GENERAL APPEAL (India): Dalit women refused medical care and asked to pay bribe at the Primary Health Centre

22 October 2007
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UG-006-2007: INDIA: Dalit women refused medical care and asked to pay bribe at the Primary Health Centre

INDIA: Caste-based discrimination; corruption; lack of accountability; failing public health system
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CASE DETAILS:

Ms. Rambha Devi (18 years old) is a resident of Rithiya village of Naugarh, Chandauli district. On September 3, 2007, Rambha was in advanced labour and was taken to the Naugarh Primary Health Centre (PHC) by her family. This government centre is the nearest PHC from the village.

When the family arrived at the centre, four staffs at the centre, namely Ms. Savitri, Ms. Lalti Maurya, Ms. Shanti Pandey and Ms. Daai were present at the centre. All the four are Auxiliary Nursing Mothers (ANM) employed at the centre. Rambha's family asked the ANMs to admit Rambha for delivery which the ANMs refused. The staff refused to admit Rambha claiming that she would have a stillbirth and that Rambha must be admitted at a private hospital or else she would die. Rambha's family being poor insisted that Rambha must be admitted at the centre. But the staff named above refused.

Rambha's family had no other choice but to go to the private hospital in Barahua, where Rambha gave birth to a normal baby. To meet the expenses at the private hospital Rambha had to avail a loan of INR 7000 (USD 178 USD), which the family now find difficult to pay back.

It is reported that the reason why the staff at the PHC refused to admit Rambha was because they wanted Rambha to go to the private hospital so that the staff at the PHC could get their commission for referring patients to the private hospital. The fact that Rambha beloged to the Dalit community added further complication to Rambha's case since the Dalits in the villages has less authority. The staffs at the PHC adopt the strategy of scaring the patients with wrong opinions without resorting to proper diagnosis so that they rush the patients to private clinics, which the local villagers allege is a very common practice by the staff at the PHC.

Ms. Kiran Devi (18 years old) is a resident of Thathwa village of Naugarh, Chandauli district. On September 12, 2007 Kiran also went to the Naugarh PHC for her delivery. The ANMs Ms. Daai and Ms. Kaushilya were at the health centre and Kiran's family requested Kaushilya to do a check-up upon Kiran.

After the ANM finished the check-up, the ANM shouted at Kiran that she should rush to a big hospital for a Caesarean section. The ANM, Kaushilya, also told Kiran that she had some other urgent private business to attend to and that centre did not have any facilities for operation anyway. During all this time the ANM had not consulted a doctor about Kiran's case.

Kiran's family took her to another ANM, Ms. Shanti Pandey, seeking assistance. Shanti told the family that Kiran would give a birth the following day normally and asked to bring Kiran back to the Naugarh PHC the next day morning. By then it was already 11pm. Kiran and her family requested whether Kiran could be admitted at the PHC. But Kiran was refused admission.

Kiran was brought back home and her family decided to take her to a private hospital. But Kiran's labour advanced during the night and her family asked the ANM Ms. Daai to come home to help Kiran with her labour. Kiran gave birth to her baby the next day morning at home.

The PHC is expected to provide referral service free of cost especially for the poor, women, and children under the National Rural Health Mission (NRHM). The two cases above, demonstrate the neglect and corruption at the primary health centres and by the staff like the ANMs. The centres are also expected to have qualified doctors, nurses and paramedics like the ANMs, and equipped with enough medical supply and other paraphernalia to provide immediate medical assistance to the ordinary people. However, the functioning of several of these centres is deplorable due to government neglect and corruption. This results in the failure of the public health system, which affects the poor, particularly the Dalits in remote villages of India.

It is reported that many poor and lower-caste women of Thathwa village have been asked to pay INR 400 to 500 each as bribe for certificates to claim maternity benefits from the government and an additional INR 5 for issuing a medical card for pre-delivery medical care. The bribes are demanded by the ANMs. The malfunction of the PHC caused by neglect and corruption of the health centre officers is referred in a previous Hunger Alert issued by the AHRC as HA-012-2007.

In addition, Ms. Viranji Devi, the Accredited Social Health Activist (ASHA) of Thanthwa village does not discharge her duty properly. Ms. Devi does not even stay near Thanthwa village but in Tiwarepur village.

BACKGROUND INFORMATION:

The PHC in India is a referral and basic health care unit to deliver the government health service at village level. According to Indian Public Health Standards for PHC and the National Rural Health Mission (2005-2012), the function and the infrastructure including manpower and facilities for the PHCs have been strengthened. One of the main purposes of the public health service is to support those who are poor in rural areas and to reduce infant mortality rate and maternal mortality ratio in India.

Under the National Rural Health Mission, on the basis of the Indian Public Health Standards for PHCs, a female ASHA is chosen by and is accountable to the panchayat (local administrative body). ASHA is supposed to act as an interface between the community and the public health system and as a bridge between the ANM and the village. In the PHC, ANM, the doctor and the nurse play a direct role in delivering health services to the people. Outside the PHC, ASHA is an important link for the success of the public health service. In practice, as shown in the above two cases, the officers at the PHC are responsible for the failure of the quality in the services provided to the poor at the PHC.

In paper the PHC provides 24 hour service, but it does not in practice. In theory the people can get primary medical treatment at the PHC free of cost, and thus the name PHC. Furthermore pregnant women can receive INR 1400 [USD 35] each as financial assistance for each delivery and INR 250 each [USD 6] to cover their transportation costs. The doctor at the PHC is accountable for disbursing this fund from the government to the patients. The pregnant women, on the contrary, are asked to pay bribes to the staff at the PHC for registering their case at the centre. Most of the people who depend upon the services of the PHC are the poor women and children from the lower caste. Due to poor financial conditions they cannot afford for treatment at private hospitals; several of them when refused treatment at the PHC does not go anywhere else, which is reflected in the health condition of these communities. To make things worse due to the absence of any monitoring process and accountability of the staff the quality of the services rendered through the public health service system in India remain alarmingly bad.

