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IIHMR Working Paper No.

1




Health Seeking Behaviour and Healthcare Services in
Rajasthan, India: A Tribal Community's Perspective









Lakhwinder P Singh
Shiv D Gupta













Institute of Health Management Research
JAIPUR



About the Authors
___________________________________
Dr Lakhwinder P. Singh, after obtaining M. Sc. in Human Biology from Punjabi
University, Patiala, worked on MAB-UNESCO Project on "Man-Environment
Interactions in Jammu Kashmir Himalayas", for four years, and obtained his M.
Phil. in Anthropology from the University of Delhi. He was awarded
Commonwealth Scholarship at the University of Oxford from where he obtained
his Doctoral degree. His areas of interest are health seeking, community
development, and nutrition and its relationship with human development.
Presently, Dr Singh is working as an Assistant Professor at the Institute of Health
Management Research (IIHMR), Jaipur. He has published several research
papers.

Dr Shiv D. Gupta is a public health expert with a distinguished academic and
research career. He graduated from SMS Medical College, Jaipur, and did his
M.D. (Preventive & Social Medicine) from the same institution. He holds Ph.D.
(Epidemiology) from the Johns Hopkins University, Baltimore, USA. The
National Academy of Medical Sciences, India, conferred MNAMS on him for his
outstanding contribution in the field of public health. A Fellow of Indian
Association of Preventive & Social Medicine, he is a long-term member of the
International Epidemiological Association. He is a member of Scientific Review
Committee, Division of Reproductive Health and Nutrition, ICMR, Working
Group for Operation Research in Reproductive Health of Sub-Committee on
Reproductive Health Research Needs Assessment, Ministry of Health and Family
Welfare, GOI, and Working Group on Ninth Five Year Plan for Medical, Health
and Family Welfare, Government of Rajasthan. He has published several research
papers and reports.



List of Contents

Abstract 1
1. Introduction 2
2. 2.1
2.2
Area and People
Materials and Methods
3
4
3. Results
3.1
3.2
3.3
General Problems
Children's Problems
Reproductive Health Problems of the Females
6
8
9
3.3.1 Ante-Natal Care
3.3.2 Natal and Post-Natal Problems
3.3.3 Health Seeking Regarding Abortion
3.3.4 Other Problems Related to Women
3.3.5 Role of Females in Using FP Services

3.4
3.5
Awareness about HIV/AIDS and the Help Sought
Utilisation of Government Facilities
12
13
3.5.1 The Timings of the Clinics
3.5.2 Problems in Utilising Government Services

3.6 Problems Faced during Referral 14
3.6.1 Quality of Services
3.6.2 Supplies of Medicines and Contraceptives
3.6.3 Using Health Facilities in the Case of RTIs and STDs

3.7 Community Needs 16
3.7.1 Additional Facilities Required
3.7.2 Need for Specialised Camps
3.7.3 New Needs

3.8 Community Participation 18
3.8.1 Community Participation
3.8.2 Community's Willingness to Pay for Improved Services

3.9 Role of NGOs/PVOs in the Health Services Delivery System 19
3.10 Role of Traditional Health Providers 20
3.10.1 Role of TBAs
3.10.2 Role of Faith Healers and Herbalists
3.10.3 Role of Private Medical Practitioners

4. Conclusions and Discussion 22
Acknowledgements 24
References 25





Health Seeking Behaviour and Healthcare Services in
Rajasthan, India: A Tribal Community's Perspective

Lakhwinder P Singh
Shiv D Gupta


Abstract : In this study, an attempt has been made to investigate the health seeking
ibehaviour of the tribal communities in four tribal districts of Rajasthan, India, namely
Banswara, Dungarpur, Udaipur and Sirohi. It was observed that people generally do not
pay much attention to the routine problems during ante-natal, natal and post-natal
periods, which they regard as a built in part of child bearing and child rearing. In the
case of reproductive health problems and general health problems like fever and
malaria, at the first stage some treatment is administered at home, followed by a visit to
the bhopa (the local faith healer) and a herbalist in that order. The next stage involves
visiting a nurse or an ill-qualified or unqualified medical practitioner, depending upon
availability. It is only in very advanced stages of the problem that the help of a qualified
medical person is sought. In the case of dental problems, as well as for cough and cold,
the problem is ignored till the last minute, until the pain becomes unbearable. In the case
of children's problems, they are mostly treated by giving some indigenous treatment, and
in case the problem should persist after a certain period, the help of a medical
practitioner is sought, who may or may not be qualified. In some specific problems like
poisoning, all people reported visiting faith healers and claimed that their treatment is
very effective. In cases of abortion also, the help of a herbalist or an experienced
traditional Birth Attendant (TBA) is sought, who may or may not be trained, to abort the
foetus by using indigenous methods.

The second part of the study deals with the community's perspective of health services
and health personnel. It also looks at the issue of integration of Private Medical
Practitioners (PMPs) and traditional Birth Attendants (TBAs) in improving the delivery
of health services. Finally, the paper overviews the community's perception of the Non-
Governmental Organisations working in the health sector.


















