At the front line of health care, policy, or research in a developing country? Get your stories, plans, reports, or results published here for the world to see. Contact Robert Walgate

Goa - health at the front line

7 May 2008, 21:50

Comments - Commentaires

by Rupa Chinai

Reporting from the old Portuguese maritime state of Goa, in Western India, our correspondent Rupa Chinai asks what health care looks like from the patients’ perspective. She identifies major problems that need to be solved, both by researchers and by policy-makers, and offers a way forward. Her report is an indicator for all of India – and for many other countries with challenged primary health care systems.

Ideas for good health research and policy interventions, it is said, are born out of good observation. India’s cultural and geographical diversity does not lend itself to tailor made remedies. The studies from Goa do however conform to trends noted elsewhere in the country – the crying need for comprehensive services based on a strong primary and referral system. This was one of the key perceptions on India’s health policy articulated at the time of Indian independence by the Government appointed Bhore Committee. People who had roots deep in the Indian soil further developed this vision. Their work has demonstrated how this approach can make a difference in the lives of the poor within communities.

Unfortunately, the country’s policy makers, influenced by Western donors, undermined this excellent blueprint for Indian health. Right from the time of India’s Independence in 1947, the country has seen an emphasis on ‘vertical’ or stand-alone programmes that have ignored the community’s need for comprehensive health services. This has placed enormous pressure on existing staff who cannot cope with the target driven programmes and their misplaced emphases.

SEE BOX: What the people say

Research in Indian health requires partnership with local communities to understand and articulate their concerns. It needs field-based epidemiology rather than extrapolations that have no basis in ground reality. It calls for an understanding of the wider socio-economic linkages to understand what factors shape people’s health and health seeking behaviour.

Without such insightful research India’s health agenda will continue to lurch from one meaningless priority to the next. Its public primary health system will remain a mere shell while its referral services will continue to be overloaded and increasingly at the receiving end of public rage when patients continue to die from negligence, wrong diagnoses and lack of drugs. The current push towards privatization and reduced subsidy to public health care will meanwhile leave the poor with little option but to quietly lie down and die.

The perfomance of the health system in Goa, despite the State’s remarkable achievements of over 82% literacy rate and second highest per capita income in India, is symptomatic of all these challenges.

“A huge work burden and ill-motivated staff plague the primary health system in Goa.”

RUPA CHINAI

While the Government of Goa claims a wide network of primary health centres and referral institutions, real health services do not match up to the investments made in buildings and equipment. Policy makers may be trying, but they are also failing to solve the real problem on the ground – caring for the health of the poorest.

A huge work burden and ill-motivated staff plague the primary health system in Goa. Access to services remains a huge issue for Goans in the rural areas. Many primary health centres here suffer from vacancies, poorly trained and motivated health staff and lack of essential drugs, while higher-level referral institutions are overloaded with patients, super-specialists and expensive machines.

Compounding this is constant political interference in the name of improvement. At the Sanquelim primary health centre in the Bicholim taluka (local administrative area) for instance, all the administrative staff were recently removed and transferred to the primary health centre of a different taluka, an official revealed.

“This trend started with the earlier government when everyone from the doctor to the peon [clerk] was transferred. Now this continues with a new government in power. The local Member of the Legislative Assembly is helpless to prevent it because he belongs to the party that initiated the first spate of transfers. They are making a mess. Everyone is new here and they do not know anything about this area”, a health official said.

Meanwhile there is a growing trend of private medicine catering to the wealthy – and the poor who have nowhere else to go. In order to pay for urgent medical costs they are forced to cut back on other essential requirements of nutrition, education and savings.

In the interior districts of Goa, the 41 000 residents of Canacona have recourse to no more than 60 beds at the health centre, journalist Rahul Goswami has reported. Patients are forced to share a bed with others, irrespective of whether they might pass on an infection. The centre’s X-ray machine has not worked for over a year; the kidney dialysis machine cannot work for the poor quality of electricity and the absence of a generator, says Goswami.