SUGGESTED ACTION:
Please write a letter to the Chief Minister of Uttar Pradesh and the Minister of Health to express your concern in this case. The AHRC is also writing a separate letter to the UN Special Rapporteur on violence against women and Special Rapporteur on the right of everyone to the enjoyment of the highest attainable standard of physical and mental health.

Sample letter:

Ms. Mayawati
Chief Minister, Chief Minister's Secretariat
Lucknow, Uttar Pradesh
INDIA
Fax: + 91-522-2230002/2239234
Email: csup@up.nic.in

Dear Chief Minister,

INDIA: Dalit women refused medical care and asked to pay bribe at the Primary Health Centre

Place of incident: Naugarh Primary Health Centre, Chandauli district, Uttar Pradesh, India

I am writing to express my concern regarding the failure of the public health service in Uttar Pradesh due to lack of accountability and corruption in the health service sector, particularly at the Public Health Centres (PHC) in rural areas of the state.

I am informed that the PHCs are most often the only source for medical care for the rural poor, particularly the Dalit community in Uttar Pradesh. However, I am concerned about the widespread corruption in the PHCs, which denies proper health care to the rural poor.

For example on September 3, 2007, Ms. Rambha Devi (18 years old), a resident of Rithiya village in Naugarh, Chandauli district went to the Naugarh primary health centre for delivery. Rambha and her family belong to the Chamar community and are too poor to go to a private hospital. I am informed that the Naugarh PHC is the nearest health centre from Rambha's village. I am also informed that the PHC, since it is located near the forest, is not easily accessible, particularly by the pregnant women.

I have heard that the Auxiliary Nursing Mothers (ANM), Ms. Savitri, Ms. Lalti Maurya, Ms. Shanti Pandey and Ms. Daai refused Rambha to be admitted at PHC even though Rambha was in her advanced labour. Since Rambha was denied admission at the PHC, she had to seek help from a private hospital incurring much expense. I am also informed that the ANMs at the PHC refused admission to Rambha on the pretext that Rambha will have complications during the delivery for which the PHC was not equipped for. I am informed that this scaring tactic is regularly used by the staff at the PHC to refuse admission to the general public and thus forcing them to seek private medical aid. I am also informed that through referring people to the private clinics, the staffs at the PHC obtains illegal commissions from the private clinics.

I am also informed of yet another case which reaffirms my belief that the staffs at the Naugarh PHC are corrupt. On September 12, 2007, Ms. Kiran Devi (18 years old) living in Thathwa village of Naugarh, was also refused medical care for her delivery at the Naugarh PHC. Kiran also belongs to Chamar community and is poor.

In Kiran's case the ANM, Ms. Kaushilya, advised Kiran to have a caesarean section at the private hospital and refused to admit Kiran at the PHC. I am surprised to know that unqualified paramedics like the ANMs providing medical diagnosis in your state, which is also a breach of law and a crime. In Kiran's case she was forced to return home, where she delivered safely the next day early in the morning.

Local human rights groups working for the welfare of the people and supporting the government schemes allege that such practices by the ANMs at the Naugarh PHC is very common so that they get a cut from the private clinics for referring patients to be treated at the private clinics by refusing admission at the PHC.

The above two cases are ample enough for me and anyone else to suspect that the staff at the Naugarh PHC are negligent and corrupt. It is reported that many dalit women availing the service of the Naugarh PHC have been either refused medical help or asked to pay a bribe by ANMs. I am informed that they are asked to pay INR 400 to 500 for certificates to claim maternity benefits and INR 5 each for obtaining a medical card. I have learned that the absence of a doctor at the PHC also creates an irresponsible environment for the ANMs.

I have learned that the PHC is a fundamental unit to provide medical service free of cost for the people especially the poor, women, and children. I am also informed that the Accredited Social Health Activist (ASHA) of Thathwa village is not living in that village but in Tiwarepur village, which affects the availability of that officer for the villagers in Thathwa.

I have also learned that pregnant women are entitled for INR 1400 [35 USD] as maternity aid and INR 250 [6 USD] for transportation costs. However the ANMs at the Naugarh PHC demand bribe from the patients to issue necessary certificates to the patients so that they could collect this aid money from the government.

I therefore urge you to intervene in this situation in order to ensure that the functioning of the PHC in Naugarh is regulated so that the poor, members of the lower caste and children are not denied medical care at the centre. I also request you to initiate an enquiry about the conduct of the entire staff at the Naugarh PHC so that if they are found corrupt, appropriate actions are initiated against these officers.

I hope your appropriate intervention will benefit the poor availing the services of Naugarh PHC and their living condition.

I look forward to your further action in this matter.

Yours sincerely,

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PLEASE ALSO SEND A COPY TO:

1. Mr. Anant Kumar Mishra
Health Minister
Lucknow, Uttar Pradesh
INDIA
Fax: + 91-522-2230002/2239234

2. Ms. Renuka Chowdhury
Minister of State – for Women and Child Development
Shastri Bhavan, New Delhi
INDIA
Fax: + 91 11 23074054
Email: min_wcd@nic.in

3. Dr. Anbumani Ramadoss
Minister of Health and Family Welfare
Nirman Bhavan, Maulana Azad Road
New Delhi 110011
INDIA
Fax: + 91 11 2301 6648
Email: hfm@alpha.nic.in

4. District Magistrate
Chandauli District
Uttar Pradesh
INDIA
Email: dmchn@up.nic.in

Thank you.