Abstract: After the formation of the new state of Chhattisgarh, a female Community Health Worker (CHW) program was initiated. Launched after numerous consultations with health experts, this programme was innovative in many ways. The implementation on the ground however, was effected by the complex socio economic and political dynamics. This paper attempts to understand the interplay of this dynamics by studying four critical processes of the programme(selection, training, support by health services and the community) and the direction it led to.
Keywords: structural constraints of programme intervention, community health workers, cultural constraints for Mitanins, medical and non medical benefits
Community Health Workers (CHWs), as the name suggests, are chosen from the community and expected to represent its interests. This differentiates them from other auxiliary or Para medical workers. There has been always been an inherent tension between the architects of the CHW program who hope for the CHWs to have a small controlling influence on health systems and the health services who want to appropriate the CHWs as subordinates.
The Mitanin Programme in Chhattisgarh was one such female CHW programme, initiated in 2002 after the formation of the new state to deal with the poor health indicators of its people. A State Health Resource Centre (SHRC) was set up to provide additional technical support to the government of Chhattisgarh. A State Advisory Committee (SAC) was to provide guidance to the Mitanin Programme. However with time, differences came up between the two and as a result the SAC meetings gradually stopped. Over time SHRC became the primary agency that guided and implemented the Programme (Som 2009). A distinct feature of the Mitanin Programme was the separate cadre of trainers. The hierarchy comprised of one Field Coordinator (FC), three District Resource Persons (DRPs) and 20 Block Resource Person (BRPs), in that order. The FC was responsible for the district, while the rest for the block. Each BRP was responsible for around 20 Mitanins. This was different from the earlier CHW programme where the multi-purpose worker (MPW) had the additional burden of training the CHWs. Here, SHRC trains the FCs, they train DRPs for training BRPs, who finally train the Mitanin. The Mitanins were supposed to receive continuous trainings through the BRPs in the village as well as phase wise camp based trainings.
A good CHW programme should act as a bridge between the health services and community. Its success depends on a complex interplay of factors like selection, training, support from health services, community and family support. All these factors are impinged upon by the socio- cultural and economic structures and their constraints within which the Mitanin programme functions. These factors and the social dynamics around them are being explored in this paper, and also their impact on the working of the Mitanins and the Programme as a whole. The paper begins with an introduction to the Mitanin Programme. Then deals with each of the factors mentioned above and the way socio-cultural and economic context influence these factors. Finally, the paper discusses what it means to be a Mitanin, how gender impinges at each level and how its pervasive reality distorts each level thereby affecting the efficiency of the Programme.
This paper is based on field research conducted in 2003-2004 and 2006-2008. The objective of the research study was to look at the linkages between working of the Programme and socio cultural and economic processes. The 2003-2004 study was in the initial phase of the Mitanin Programme where two pilot blocks were taken up. Subsequently, data was collected from one of the better performing blocks of Rajnandgaon district, namely Dongargaon, during 2006-2008. Dongargaon block is divided into four sectors. Two BRPs and their Mitanins were chosen from each sector. Dongargaon block has 328 Mitanins out of which 75 Mitanins were interviewed to develop a social profile. As the indepth interview data for some remained incomplete because of certain constraints, the rest of the analysis was done on 52 interviews spread over Mitanins of 23 villages. BRPs and other key officials in the block, district and state level were also interviewed. Observations, group discussions, case reports and in-depth interviews of the subjects were used as tools for data collection. The operationalisation of the programme was also observed through numerous meetings of the trainers, cluster meetings, DRP meetings, staff meetings, Nodal officers meetings, health camps, sterilisation camps, and house visits.
The beginnings of the Mitanin Programme
Being the backward tribal part of earlier Madhya Pradesh, Chhattisgarh inherited poor health infrastructure and health status of its people. The formation of the new state provided an opportunity to strengthen the health services and revamp it. The government health administration with the help of the civil society (non-government entities working on public health) initiated discussions around the central idea of a female CHW based ‘Mitanin Programme’. Substantial discussions were held with public health experts in the country. An important workshop in January 2002 – ‘Moving Towards Community Based Health Services for Chhattisgarh’, was held. One of the major concerns of public health experts was that a standalone CHW programme won’t be able to achieve much without a parallel reform in the health service system. Consensus emerged around the vision of the Mitanin as the one who:
Will assist the residents of her hamlet to identify the social and biological causes of morbidity and mortality; help organise them to secure services from the state health department and any other relevant government departments; and to address the social causes of ill-health (GoC and Action Aid, 2002: 8).