READ ON: India’s National Family Health Survey NFHS-2

Goan women in the rural areas face a particularly difficult time accessing health services. According to India’s National Family Health Survey NFHS-2, for almost 30% of rural women a primary health centre is over 10 km away.

The survey further reveals that two in every five married women in Goa report some type of reproductive health problem; of these, close to 60% have not sought any advice or treatment. The results of the NFHS-2 show the need to expand reproductive health services in Goa. There is also need to launch information programmes that encourage women to discuss their problems with a health-care provider, experts said.

Rural Goan health centres, however, lack health providers to provide these services. A visit to the Curchorem Community Health Centre in Quepem taluka reveals key staff vacancies – there is no anaesthetist, gynaecologist or surgeon, nor any essential drugs. Women desperately need services for gynaecological and infertility problems. This centre only has three doctors – one health officer (a senior administrative post) and two medical officers – when officially there should be five.

In an emergency, such as the one they had had the day before my visit – when several severely injured bus accident cases were brought in – the services of a private doctor had to be sought. This centre sees many cases of dog bites; but no anti-rabies injections are available. There have been several cases of death from rabies, but these have not served to sharpen the response of the centralized drug supply depot.

READ ON: Voluntary Health Association of India

According to Raj Vaidya, a pharmacist at Hindu Pharmacy in Goa’s capital, Panjim, and a secretary of the Voluntary Health Association of India, Goan division – VHAI-Goa – the State still does not have a rational drug policy that ensures that essential drugs relevant to local needs are made available to the network of health centres across the state. Doctors have a tendency to prescribe expensive drugs and dietary supplements, influenced by the companies that aggressively promote them, he said. “We see a lot of prescriptions from the Government Medical College for iron and calcium tablets which are costly and should not be prescribed to the poor. A slum woman would be better off spending that money on vegetables and fruits instead”, he said.

Tuberculosis

READ ON: Revised National TB Control Programme

TB is another monster in Goa’s health system. The Revised National TB Control Programme (RNTCP) estimated that there are 160 cases of TB per one 100 000 population in Goa. The programme however has failed to meet its target of detecting 70% of new cases. It has also failed to follow-up defaulters who start treatment but do not complete it. The programme in Goa has failed to meet its targets because of its dependence on a weak primary health care system, a pattern also found in the rest of India.

“Incomplete treatment results in one TB patient spreading the infection to at least 15 other patients, said an RNTCP senior treatment supervisor.”

RUPA CHINAI

According to an RNTCP senior treatment supervisor, Goa – along with Pondicherry (a former French colony, on the South-West coast of India) – has the country’s highest rate of defaulters (patients who do not complete treatment). This is largely because of its migrant populations who have no fixed address, the supervisor said.

Incomplete treatment results in one TB patient spreading the infection to at least 15 other patients, he said. Although primary health centre staff must visit patients in their home and motivate them to continue coming to a DOTS (Directly Observed Treatment, Short Course) centre for their regular TB drug dosage, they have failed actively to pursue cases, said the supervisor.

Private practitioners in rural Goa said the RNTCP has not sought their help in supervising the drug therapy of TB patients being treated under DOTS.

The RNTCP started in September 2004 in Goa and provides free treatment to patients through DOTS provided at their nearest government health centre. Each patient has a box containing his or her entire supply of drugs. The medicines are kept at the nearest public health centre, where the health worker ensures drug compliance and should follow up if the patient fails to turn up regularly.

The patients are first detected during their visit to a public health centre, where the doctor, suspecting TB, refers the patient to one of the 18 designated microscopy centres specially set up by the RNTCP to ensure accurate TB diagnosis. A TB Unit, covering a population of 500 000, ensures supervision of the RNTCP in their area.

Enquiries into the functioning of Goa’s TB programme revealed that many patients are simply unaware of the RNTCP and the fact that they can access free treatment. Pushpa, a patient with extra-pulmonary TB, said that a doctor at Goa Medical College had detected her disease – but nobody had told her about RNTCP or the DOTS programme. She has been taking treatment from a private practitioner.

