Rural Amenities) mission of APJ Abdul Kalam needs to be adopted.
According to Dr Seetharam, decentralized contextual approach and development perspective with long term vision is a viable solution. We have to use this as an opportunity and be optimistic. And build resilience at the community level.
Dr Purnima concluded by propounding that we have to start thinking about rehabilitation and disabilities. A long -term lens is needed and start thinking from now as we will have more widows and orphans post-Covid. We have to use trusted mechanisms for transmitting trusted messages. We have to involve communities. We have to go door to door and educate people. Communication is crucial for building trust.

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