1. Introduction

This working paper looks at two major issues related to health management: health
seeking behaviour and other issues related with the community's perception of the health
services, the service providers and others like traditional healers and private
organisations involved in the health sector.

Health seeking behaviour is an important factor in health management, but this is often
ignored while considering schemes for providing health facilities to people. As a result,
new schemes for providing health care do not get the desired acceptance of the
community, and are therefore rendered unsuccessful. The decision makers in the health
sector are recognising the need for understanding the health seeking behaviour of the
community and its acceptance and usage of traditional and modern methods, as also the
perception of the community regarding the service delivery. This becomes especially
relevant among traditional and tribal societies.

Many attempts have been made to document the health seeking behaviour of the tribals
in India. Of late, some attempts have been made to study it among the tribals of Madhya
Pradesh and Orissa (Sawain, 1994, Basu, 1994 and Singh, 1994). The cultural patterns
and the life style of the tribes vary a lot, and so does their health seeking behaviour. In
the present study, an attempt has been made to document the health seeking behaviour of
the tribal communities inhabiting the southern fringes of Rajasthan, bordering the tribal
regions of Gujarat and Madhya Pradesh.

Of late, the focus of health services, especially RCH services, is shifting towards better
quality of service delivery. The concepts of Quality of Care (QOC) and Total Quality
Management (TQM) are gaining wider acceptance among the health professionals. Major
efforts are under way to improve the quality of services. One of the aspects of quality
care demanding attention is how the client perceives the quality of service delivery.
Since the efforts being put in by health professionals are meant for the community at
large, it becomes crucial to understand its perception of quality and its viewpoint on the
organisations and the personnel providing health services.

















The Institute of Health Management Research (IIHMR), Jaipur, conducted this study
during July-September 1996. An investigation was carried out among the community
members regarding their health seeking behaviour and their utilisation of the government
health services. An effort was also made to find out their perception of the quality of
health services and the changes and restructuring that the health system needed.

2. Area and People & Material and Methods

2.1 Area and People

The area under investigation for the present study covered four tribal districts of southern
Rajasthan namely Banswara, Dungarpur, Udaipur and Sirohi (Fig. 1). In Banswara and
Dungarpur districts, the population in the rural areas is largely tribal; in the pockets
studied in Udaipur and Sirohi districts also, it was so, though the overall percentage of
Scheduled Tribes in these districts is on the lower side (Table 1). These are
predominantly tribal, and the population break-up of these districts is given in Table 1.


Table 1: Vital Statistics of the Tribal Districts of Rajasthan
S.No Variable Rajasthan Banswara Dungarpur Udaipur* Sirohi
1. Population
Total
Males
Females

44005990
23042780
20963210

1115660
586855
568745

874549
438324
436225

2889301
1470028
1419273

654029
335517
318512
2. Sex Ratio
(number of females/ 1000
males)
910 969

995

965

949
3. Literacy Rate
Total
Male
Female

38.55
54.99
20.44

26.00
38.12
13.42

30.55
45.17
15.40

34.88
49.27
19.00

31.94
46.24
16.99
4. Percentage of
Scheduled Castes
Total
Males
Females


17.29
17.39
17.18


5.00
5.00
5.11


4.61
4.64
4.57


8.32
8.39
8.23


19.24
19.67
18.97
5. Percentage of
Scheduled Tribes
Total
Males
Females


12.44
12.31
12.58


73.47
73.11
73.84


65.84
65.83
65.85


36.79
36.72
36.87


23.39
23.52
23.26
* The data for Udaipur district includes information on Rajasmand and district also, which was
created after the 1991 Census.
Source: District Census Handbooks, Census of India, 1991


It was decided to study a set of four villages in each of the four districts. Each set chosen
included one village with a Community Health Centre (CHC), one with a Primary Health
Centre (PHC), one village having a sub-centre (SC), and one without any health facilities
available locally (NF village). The rationale behind selecting this set was to see whether
the health seeking behaviour and perception of the tribal people about health services
vary according to the facilities made available to them locally. A list of the villages
visited in each of these four districts is provided in Table 2.

Table 2: List of the villages visited, along with the existing facilities

S.No Health
Facility
Banswara Dungarpur Udaipur Sirohi
1. CHC Village Bgidora Bichhiwara Jhadol (P) -
2 PHC Village Kalingra Sisod Phalasia Dildar
3. SC Village Lalawara Bokla Karel Naya Sanwara
4 NF Village * Vadali Para Bijura Amila Dedna
* Village without any health facilities available locally


The sub-centre is the lowest level health facility in the state, staffed mostly by an
Auxiliary Nurse-Midwife (ANM), and catering to 5,000 people approximately. The
PHC, the next level of medical care provided by the state, has a qualified medical
practitioner assisted by some para-medical staff. It also has some in-door facilities and
caters to 30,000 population. At the CHC level, there are four sanctioned posts of
qualified doctors, assisted by para-medical staff, and there are facilities for in-door
patients as well as a laboratory attached. Each CHC caters to a population of over
100,000.