Such lack of awareness is particularly widespread in the interior areas of rural Goa. The incidence of undetected TB is particularly high in areas like Madkai, Ponda district, where poor communities like the Gauddes are badly affected. The pressure of daily survival prevents them from seeking treatment until the disease has advanced to its final stage.

SEE BOX: Traffic accidents in Goa

In cases where patients do seek treatment, they are defeated by the long distances they have to travel, often over two kilometres and sometimes even 35 – a huge distance for a sick or elderly person to walk – to reach a DOTS centre. The paucity of public transportation in Goa is a huge problem.

Meanwhile the low detection rate of new TB cases is because of the programme’s dependence on the medical officers in the health centre outpatients department – who must identify and refer suspected cases. Any patient having a cough for more than two or three weeks must be referred to the TB programme for sputum tests, but primary health centre doctors fail to make such referrals, the RNTCP official said.

Cancer and cardiovascular disease

“I realized with a shock that practically all of these women were in fact patients – who were either undergoing treatment or in the process of remission from breast cancer.”

RUPA CHINAI

When I arrived at a large meeting hall in a hotel in Panjim, it was packed to capacity, filled with young women coming to attend a meeting on breast cancer. Surprised by the huge turnout I assumed these were women interested in knowing how to prevent cancer. As the meeting progressed and members of the audience got up to address questions to the panel of cancer specialists, I realized with a shock that practically all of these women were in fact patients – who were either undergoing treatment or in the process of remission from the disease.

The last decade has seen a tremendous increase in the incidence of female breast cancer in Goa, said Shekhar Salkar, an oncology surgeon at the Manipal-Goa Hospital, Goa. The disease is increasingly seen in younger women around 35 years of age. In 2005 ten patients detected were in the age group of 20-39 years.

According to Salkar the profile of these patients show some common factors of risk such as high income, junk food, obesity after menopause, delayed birth of first child, not breast feeding their child for at least one year, early menarche and late menopause. In addition, 40% of the women had a ‘late’ marriage and 30% of couples did not have children because of infertility, he said.

Although there is no official data on cancer incidence in Goa, Salkar said the state records around 250 new cases of breast cancer every year. Going by these figures, based on actual cases detected, it would imply that Goa’s female population of 650 000 would see an incidence of 35 breast cancer cases per 100 000 people. The all-India figure for breast cancer cases is estimated to be 80 000 [in a population of 1.1 billion, ie about 8 per 100 000, a quarter of the Goa figure] Salkar pointed out.

“The rate of breast cancer cases in Goa is very high – and is comparable to the incidence in Indian metros”, Salkar said. “It is vital that the Goa government initiate a pilot study to estimate the actual number of cases detected in a field survey. Goa sees around 600 people dying of communicable diseases but 5 000 from non-communicable diseases each year. It is high time the health system is geared to early detection and prevention of non-communicable diseases like cancer, diabetes and hypertension which are on the rise here”, he said.

Goa is in the process of a health transition with the rapid rise of chronic diseases. Goa faces a serious problem of coronary heart diseases – conforming to the pattern seen elsewhere in India – but Goan women are more prone to it, according to a recent study conducted by VHAI-Goa.

The as yet unpublished study examined 1 500 patients attending the clinic of ten general practitioners in Goa. The prevalence of coronary heart diseases was found to be very high with rates of 4-6% in men and 6-11% in women 40 years of age and above. In most cases the disease had been undetected, and patients of both sexes were at risk of a heart attack because of poor control of blood pressure, cholesterol and diabetes.

According to VHAI-Goa, there is a cardiovascular disease epidemic unfolding in Goa, and there is an urgent need to develop evidence-based interventions for primary and secondary prevention of coronary heart disease.

Depression amidst wealth

One of the most glaring missing elements in this wealthy State’s health system – as across all India – is any serious concern for mental health, particularly among women and the vulnerable. This is the dark side to Goa’s economic success story, evident in studies highlighting a high prevalence of depression and stress-related problems in young adults and women in the reproductive age group.