Women were chosen as Mitanins with the understanding that, “women are better able to reach out to women…..the cultural conditioning as natural caregivers to the family makes a women look at health care as a necessary area of intervention…There is lesser tendency of women to settle down as quacks” (SHRC, 2003: 20-1). Importance of all the trainers being women was also stressed.
Efforts were made to learn from earlier CHW programmes. The Mitanin was to be selected from each hamlet rather than the village mitigating the effect of caste to some extent. The programme was designed to have an elaborate community selection and a separate support structure of trainers with continuous training. Curative care training was to be preceded by preventive care training. No compensation was given in the initial stages with the understanding that giving compensation would make her feel a part of health services and not a representative of the community. Parallel improvement in the health services was also envisaged.
The Programme was rolled out first in 14 pilot blocks by different implementing agencies (six NGOs and one district health service system). Based on the experiences of the different agencies, the best practices and model were to be replicated throughout the state. However, due to political exigency (government desire to expand the Programme before elections), the Programme was expanded throughout the state in two phases in December 2002 and January 2004. Due to this haste, the ‘best practice selection’ plan failed to take off, rendering a suboptimal Programme implementation. The way the social structures and socio-economic and cultural process pervade different levels of operationalisation is presented in the sections below.
Selection of Mitanins
In her review of the nationwide CHW scheme of 1977, in Shahdol district, Qadeer (1985) brings forth that ‘a handful of non-tribal elite in collaboration with the well-off tribals controlled the majority of the poor- individually through terms of work and collectively through social institutions like panchayat’. Further, with no access to information and education, the poor depended on the elite. Within this setting, like any other developmental programme, it was appropriated by the elite and distorted to help themselves (Qadeer 1985). Though in the initial period of the scheme, the rich sometimes appointed the lower caste because the former did not want to do the ‘dirty’ work and visit all houses. Gradually, as the special status and incentive for the CHW became known, the dominant section, the upper caste and class appropriated the selection (Bhanot et al 1992).
To counter this, the Mitanin Programme had an elaborate and well designed selection process that included social mobilisation (by local troupes) about the programme. This was to be followed by several discussions by facilitators (mostly nominated from the health services) aimed at evolving a consensus for selecting the Mitanin. The formal selection was to be then made in the village meeting.
Even here, the facilitators were health workers who had been working in the block for many years, knew the villages and its power structures and had their own network of relationships. This interfered with the selection of the Mitanin. Of the Mitanins interviewed, 13 percent were nominated either by the sarpanch or the facilitator (Som, 2009: 107-8). Village meetings for selecting the Mitanin were held only in 53 percent of the hamlets in our study population. However, in most of these meetings the number of people present ranged from 15-20 only. Selection in these village meetings were better. There were instances where the lesser educated woman was chosen in favour of more educated upper class woman as people were not comfortable with the idea of visiting the latter’s house. Thirteen percent of the Mitanins were selected in absentia without being consulted. Around five percent of the Mitanins were selected through self-help group meetings. These groups were not always representative especially when the marginalised group formed the minority in the village. Thus the power dynamics of the village interfered with the apparently valid method of selection, resulting in some biased selections.
Mitanins were selected because of their active social life, ability to speak well and travel outside the village (22 percent). This was followed by Mitanins selected because of their family linkage (18 percent). Interestingly only 16 percent of the Mitanins were chosen for their educational qualifications. Illiteracy was not a hindrance as of the total 328 Mitanins in Dongargaon, 10 percent of the Mitanins were illiterate or barely able to write their name. Another 30 percent of the Mitanins had studied only till 5th. The initial rounds of trainings were sensitive to these Mitanins but in the later rounds, these Mitanins faced problems as we shall see later.