2.2 Materials and Methods

The population in these villages is mostly tribal, except in the CHC villages, where a
good number of non-tribals have settled. In most of the PHC and SC villages, as well as
in the NF village, the tribal population ranged from about 50% to 100%. The main tribes
living in the area are Bhils, Garasias and Meenas. Some other tribes such as Rebaris were
also present in the area studied. Of these tribes, the Meenas are relatively more
developed due to their exposure to modern life, whereas the others remain largely
underdeveloped and under-exposed. They can be grouped amongst the poorest sections



of the society and the population is by and large illiterate. As shown in Table 1, literacy
rate among these tribals is very poor, though no break-up of literacy rate as such among the
tribals is available. Most of the males and almost all the females among these tribals are
without any formal education. Utilisation of the state health services by them is quite low.
It was observed during discussions that the level of awareness about the government health
system and the facilities available was extremely poor in the people of these areas. Another
reason for not utilising health services was the faith these tribal people have in the
traditional healers like the bhopas (faith healers) and herbalists.

The information for the study was collected through informal group discussions (IGDs)
with groups of females and community leaders in each village under study. In addition, in-
depth interviews were held with the local health providers like bhopas (faith healers),
TBAs and jarhi booti walas (herbalists). In all the sets of villages studied, the community
leaders interviewed included members of the Panchayat (present as well as former), local
teachers and members of the Mahila Mandals (village level organisation of women) and
other socially influential persons including TBAs and faith healers. The number of the
participants varied from eight to over a dozen, and it was possible to get a fair picture of the
community's views on the issues short-listed for discussion.

Likewise, during informal discussions with the women, the strength of the group varied
from a minimum seven to over a dozen in some villages. Most of the women participated in
the discussion very actively, and expressed their views on issues concerning their health
and that of their family members. Some had difficulty speaking Rajasthani or Hindi and
spoke in Vagdi (a local dialect, which is a blend of Rajasthani and Gujarati). This problem
was overcome with the help of local facilitators recruited from Udaipur for the purpose
who took detailed notes in Hindi, which were later revised and translated into English, as
far as possible on the day of the discussion itself. The discussions were moderated by an
anthropologist. Some of the participants, who knew Hindi, Rajasthani as well as Vagdi,
also helped to cope with the language problem. No such problem was faced while having
discussions with the community leaders, as all of them were well conversant in Hindi and
Rajasthani.

In-depth interviews were also held with local TBAs, faith healers and herbalists to know
about the kind of problems the community faces and the type of treatment dispensed at
home by the patients themselves or their family members before they approach the local
healers. An effort was also made to know the type of treatment dispensed by them.

3. Results

The results of the study are presented in the following two sections.

I. Health Seeking

The problems necessitating health seeking among the tribals can be broadly classified
into three groups:

3.1 General Problems
3.2 Children's Problems
3.3 Problems of Females

II. Issues Related with Health of the Community

3.4 Utilisation of Government Facilities
3.5 Problems Faced while Accessing Health Services
3.6 Community Needs
3.7 Community Participation
3.8 Role of NGOs
3.9 Role of Traditional Healers

3.1 General Problems

Fever (Bukhar /Taav)

The first stage of treatment normally is giving the patient some tea. Then, people seek the
help of the bhopa, the faith-healer (also called jhare wala). If it does not get cured, then
people resort to allopathic medicine.










Likewise, in the case of Malaria (Malaria taav) also, which is very common during and
after the rainy season, the treatment sought is the same. This was the general trend in
case of most of the villages, but at certain places located on the highways and where
health facilities existed, non-tribal people directly went to the hospitals after the home
treatment. In the villages with 100% tribal population, and located off the main roads,
people normally went to the bhopas. Since most of them could not afford to visit towns
or cities for treatment, they stuck to the treatment offered by the faith healers for a
relatively longer period. It is only in very advanced stages that a qualified allopathic
doctor is consulted.

Poisoning (Jahar, Vish)

In case of poisoning as a result of snake bite, scorpion sting, etc., and ingestion of
poisonous material, in all the discussions, the help of the bhopa was mentioned as the
only effective treatment. It was claimed that over 80 per cent of the problems related to
poisoning were cured by the faith healer. None, except in one CHC village, mentioned
taking the help of a nurse/doctor in the case of poisoning.

Dental Problems

The dental problems identified were caries (keera), tooth-ache (dant dard), swelling
(sujan) and pyorrhoea (peek). It was observed that people do not attach much importance
to dental problems. They apply i.e. rub tobacco (tambacoo) to the aching parts. It was
reported that most of their problems got cured by tobacco, and none was reported going
to a hospital for dental treatment in any of the villages.

Some people mentioned applying cloves (long) or clove oil (long ka tel) for curing dental
problems. Some others mentioned applying the juice of the leaves of the Climbing bean
(Dolichos lablab) (Sem ki phali ki pattion ka ras) or Garhia ki patti as home treatment.

Other Problems

Other problems mentioned during the discussion included cough and cold. The common
treatment mentioned for this problem was taking honey, crushed tulsi leaves (sacred
basil) and tea with black pepper. Again, as in the case of dental problems, not much
attention was paid to them. People believe that these problems are part of one's life, and
carry on as normally as possible in such cases.














In the case of Jaundice (peelia), another problem identified, the sufferer is given sugar-
cane juice as local treatment. This, people believe, is an effective treatment and none
mentioned going to a hospital for treatment of jaundice.