READ ON: Disease Control Priorities Project 2 – mental health

This trend in Goa parallels a worldwide epidemic of depression. Globally, “depression is the most common psychiatric disorder… [It is] ranked fourth among all causes of DALYs [years lost due to disability] and… the leading nonfatal condition globally” according to the Disease Control Priorities Project.

It estimated that over a one year period, nearly one in fifty women in Goa will develop new episodes of depression, which means about 6 000 women in this age group will develop a new episode each year. Over one year, 0.8% of women will attempt suicide – some 2 500 attempts.

Doreen Dias, senior psychiatrist at the government hospital in Margao said she sees a larger number of attempted suicides amongst females in the early teen to mid-30s age group. These are usually precipitated by conflict in love affairs and relationships. Factors such as alcoholism of the father, fragmentation of families and a dysfunctional background make young people vulnerable to such behaviour. Attempted suicide by young males is not an impulsive action and is usually on account of their unemployment, and depression over a long period of time, she said.

READ ON: Sangath

Studies by Sangath, a Goa-based NGO which works on mental health issues within the primary health setting, reveal that one in five adults attending the primary health centre and one in four mothers attending antenatal clinics suffer from depression.

The symptoms of depression are typically expressed indirectly – through physical complaints like fatigue, aches and pains, and gynaecological problems such as abnormal vaginal discharge. Thus primary care doctors and gynaecologists are the practitioners most likely to be consulted by depressed women.

Other findings show that in mothers, the birth of a girl child is a risk factor. Sangath has demonstrated the disturbing tendency to ‘son preference’ in Goan society – and its impact on the mother’s mental health.

SEE BOX: Alcoholism in Goa

Depression in women is also strongly linked to the alcoholism of their husband. Alcoholism is a predominantly male affliction in Goa, as elsewhere in India. This alcoholism is a major risk factor for domestic violence, which in turn affects women and children. Thus depression and alcoholism affect the two sexes in different ways, but interact with one another closely. Disadvantage and mental ill health typically cluster in the same families.

Studies further indicate that babies born to depressed mothers are three times more likely to suffer from malnutrition. Boys born to depressed mothers show delayed mental development. Depression is thus a profound disability to be addressed for the benefit of the whole family.

Treatment for depression results in high out-of-pocket expenditure. Sangath investigations showed that depressed women are three times more likely than non-depressed women to have spent 50% or more of their household income on out-of-pocket health care in the previous month (independent of their other physical health problems).

While the more serious cases of mental illness and suicide attempts are referred to the Institute of Psychiatry and Human Behaviour, Goa, Dias said, “There are a large number of cases who simply do not have anyone to talk to about their problems. Many feel they do not have the support of parents. A suicide attempt is their way of saying ‘I need help’ – they feel they will get attention”, she said.

Nandita D’souza, paediatrician, also stressed her experience that most people merely need someone they can talk to about their problems. Her work in child development and family guidance seeks to create networks between teachers, parents and communities in helping children work through the difficulties they face.

In a pioneering move, Sangath – along with the Goa government and the Goa Chapter of the Voluntary Health Association, are collaborating in a pilot project, ‘Mana shanti sudar shodh’ (Manas), launched in August 2006, to introduce trained mental health counsellors within the primary health setting.

“The Manas pilot project, soon after its launch in Goa in 2006, showed that 10-20% of patients attending a primary health centre are suffering from stress and depression. They are primarily women in the age group of 25 and above.”

RUPA CHINAI

The Manas pilot project, soon after its launch in Goa in 2006, showed that 10-20% of patients attending a primary health centre are suffering from stress and depression. They are primarily women in the age group of 25 and above. This programme however is not able to reach the adolescent and youth group who have little reason to routinely visit a primary health centre.