Initially, no compensation was announced for the Mitanins. Therefore, influential sections of the village did not find it worthwhile to lobby for the Mitanin in many villages. This reduced the interference in the selection process to some extent and women inclined to social service were also selected. The Mitanins belonging to SC category were 12 percent of all 328 Mitanins in Dongargaon, whereas they form nine percent of the total population in Dongargaon. However, the Mitanins belonging to ST category were 13 percent of all the Mitanins selected in Dongargaon whereas they form 16 percent of the population in the block. The OBCs who form the dominant group in the population form 69 percent of the Mitanins. The planners had taken the heterogeneity of the village into consideration and had therefore made hamlet as a unit of selection instead of the village. However, in many cases the hamlets have mixed caste groups with SC and ST castes forming a minority. It is only in hamlets where STs are a sizeable number that they have STs as Mitanins. Based on income source, land, additional sources of income, the interviewed Mitanins were divided into different classes in a relative scale. It was seen that 12 percent Mitanins were in the low category, 41 percent in middle, 22 percent in upper middle and 18 percent in high category. The representation of the high and upper middle class is proportionately much higher. Seen according to caste, among the OBCs 48 percent were in the low and middle category as compared to 70 percent among SC and 54 percent among ST Mitanins.
In the event of a Mitanin opting out of the Programme, there was no mechanism in place to select a new one. This was critical as the popularity of the Programme and added incentives made it lucrative. New Mitanins came from influential backgrounds as their families had persuaded the trainer to select them. In other cases, the baton was passed from the illiterate mother in law to the educated daughter in law. There were cases where the Mitanins who were more vulnerable were pressurised. One ST and illiterate Mitanin said she was under pressure by the influential in the village and could not skip even one session of immunisation for fear of being replaced. The incentives changed the way Mitanins were selected. Now the poor and illiterate had lesser chance of getting in as the trainer or the ANM in the area could decide arbitrarily and were inclined to favour the elite. This affected the Programme, as a Mitanin belonging to the dominant and economically, better off class and not representing the majority in the village is disinclined to serve the poor who need her services the most and used her without reservations.
Training of trainers and their support structure
To overcome the problems seen in earlier CHW programmes, a separate structure of trainers were created. However, the expectation that these trainers would be autonomous and would be able to stand up to the health services was farfetched. In the initial stages, there was no formal way of recruiting the BRPs and DRPs. The appointment happened in an adhoc manner as the health workers located potential BRP in the villages. Dongargaon had 16 BRPs of which 12 had studied upto Class 10th or more, as the minimum requirement was 8th pass. There was only one ST, one SC, one Muslim, one upper caste BRP and the rest were all OBC which formed the dominant group. In terms of performance, the Muslim and the SC Mitanin were better than the others and only these two had any prior experience of working on issues of health or social issues. Thus there was little to differentiate the trainer (BRP) from the trainee (Mitanin). Also, the trainers (BRP and DRP) were dependent on the same books and training meant for the Mitanin. Their training did not inculcate any awareness of the social structure of the village and how it would affect the functioning of the Mitanins. Further, the trainers relied on the ANM for technical knowledge. The field coordinator, found it difficult to mentor the BRPs and DRPs as she was over burdened with training in the entire district. This left a void which was filled by the health services. The trainers identified themselves with the health services and tried to cover up its deficiencies like irregular supply of medicines. The premise was that ‘we are in the same department and therefore should not complain about the other’. This defeated the objective of keeping the training hierarchy separate from the health services with the understanding that they would be more sensitive to the community.
In the beginning, the selection criteria for Mitanins included education upto Class 8th as desirable. Among the Mitanins interviewed, 12 percent were illiterate or barely able to write their name. To assist them, SHRC introduced a separate pictorial booklet before the fifth round of training. But in the later trainings, especially the seventh round onwards, Mitanins were asked to fill in forms, write tests etc. during training. They were also expected to fill up registers and diaries which help in reporting. Those who could not do it felt left out. Even the trainers felt burdened as they had to help these Mitanins. This was unfortunate because these illiterate women were selected based on their suitability for the job over literate ones in their hamlets, for their inclination towards social service. Conscious of their illiteracy, they put in extra effort in trying to understand and remember the trainings. Their lack of literary skills in no way affected their ability to interact with other women and understand their concerns. Thus, the emphasis on literacy for administrative records (forms, test, etc.) defeated the original purpose of selecting the Mitanin on the basis of their social effectiveness and it became a reason for trainers apathy towards them.