Bhopas or faith-healers (jhare wala) were especially called in for removing the ill effects
of 'evil eye' (nazar), spells of black magic (tona), etc. Though some people were initially
reluctant to admit this, later on they admitted that though they knew the treatment was
not as effective as allopathic treatment, it was still being used by poor people owing to
the very high cost of allopathic medicine.

Constipation (kebjee), abdominal pain (pet dard) and head-ache (sar dard) were other
health problems mentioned during the discussions.

3.2 Children's Problems

Diarrhoea (dast) was the main problem faced by children under 5 years of age. The local
treatment administered at home was giving some water with lemon (nimbu paani) and
salt, milk with sugar (doodh) or a kind of soup. Some people in the CHC villages
mentioned ORS (Oral Rehydration Solution) being administered. If things did not
improve with this, the help of a qualified person, ANM or qualified doctor, was sought in
that order.

Acute Respiratory Infection (ARI) (Saans chalna)

After Diarrhoea, Acute Respiratory Infection (Pneumonia) was the second most common
problem among the children. The domestic treatment included giving nutmeg (jaiphal),
clove (long) and saffron (kesar) at the first stage. People living in remote areas would
also take children suffering from ARI to the local herbalist, who administered some
herbs. In some areas, mention was made of applying a hot iron rod by the faith healers to
cure respiratory problems. This process is called daam. Only at the third stage was the
help of a qualified practitioner or ANM sought.



















3.3. Reproductive Health Problems of the Females

These are discussed under the following heads:

3.3.1. Natal care; including Ante-Natal Care (ANC), Natal Care & Post Natal Care
(PNC)

3.3.2 Health Seeking vis--vis Abortion

3.3.3 Other Problems Related to Women's Health

3.3.4 Problems in Utilising FP Services

3.3.1. Ante-Natal Care

The problems faced by pregnant women during their term included indigestion,
vomiting, oedema (haath pag sooje), general weakness (kamjori) and body ache (haath
pag toote). Some home remedies practised include giving "burnt and ground corn cobs"
to those suffering from vomiting. Generally, the females looked upon these problems as
part of being pregnant and a price one had to pay for being pregnant. They would try to
take them in their stride and carry on as normally as possible.

If the problems persisted for a longer duration, they would consult the TBA (dai) who
would do some massage, etc., and give some instructions to reduce pain. The next stage
of help would be the ANM (the village level nurse) posted at the nearest sub-centre. If
the problems still persisted, the help of a doctor would be sought, depending upon the
economic status of the family.

3.3.2. Natal and Post-Natal Problems

The problems during childbirth identified are: excessive bleeding (gano khoon chale) and
weakness following the delivery (kamjori). The home remedies for these include giving a
solution of unrefined sugar in water (gurh ka paani), solution of the gum of certain trees
such as Babool (Acacia nilotica) (gond ka pani), and turmeric powder in milk (haldi ka
doodh). If the problems persisted beyond a few weeks after delivery, the help of the
ANM was sought.


Infertility, prolapse (Bacchedaani kamjor ho go hai), excessive bleeding during menstruation
(menorrhagia), irregular menstruation, convulsions (akrana) and miscarriages were the other
problems mentioned by the women. The treatment for these problems was restricted to the
local herbalists or other unqualified practitioners, owing to the high cost of allopathic treatment
and the unhelpful attitude of the staff dispensing government health services.

3.3.3. Health seeking regarding Abortion

Health seeking vis--vis abortion, one of the major health hazards, was a very sensitive issue.
The women, to begin with, were reluctant to talk about it. After establishing a rapport and
discussing other problems related to health, it was possible to ask them about their health
seeking in relation to termination of pregnancy.

Termination of pregnancy was not resorted to avoid unwanted children in the marital alliance.
But, it was resorted to in cases of pre-marital pregnancies and pregnancies resulting from extra-
marital relationships, such as when a wife conceives in the absence of her husband. In these
cases, the pregnancies are kept secret, and the help of the local herbalist is sought. They mostly
terminate pregnancies of up to 10 -12 weeks.

For induced abortion, the first step is orally administering the root portion of a plant locally
known as Gainski. If it fails, the next stage involves giving a liquid blend of jaggery (gurh)
and black pepper. In the unlikely case of that also failing, the last step is adding some
country liquor to the above mixture, which in most cases induces bleeding, leading to
abortion. After this, if there are any complications, a woman is referred to a doctor, who may or
may not be qualified. In some villages, people mentioned taking the help of the Para-medical
staff (ANMs) for carrying out abortions. For any complication arising, the help of unqualified or
ill qualified practitioners, and in some cases qualified doctors, was sought. All this is done
very secretively. Some herbalists opined that people were reluctant to approach
medically qualified doctors for reasons of maintaining secrecy.



3.3.4 Other problems related to women

Leucorrhoea - White Discharge (safed paani) was invariably mentioned by all women at
all levels as their problem Number 1. According to the women participants in the
discussions, the prevalence of white discharge varied from almost one hundred per cent
in some villages to over 50 per cent in others, including the CHC villages. Nowhere was
it mentioned that less than half of the women suffered from white discharge. It emerged
as the main problem, followed by swelling (soojan), syphilis (challe) and pus discharge
(Gonorrhoea).