Evidence of suicide by farmers in Maharashtra or weavers in Andhra Pradesh is a further indicator of how common mental disorders assail vulnerable groups, particularly in rural India where no psychiatric help is available. The Manas project attempts to examine whether treating these disorders at the primary health level is effective and affordable and reduces the high out of pocket costs and irrational treatment suffered by patients at the hands of quacks.

India’s new Mental Health Policy proposes treatment of these disorders in the primary health setting. The approach of basic treatment along with counselling, as advocated by the Goa experiment, is also applicable to a variety of health problems. Trained community based counsellors situated in the primary health centre or school, can address a variety of problems and create awareness on prevention.

Multilingual depression?

“We see depression but we are not looking at the stressors”, said Rajesh Dhume, a Goa-based psychiatrist. “Pro-active mental health has to start with education. Goa’s education system has not resolved the issue of the [multiple] languages used for learning. As a result, children first think in their local language and then translate what they are hearing or trying to convey.”

“The youth here are Konkani-speaking but their primary education up to class four, focuses on reading and writing in Marathi,” said Dattaram Desai, a private GP in Savorverem, Ponda taluka. “The switch to English from class five onwards finds them without a grasp of Marathi or English, while their thinking is in Konkani”, he said.

Rajesh Dhume said that “having no grasp of basic theories or concepts, such a child’s learning is based on rote. Children lacking confidence in speaking also have a reduced capacity for a problem-solving approach to real-life interpersonal problems. They cannot cope with competition from others and focus only on claiming certificates”.

According to Dhume urban children are able to get by with extra coaching but first generation learners in the rural areas are severely affected. Inability to compete has caused them stress and insecurity. How to strengthen a person’s ability to solve their problems is the key issue we face, he said.

Supporting the view that rural Goan children are unable to cope with stress, Desai said his clinic sees many young people who suffer from an acute sense of failure and stress over their inability to cope with life. This has led to several cases of suicide amongst the young, he said.

Also attributing this sense of failure to the education system Desai said, “Parents cannot provide money for coaching. The youth have no knowledge of English and their background is not conducive for academic studies. With classrooms packed beyond capacity, individuals cannot get special attention and many remain behind.”

Community health workers

One solution to some of these problems may be to train and support health workers from the community. Indian experience has repeatedly shown that the country will never have enough trained medical professionals willing to work in the rural areas; and that in practice the emphasis on vaccines, allopathic [modern] drugs and technology has failed to be the promised magic wand.

If the health system fails to deliver its goods and services to the people, how can they be expected to rely on them?

A number of groups in India working in community health have already provided invaluable contemporary experience. Deeply rooted in the community, they are demonstrating a course of action that has the country’s neediest at its heart.

READ ON: National Rural Health Mission

One such approach is to develop a cadre of village based health workers – the ASHA (Accredited Social Health Activists) – trained in preventive and curative health. This is now a key recommendation of the National Rural Health Mission (NRHM) of the Government of India, which calls for such a cadre, supported by a strong primary based referral system, to be created across the country.

READ ON: Abhay and Rani Bang, founders of SEARCH

The validity of community approach has been demonstrated by SEARCH (the Society for Education, Action and Research in Community Health), whose work in training village health workers in neonatal care they say has brought down the infant mortality rate from 120 to 30 per 1 000 in their project area in Gadchiroli district of Maharashtra. Their evidence was so convincing, the NRHM incorporated it as a key policy recommendation. The Indian Council of Medical Research is also currently testing it as a pilot project in five north Indian states.

READ ON: Indian Council of Medical Research

The NRHM policy requires individual states across the country to implement this kind of approach – one that is rooted in Indian experience and reality. But Goa has not yet put such a programme in place, admitted Goa’s Director of Health Services, Arvind Salelkar (now retired).

The anganwadi

One element of Goa’s health system that does seem to be working well is its ‘anganwadi’, a network of localized crèches that are part of a nation-wide programme. The ‘anganwadi bai’ (worker), supported by a helper, takes care of children between 2-6 years old for a couple of hours each morning. These workers provide a nutritious cooked mid-day snack to all the children attending the informally run nursery school.