The Mitanin was supposed to draw her strength from the community and so the Programme was designed with a view to promote interaction between Mitanins and all sections of community to disseminate knowledge and seek support. For this, house visits by Mitanins were the key and initiated early in the programme. The emphasis however lessened after the first few rounds of training and again picked up around the tenth round (Som 2004 and 2009). By this time, as a consequence of the shifting focus of training on maternal and child health, the Mitanins concentrated on pregnant, lactating women or women having children up to two years of age. Incentives of JSY and sterilisation also encouraged this tendency. Thus, from a more comprehensive coverage, the Mitanins focused only on women and young children.
As women who worked full time to run their own households and also contribute to their livelihood, the Mitanins found it difficult to spare time and visit houses. In addition, they did not find it comfortable to visit houses alone in their hamlets. They preferred the company of the other Mitanins of the village or the trainer. There were only four Mitanins from two villages who visited all the houses. Both the villages were small and the Mitanins chose to visit houses together.
The Health committee was another institutional medium for interaction with the community. Since Mitanins had no experience in organising people, they could not gather the poor women in the hamlet, whose priorities revolve around their livelihood, to talk about issues of health. At the most, information about availability of medicines was passed on by about half the Mitanins in the self-help group meetings and 16 percent of the Mitanins have reported that they at times raise health issues in the self-help group meetings. In a mixed community, it is mostly the marginalised sections that are left out of these groups and thereby any information or discussion however small. The Mitanins were seen by the people as linked to the health services because of their association with the ANMs and soliciting cases for health programmes. Thus the idea of community supporting her was not able to germinate and neither was she able to effectively disseminate knowledge that inspired community support. There was no social pressure on the Mitanin either from the needy.
Family Support for the Mitanin was a crucial factor. The Mitanins consider that ‘permission’ from their family is important as they have to go for house visits within the village and outside the village for cluster meetings, trainings and accompany patients. Most Mitanins do their household chores before going for meetings and visits, so that the family does not have much to complain. The elderly Mitanins who have daughter-in-laws or young daughter to do the chores have it relatively easy. Sixteen percent of the Mitanins in the studied sample were residing in their maternal homes. These were selected as it was believed that being a daughter in the village, she will have more freedom and mobility as compared to a daughter-in-law. However, the data showed that this factor alone did not make much of a difference in the effectiveness of the Mitanin. Not surprisingly, in the interviews done with the Mitanins after incentives were started, the family seemed to support her in most cases. Whereas, earlier interviews reveal that the families were not supportive, their main complaint was that the Mitanins have to go out of the house and yet do not get any reward.
Health services and its utilisation
Eighty three percent of the poorer sections and overall 78 percent of the households have used medicines available with the Mitanins. Of the people who have not used the medicines, there are many especially in the poorer section who were not part of SHG, and the Mitanins did not come to their house as there was no pregnant woman or infant child. As discussed in the earlier section, narrowing the focus of the programme is affecting the utilisation of the Mitanins for those who need them most.
The middle and upper class who have not used medicines from the Mitanin, prefer some particular clinic or physician. This was not unexpected given the scant help from the PHC that Mitanins received.
Since the Mitanins were heavily dependent on the health services, the need for better and supportive health services was emphasised from the beginning of the Programme. However, except for some small changes, the parallel initiatives and changes which were envisaged did not materialise. The CHC in Dongargaon had a dynamic Block Medical Officer (BMO) who ensured that the CHC was functional. In the absence of specialists, he managed with the four doctors. The focus was on achieving the targets of the national programmes which was always emphasised in the staff meetings. Of the six PHCs in the block, only two PHCs had doctors on contract. However, they did not have the full team to run the PHC. In the other PHCs, support staff like the dresser or the pharmacist or the staff nurse gave medicines to the patients. Lack of basic infrastructure like resident quarter for staff, water supply etc. also hampered their functioning. Thus the Mitanins could not expect much support from the health services. Interestingly Mitanins themselves have taken patients to the private services since patients wanted to go there. Few higher class Mitanins themselves have never availed of the health services before joining as the Mitanin.