Most of the women living in the remote areas did not bother about the treatment of STDs
and regarded them as their fate (kismat). Some expressed inability to undergo treatment
owing to the high costs. Others went to unqualified doctors for treatment. Only at a
couple of places, mention was made of Lodh (Simplicos racemosa), an ayurvedic
medicine, claimed to be effective in curing gynaecological disorders.

On being asked why these problems occur, the women invariably mentioned promiscuity
and poor nutrition in the case of white discharge. In case of the other problems, the
answers given included polygamy and indulgence in sex with strangers. Mention of non-
tribal people, including truck drivers, was made as the reason for the spread of STDs in
the villages along National Highway #8 connecting two major cities of India, Bombay
and Delhi. People said that some women in these districts, both tribal and non-tribal,
were commercial sex workers (CSWs), who after getting infected by these diseases
became a source of infection in the community, through their local clients, who would
get infected and then pass on the disease to other women with whom they had sex and so
on.

The studies by Mavli (1980), Vyas (1980) and Vyas (1980) also report high incidence of
STDs among the tribals. This is due to promiscuity and a liberal attitude towards pre-
marital and extra-marital sex. This is also due to higher interaction of the tribal women
with non-tribal men in some high-risk areas such as along national highways, in regions
where mines and industrial units are located, and around places of tourist interest in the
region.

3.3.5 Role of Females in Using FP Services

It was observed during the discussions that the need for family planning is widely felt by
the tribal women, though the men, by and large, are not very keen on it. To begin with,
during community discussions, men folk maintained that it was the female who had the
final say on family planning matters; but the females asserted that though they played an
important role in FP matters, it was their husbands who took the final decisions. An
example can be quoted from one of the discussions. In case a female has two or three
daughters and wishes to undergo tubectomy, she cannot do so without the consent of her
husband. In such cases, the husbands mostly are keen on having at least one male child,
and they continue to reproduce till they get the desired number of male children. In case
a female is reluctant to co-operate, her husband threatens to acquire another woman, who
could bear him sons. In such cases, say the females, they have to yield to their husbands.
It was observed during the discussions that, by and large, people are not very keen on
family planning. Whenever somebody felt the need for it, she would ask for the help of
the local TBA, who mostly would direct her to the nearest available ANM.

3.4 Awareness about HIV/AIDS and the Help Sought

At most places, both the community leaders, and the women were not aware of AIDS. At
some places, people mentioned having heard about AIDS, but they could not say what it
is and how it is transmitted, except at two discussions with community leaders, one in a
CHC village and the other in a PHC village. Though prevalence of sexual contacts with
non-tribals and the level of promiscuity among tribals are high, people are not aware of
the potential dangers of AIDS and STDs. None among the community leaders and
women, who participated in the discussions, admitted that they had knowledge of anyone
suffering from AIDS. On being asked about where people go, in case some one has
AIDS, they had no answer obviously due to lack of knowledge since they are not aware
of the disastrous effects AIDS might have on people's lives, and they are yet to see
someone suffering / dying from AIDS.

3.5 Utilisation of Government Facilities

Government health institutions were used by the people at the third stage, after home
remedies and the faith-healers, for seeking health care. The people mentioned going to
health centres first and said that though check-ups at the government clinics were free,
the cost of allopathic medicines prescribed by the doctors was high, and the treatment too
prolonged. Owing to their inability to pay for such long treatment, they opted to go to
unqualified doctors, popularly called "Gujarati Doctors" or "Bengali Doctors". (Most of
them belong to these two states.) According to the villagers, the duration of the treatment
by them was shorter and effective, and the cost less as compared to the full course
prescribed by a government doctor.

Another reason for the popularity of PMPs (Private Medical Practitioners) is their
sympathetic attitude towards the patients, and their willingness to listen to the patients,
and in some cases, deferring of the payment to a later date, a facility not available in the
case of allopathic treatment.

It was mentioned at most of the discussions that the attitude of the doctors posted at the
government institutions was not very sympathetic during duty hours. Similar perceptions
were shared regarding the Para-medical staff posted in the remote villages, as well as the
PHC and CHC villages. However, after duty hours, the doctors continue to see patients at
their private clinics for a fee, during which, their attitude towards the patients is more
sympathetic.

This was also true during the home visits of doctors in the CHC and PHC villages and of
the Para-medical staff in the sub-centre villages and villages without any health facilities.
In some of the remote villages, the female participants reported that some ANMs charged
upto Rs.350 for supervising a delivery, and likewise the doctors were reported to be
charging upto Rs. 75 for a home visit.

3.5.1 The Timings of the Clinics

Even the people living in a CHC village were not aware of the working hours of the
CHC. Most people reported that it was open in the morning and again in the late
afternoon. Very few mentioned that it was open between 8 AM and 2 PM, and then again
for one hour between 5 PM and 6 PM. This might be due to poor sense of punctuality in
the villagers. On being asked what they do in case the doctors are not available, the
respondents were divided in their opinions. Some said they would wait for the doctor or
go to the residence of the doctor, where doctors mostly see patients for a fee. Those
coming from remote villages said that since they had to return home, they preferred to go
to private practitioners instead.