The main task of the anganwadi workers is to monitor the growth of these children by a standardized measurement of weight for age along with some other growth indicators. Those children that do not match up to the required measurements are graded on a scale of 1-4 of malnutrition. The first two categories are considered to be at risk and need to be closely monitored, while the latter two are in a serious stage and require additional supplementary food or hospitalization.

When I visited an anganwadi in Madrekarwada in Bicholim town, there were 45 children registered on the muster roll. The state provides a rich fare of ragi (finger millet, which is sprouted and roasted), gram flour (ground chick peas), groundnut, jaggery (unrefined sugar), dried green peas, mung (sprouted beans), rice and ghee (clarified butter).

Supplies are received regularly, said Lourdes Miranda, the anganwadi worker. Packets of dry supplementary food are prepared by the anganwadi workers and delivered to the homes of all pregnant and lactating mothers as also to infants from six months to two years of age.

Children attending the anganwadi, though cramped into a small rented room, are fed a nourishing mid-morning snack cooked by the anganwadi helper. Sprouted mung usal (mung bean curry), misi roti (a Rajasthani bread), rice idlis (rice with dal), groundnut ladoo (a sweet), kabuli chana (a chickpea dal) and mixed ladoo (sweets), are on the weekly menu. The idlis offered to me that day were fresh and delicious. The children are obviously at home and comfortable with their teachers and entertain the visitor with action songs and stories. Such supportive care for young children has clearly been a boon to rural women, particularly those working in agriculture.

Other states that only offer calorie support through khichdi (rice and lentils) through their anganwadi programme, could draw inspiration from Goa’s commitment to the health of its children. The Goa government should additionally consider support for a kitchen garden that provides fresh green vegetables and fruits for the children. Maintained by the community, it would further enhance the need for micronutrients that enhance immune status, and ensure against leakages and corruption, which is commonly seen in other states.

A doctor visits the Bicholim anganwadi once a month. The anganwadi workers are able to administer oral rehydration treatment to diarrhoea cases and refer those that require medical attention. The contribution of these anganwadi workers to the community, both in Bicholim and in Madkai, where I had an opportunity to observe their work, is incalculable.

The efforts of Sangath have helped to sensitise anganwadi workers in identifying children with learning disabilities or dealing with child sexual abuse, said Lourdes Miranda.

Martha Mascarenhas, a senior official of the Integrated Child Development Services in charge of Salcete taluka, said a new innovative dimension to Goa’s Integrated Child Development Services (ICDS) programme has been nutrition education camps for adolescent girls, including school dropouts and young women, in the 14-45 age group. Here they are taught the importance of nutritious food along with cooking demonstrations emphasizing low cost and locally available food with an emphasis on salad recipes. At these camps issues such as relationship problems are discussed and vocational training skills related to tailoring, catering and craft are taught.

“Research has a role in developing our ability to see the wider picture, confirm results, and pinpoint linkages. Sharing these insights with the wider community would help to create a common pool of knowledge and experience.”

RUPA CHINAI

The Goa government is expecting the anganwadi worker to play the role of the ASHA worker. But as shown elsewhere in the country, she is heavily over-worked with her present responsibilities in running a crèche and monitoring malnutrition in children. Taking on the role of community health worker in preventive and curative work, adhering to targets imposed by various health programmes and so on would place a huge work burden on her. Hence the simple necessity to have a cadre of trained, locally based health workers.

But with successes like the anganwadi in their allotted role, and of ASHA workers elsewhere in reducing infant mortality, and the many other community experiences throughout India which have been proven by people of both dedication and science, the bottom line seems obvious: the community – there is where India’s health can and should begin.

Research has a role in developing our ability to see the wider picture, confirm results, and pinpoint linkages. Sharing these insights with the wider community would help to create a common pool of knowledge and experience that can be drawn upon by individuals and groups to better understand their own dilemmas and in their work for social good.


Please write your comments below, click preview, and then submit

Textile Help