The private services are a varied group. It includes the unqualified practitioner who comes to their village, treats them at their home on credit, mostly in the morning and evening hours thus not affecting their livelihood. It also includes clinics run by unqualified practitioner, the government health providers like MPW, dresser who do private practice. The village level data of 45 households collected from two villages showed that only two households preferred the government health services and nine households prefer government health providers who do private practice (including five poor households)! When asked about their preference, the poorer section of the village said they preferred using non-governmental health care like the unqualified practitioner coming to village (22 percent), small clinic in nearby village (39 percent) or government staff giving private care (28 percent). However, when it came to actual usage, 61 percent of the poor households ended up using government health services even though none wanted to do so. This reflects the dissatisfaction with the existing state of health services that were visited despite its poor quality.
Of the 27 ANMs posted in sub centres, only two belonged to ST category, one SC and the rest OBC and general category. In addition, her salaried health worker status, perceived modernism made her hierarchically superior. The ANMs with this background and overloaded with writing reports and achieving targets, offload some responsibility to the Mitanin. The Mitanins found it difficult to refuse the ANM as they were also dependent on her for technical support. Monetary incentives were also routed through the ANM. Thus the health services see the Mitanins as a new cadre and use them as well as the BRPs to complete their targets. The ANMs also use the services of the BRPs in the various camps. They are also expected to guide the women coming in the health facility by setting up a help desk. Not being exposed to any other alternative, the trainers and Mitanins also liked to associate themselves with the health services as it gives them a sense of importance. The Mitanins have spoken about the importance that they get as the ANM or the doctor looks for them when they come to the village. For the poor and marginalised this has a greater significance, despite being treated as subordinates and paid the bare minimum. This desire to be a part of the health services is also manifested in the dress code of the BRPs in which they take pride. Thus instead of representing the community, they identified with the government services. In the absence of a functional health service system, the Mitanins could not get adequate support. Instead, the Mitanins and trainers were used to compensate for some of the inadequacies of the health services and for achieving national health programmes targets. The Mitanins could not force the health system to address the demands of the community as not only the system but they themselves their role as subordinate health workers rather than representatives of the community.
It is often said that the Mitanin Programme was designed well with some innovative components but the socio-economic-political realities changed its direction. We would like to argue that unless and until the design itself takes into account the socio-economic, cultural and political context of women and children, it will not succeed in achieving its objective to the optimal level, however pro women and child it might appear to be. In the present context, the health services views itself as the modernising, scientific and therefore inherently superior agency with respect to the community it serves. The upper caste and class composition of the health services along with education gives them cultural superiority as well. Given the acceptance of hierarchy and superior attitudes of the upper class formal providers, the village community also does not object or resist these values. Instead of focusing on the inherent organic strength of the Mitanin and her understanding of the community, she is looked at as an agent of the formal system while the system looks down upon her as an inferior being at it service and under its supervision. In the absence of support from both sides, the Mitanin’s voluntarism quickly degenerates into becoming an informal arm of the government services.
Only when the community has had some background of social mobilisation or movement by which they come together and share their needs and understand their strengths, will it form an effective collective identity to press for its rightful needs. Only then will they be able to face the health services and its official superiority with confidence. Only then will the people of the community also value the voluntarism of the health worker. Otherwise she will be seen as, and will in actual fact be reduced, to an informal worker linked with the health services.
Our analysis of female community health workers in Chhattisgarh brings this out vividly. The Mitanin Programme was based on pure volunteerism to begin with. Secondly, its potential lay in good selection, training, supervision and more importantly the support they get from the formal health system. The new infrastructure created, and the health system support required to be sensitive to gender bias and the prevailing socio-economic divisions in the society. Our data shows that given the patriarchal structure, socio- economic constraints and ensuing lack of encouragement for women to participate in the social sphere, this was not possible. The programme got distorted right from the early implementation phase. The selections were without consultation in 13 percent and without meetings at the village level in 47 percent of the cases. What worked was the social linkages that the health personnel had or wished to create with the village elite. So they opted for nominations and gave weightage to certain important families. As a result the STs were underrepresented. While some social service oriented women did get selected initially as there was no remuneration, when honorarium was added, more of the elite families got into the programme showing interest in paid work.
The training of Mitanins depended upon the quality of trainers who were not competent enough and had no prior experience in medical or social aspects of health. Also, the content of training was limited as was the design which neglected absences, gaps and midway exodus of Mitanins. Thus the training was not uniform and remained incomplete for the new Mitanins. And though 12 percent of the Mitanins were illiterate there was no effort to have teaching methods that would be inclusive of them in the later stages of the Programme. The absence of any relevant social content, inadequate training of trainers and lack of community support obliterated all potential for Mitanins becoming representatives of the community interest. They were in fact reduced to lower level paramedical functionaries.