3.5.2 Problems in Utilising Government Services

The problems being faced by the people while utilising government health services were
inaccessibility due to lack of transportation, unsympathetic attitude of the staff
dispensing the health services, and shortage or non-availability of medicines locally.

The community, especially those living in remote areas, strongly felt the need for
providing primary health facilities locally so as to deal with both routine and emergency
cases. The personnel posted at these centres could also act as referral units. Non-
availability of essential medicines locally and the time lost in getting them from chemists
located away from the locality were the problems cited. The community leaders opined
that they were willing to pay for the medicines if they were made available locally, since
the time saved in procuring these medicines could be used for other economically
productive activities.

3.6. Problems Faced During Referral

On being asked what problems the people faced while using the referral system, non-
availability of conveyance, exorbitant rates charged by taxis for transportation of
patients, and negligence at the big government hospitals were some of the problems
mentioned during the discussions. The others include anxiety of going to bigger hospitals
and longer absence from home, resulting in loss of income.

3.6.1 Quality of Services

It was difficult to communicate the concept of 'quality of care' to the community.
Therefore, the community was asked what their idea of good service was. The response
of the community was that, first and foremost, it includes civil behaviour on the part of
the medical and Para-medicals personnel. The next requirement, according to the
community, was making more medicines available in the health institutions. Better-
qualified staff should be posted at the health institutions and vacant posts of doctors and
Para-medical staff should be filled.

On being asked about the hurdles the community faced while utilising the government
health services, the response of the community, at all levels, was more or less the same.
The traditional beliefs of the people in the indigenous systems of medicine along with
inaccessibility of government services was the main reason for people not using the
health services.

On being asked what problems the community faced in utilising the existing health
facilities, long waits at some clinics, where the patients were more than what the "doctors
in position" could cope with, and the time spent in going to and from the health centre
being very long, were the problems mentioned.

3.6.2 Supplies of Medicines and Contraceptives

There was a great deal of resentment among the community members at all levels about
very few or rather none of the medicines prescribed by the doctors being available in the
dispensaries of the PHCs and the CHCs. In discussions with the community leaders and
the women, people at all levels mentioned this as their main problem.

Regarding supply of contraceptives, people said that they got them from their ANMs.
Mostly, supplies at CHC villages are regular, but, at other places, a few complained
about inadequate supply of Oral Pills, etc. It was mentioned that, in case anyone bothered
to ask for contraceptives, they were made available by the Para-medical staff. But, in
most of the villages visited, the Para-medical staff took no interest in motivating people
to use these methods and explaining to them their importance. The people complained
that all that the Para-medical personnel were bothered about was sterilisation, popularly
called 'operations' by the community, and maintaining records, and not helping people
plan their families.

3.6.3. Using Health Facilities in the Case of RTIs and STDs

The information on Reproductive Tract Infections (RTIs) and Sexually Transmitted
Diseases (STDs) was sought, based on symptomatic approach and no examination of any
kind was carried out. The discussions revealed that there was a very high prevalence of
Reproductive Tract Infections (RTIs) in the area. People normally do not attend to these
problems. Most of the women reported that, in some areas, almost 100 per cent women
suffered from RTIs, and that nowhere was the prevalence less than 50 per cent. Even if
there is some exaggeration in this, the figures are quite high. Most of the women suffer in
silence and take no curative steps, regarding it as their fate. Some relatively well off
women among the tribals talked about taking the help of Indigenous System of Medicine
(ISM) practitioners in coping with these diseases. The reason cited most often for not
using modern health facilities was the inaccessibility of the doctors for RTIs. Owing to
these reasons, people in the area go to the unqualified practitioners, who, according to
them, offer cheaper treatment. It was felt that besides cheaper treatment, another factor
that drives people to the private practitioners is their civil behaviour towards the client,
which is something that the community does not find among the people working in the
government sector.

3.7 Community Needs

3.7.1 Additional Facilities Required

On being asked what additional facilities they would like to have at their local centres and
at their nearest PHCs and CHCs, the response of the community was very sensible. They were of
the view that primary health facilities should be provided first in the villages where there are no
health facilities available. They wanted provision for delivery centres, X-ray machines, well-
equipped laboratories and the services of gynaecologists at the primary health centres. At the
CHC level, the list of facilities desired included provision for specialists (surgeons,
gynaecologists, orthopaedicians and paediatricians) and new equipment like X-ray machines.
More doctors, especially lady doctors, were among the major needs identified.


Facilities for minor operations at the PHCs and for major operations at the CHCs were
also mentioned as the need of the community. Some respondents mentioned the need for
new buildings and more beds in the hospitals for indoor patients. Some others mentioned
that more medicines should be made available free of cost from the health centres.

Some other problems mentioned by the people were dirty beds and linen, and generally
unhygienic conditions at the PHCs and CHCs. In this context, some villagers went to the
extent of saying that these government hospitals, due to their poor hygiene, are not
centres for effecting cure but for spreading disease.

3.7.2. Need for Specialised Camps

Except for some CHC villages, where some camps are being held with the co- operation
of voluntary agencies, nowhere was any mention made of specialised camps being held
during the last one year. However, people were overwhelmingly in favour of having such
camps in the villages. On being asked what sort of camps they would like to have at their
villages, people mentioned a variety of them - general check-up, orthopaedics, FP
camps, paediatric camps, gynaecological check- ups, eye camps, etc. Some people even
said that they were willing to pay in case the camps were held in their area.

3.7.3. New Needs

When asked where money needs to be invested, the people were of the view that it
should be for providing basic health facilities in remote places, and for improving the
existing facilities and making the health system "really" functional.

Providing free or highly subsidised medicine in the tribal areas was another idea, which
came up during the discussions. A major shortcoming at PHC level mentioned by the
community was most of the equipment supplied to these centres being in a non-
functional state. New equipment, like X-ray machines, etc., should be provided. Even at
places where such equipment is already there, it is not functional since there are no
qualified technicians to operate the equipment. At some places, there are technicians, but
no machines. These shortcomings, in the community's opinion, should be taken care of.















A similar response was given in case of ambulances at CHCs, the positioning of drivers,
etc. Laboratories at the CHC level, according to the community leaders, needed attention
and updating. Provision for more tests at these laboratories should be made.

Another area which needs attention, according to the community, is filling up of vacant
posts of doctors as well as para-medical staff at PHCs and CHCs, especially in the
remote areas. The community leaders, as well as women participants, were very keen
that a gynaecologist should be posted at each CHC. Though this position exists at some
CHCs, most of the doctors are not in position.

Another need is the doctors, nurses and other staff at PHCs and CHCs staying in the
village itself so as to deal with emergency cases round the clock.

3.8 Community Participation

It was decided to limit the issue of community participation to two areas, namely willingness to
pay for services and provision of ambulances at the village. The reason for this was that
the proposed intervention phase is likely to include these.

3.8.1 Community Participation

It emerged during the discussions that the community had no previous experience of
being involved in planning any community-based activity, leave alone health facilities.
The community was everywhere keen to play an active part in the planning process.
They felt that since they know their problems best and know the potential of the
community to participate in any activity, they should be consulted before any project
planning is finalised.

3.8.2 Community's Willingness to Pay for Improved Services

Though most of the respondents were very poor, they were willing to pay for good health
facilities, if they were made available locally. On being asked how much they would be
willing to pay in case a good qualified doctor visited their villages on a periodical basis,
the response varied from Rs 10 to Rs 50 per patient during his / her visit.

Likewise, the community leaders' response to provision of ambulance in the villages was
very positive. They understood the limitations of the government and opined that they
would be happy to bear the expenses of maintenance and the driver's salary. On being
asked how much they would be willing to pay, they suggested that the Panchayat should
set up a committee, which would work out the tariff to be collected from the users, for
different places. Everywhere, right from CHC villages to villages without health
facilities, people were willing to pay for these services.

Community leaders in some remote villages opined that before being provided with
ambulance, link roads to the villages should be constructed.

3.9 Role of NGOs/PVOs in the Health Service Delivery System

Except for the Jhadol-Phalasia area of Udaipur district, NGOs and PVOs providing
health services are not very effective in the area covered in the study. Barring the Jhadol-
Phalasia area, the community is nowhere aware of any PVOs/NGOs working in the
health sector, except for some curative work done in some towns and big villages by
agencies like Lions Club, Rotary Club, etc.

However, in the Jhadol-Phalasia area of Udaipur district, there are over 40 NGOs
working in the health sector. During discussions with the community leaders, they
applauded the work done by some prominent NGOs like Seva Mandir, Ankur and Chetna
Arogya Mandir, to name a few. The general view of the community was that the IEC
work done by these NGOs is good, and their volunteers are more effective in motivating
people for immunisation, adopting FP, and promoting health among the tribals of the
area than the government health workers. The community leaders were of the view that
these NGOs should be provided more support in the form of equipment, etc., and more
finance to recruit more volunteers.

Though the community felt that these NGOs should be supported further, it was
mentioned at the same time, that there is much overlapping in the activities of the NGOs.
Some mentioned that these NGOs should have clearly defined areas, and that they should
adopt a whole village or unit rather than some specific number of families in a village,
which leads to some tension in the village.

However, a note of caution was added by the community that during earlier years these
NGOs had done very effective work, but with the passage of time, the attitude of the
volunteers had started changing and was fast becoming like that of the government
employees. Another issue that came up during the discussions was these NGOs
sometimes getting funds from various agencies for the same activity.









3.10 Role of Traditional Health Providers

3.10.1 Role of TBAs

Dais (TBAs) provide help to pregnant women at the first stage. With their experience
and training, they give them some massage, etc., and refer serious cases to the ANM or
the health centre. Some of them also provide promotive and preventive advice. To name
a few tips given by the dais, they ask pregnant mothers to take more vegetables and a
healthy diet, and advise them not to do heavy physical work activities like lifting heavy
objects, etc., during pregnancy. The dais also advise the pregnant mothers to go for
frequent health check-ups at the health centre and to get immunised during pregnancy.