Though Mitanins did some useful work in the sphere of maternal and child health care they had in fact curtailed a more comprehensive curriculum which initially was meant to cover health for all. This no doubt is due to the conscious shift of thrust where policy has shifted attention to Maternity, Child Health and Family Planning. Even in doing this their interactions with the community were restrained as they did not like visiting families alone, visited only houses with pregnant women and made only infrequent home visits except for four Mitanins! This hesitation is rooted in the social distances they could not overcome and patriarchal control of their families that liked the money coming in but, not the outside influences or any curtailment of household work. The poor woman, not a member of SHG and not having a young child was left behind.
Though the programme on paper envisaged full support of a strengthened primary care infrastructure, the latter was neither strengthened nor did it give importance to patients referred by the Mitanins. She was seen as technically and socially inferior and was treated more as an adjunct rather than a representative of the community. Thus the Mitanins were used for just one targeted programme- the reproductive health programme. Though the Mitanins were primarily meant for the poor, the poor women actually did not have time to sit and listen to Mitanin’s talk. They were busy earning their living and wage was a more crucial priority than learning about feeding and preventing disease. It appears then that, without building a convergence with other development programmes, strengthening primary level infrastructure for health and without addressing the socio economic constraints, Mitanins cannot be effective. Unfortunately, the review of the CHW programme, three decades earlier, also underlined the fact that the system did not consider the stratification in rural areas (Qadeer 1985; Bhanot et al, 1992). Also, posting a poor woman with little or no resources, one cannot resolve complexities like health.
Yet there is an interesting side of the experiment. The women chosen as Mitanins are discovering a world they had never seen or interacted with. This makes them curious, wanting and ready to learn more. These may be called subsidiary advantages that the Programme gave them, an opportunity to come out of their house going to other villages for training. The Mitanins have also started going to the health facilities especially after the introduction of JSY. For many, this was the first opportunity to step out of their homes and villages, access the health services and interact with the health officials. They go to different houses, albeit only those in which the pregnant women live, thus going out of their houses which holds a lot of significance. The PHC or the CHC with its yellow and white painted concrete walls stand out in the topography of a village, not quite merging with the village landscape. The presence of doctors, other health providers and alien equipment gets intimidating for a woman who has not been exposed to this. The Mitanins, with regular exposure have been able to break that barrier and are able to access the health facility in their area. The Mitanins who have taken referrals to district hospital are now familiar with this facility as well. This has given them a lot of self-confidence. The vast mobilisation of these women has also had an effect on other spheres for example, some Mitanins are now contesting panchayat elections. The Mitanins also have a sense of pride in becoming a point of contact for any health related matter in the village. Health has also become a topic of discussion. These women are now also learning to cope and deal with family pressures on one hand and fulfilling the responsibility of being a Mitanin on the other. In most cases, the families have realised the value of their work and are supportive. This in itself is nothing short of a significant social change.
It appears then that just using a women CHW in the name of volunteerism is not enough to bring about change in women’s health as this needs concerted efforts of a committed trained cadre and a comprehensive policy and strategy. Without this the Mitanin will be another experiment in community health workers blown away by the overpowering interests of the medical care provisioning system and the powers to be, yet it has become a window for women to see some light.
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Som, M. Social and Programmatic Dynamics of the ‘Mitanin’ Programme: Implications for NRHM. New Delhi. Unpublished Ph.D thesis, CSMCH, JNU. 2009.
—. An Exploratory Study of the Mitanin Programme: An innovative experiment in the Training of Women Health Workers in Two Pilot Blocks of Rajnandgaon and Dhamtari Districts in Chhattisgarh. New Delhi. Unpublished M.Phil Dissertation. CSMCH, JNU, 2004.
I would like to thank Prof. Qadeer for guiding this study and Dr. Srivatsan for the comments on earlier draft of the paper.
MITHUN SOM. Is a public health researcher based in Hyderabad. She holds a Ph.D. from Centre for Social Medicine and Community Health, Jawaharlal Nehru University, New Delhi. Her area of interest includes Rural health and health services, Maternal health, Informal labour and occupational health.