Mostly, they conduct deliveries by themselves; it is only in complicated cases that they
ask for the help of ANMs and other better-qualified persons. If they realise during an
advanced stage of pregnancy, that the delivery is going to be complicated, they advise
the pregnant mother to go for institutional delivery.

On being asked whether they conducted abortions, none of them admitted that they did.
On being asked what they do in case someone comes to them asking for abortion, all of
them replied that they would ask the concerned female to go to a qualified doctor in a
government health institution.

None of the TBAs interviewed was getting any help from the government agencies. They
would like to have support from the state in the form of training and supplies. Some of
the TBAs have already been trained, and the others expressed a keen desire to undergo
training. All those who have been trained also expressed a desire to undergo further
training.


3.10.2 Role of Faith Healers and Herbalists

These normally serve as the first stage of referral outside the home. Mostly, the same
person acts as faith healer as well as herbalist. They mostly offer free service, and
therefore people prefer to utilise their expertise as faith healers first. If things do not
improve, they go for the herbal treatment.

The faith healer part of the treatment includes performing Jhara, which consists of
waving twigs of the neem tree in the form of a broom and chanting some mantras
(incantations), which they believe drive away the evil spirit responsible for most of the
sufferings of human beings.

The herbalist part of the treatment includes administering some local herbs known to
cure certain ailments. It was interesting to note that these traditional healers (faith healers
and herbalists) are very keen to be integrated into the mainstream system of referral and
training. They all expressed a keen desire to undergo any type of training, such that they
can be useful centres for referral in future. They all seek recognition from the state and
look forward to some monetary incentives in addition to the training.

3.10.3 Role of Private Medical Practitioners (PMPs)

It was also possible to interview some of the private medical practitioners during the
visits. Except for one, who was qualified in the ayurvedic system of medicine, all the
others, though claiming to be qualified, did not have any proper training. What most of
them have done is working with some qualified doctor for a couple of years and then
obtaining a certificate, mostly from Utter Pradesh or Bihar states. These certificates
obtained by these practitioners are Ayurved Ratan, Vaid Visharad, etc. Even after
obtaining the certificates in the ayurvedic system of medicine, most of them prescribed
allopathic medicines, for which they are not qualified.

These practitioners have a good load of patients; most of them say that they see around
300 cases per month. They claim to cure seasonal and non-specific diseases like
diarrhoea, malaria, fever, allergy, vomiting, flu, etc. They said they referred complicated
cases to government hospitals. But, the community leaders opined that they do not refer
even serious cases to hospitals, but hang on till the last minute in order to earn more
money.















Most of the PMPs expressed a keen desire to undergo further training in government
institutions. On being asked what they would like to learn, they said that they would like
to undergo training in the latest research in medicine, in handling sophisticated
equipment like X-ray machines, etc., and learning more about the latest medicines.

All of them expressed keen willingness to be depot holders for contraceptives, but said
that more efforts should be made to motivate people to accept modern methods of family
planning.

4. Conclusions and Discussion

It was observed during the discussions that though considerable amount of money and time are
spent by these tribals on health, their level of health education is extremely poor. Due to their
ignorance, they visit traditional healers and ill-qualified medical practitioners. These practitioners
take full advantage of the opportunity and exploit the poor tribals. Another reason for their not
utilising the state health set-up is the indifferent attitude of the providers towards these people.

It was observed that the tribals do not pay any attention to problems during pregnancy, and often
neglect the treatment of gynaecological problems. A study on the rural women in Gadchiroli
district in Maharashtra (Central India) has also reported negligence of RTIs and pregnancy-
related problems (Bang and Bang, 1994).

Another issue is the very high incidence of RTIs like white discharge, gonorrhoea and others
among the tribals living in Western Rajasthan. This again is supported by the study of Bang and
Bang (1994). It was felt during the discussions that white discharge is the most common
gynaecological disorder occurring in the women of these tribal districts. This, it seems, is the
general problem of the women in India, especially the rural areas. This is also supported by a
study in Panch Mahal district in Gujarat across the border (Patel, 1994). This is further supported
by a study in the urban slums and rural areas of Baroda district, where women identified white
discharge as their problem Number 1 among various gynaecological disorders (Patel et al., 1994).

It was observed that the people of the tribal populations living in the different sets of villages
adopt more or less similar methods of health seeking. Though non-tribal people living in the
CHC villages as well as a few progressive tribals are adopting modern methods of health seeking,
people living in the tribal region resort to indigenous methods out of compulsions like poverty
and ignorance about modern methods of medicine. Though a majority of them realise the futility
of faith healing, they adopt it as the last resort for the reasons given earlier. However, some
tribals, who have been exposed to the outside world, refuse to rely on these methods, through a
majority of them still do so.

Acknowledgements ____________________________________________________________

We are grateful to the participants in the discussions for their active co-operation and
participation and for bearing with us during the discussions. The study was supported by a
research grant from KfW, Germany. Thanks are due to IHMR for providing excellent research
facilities. Special thanks are due to Prof. Rushikesh M. Maru, Director, IIHMR for his
contribution to the study. Prof. G. R Rao's help in editing the manuscript is gratefully
acknowledged.

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