Health and hygiene, the third basket of Tata Steel Rural Development Society (TSRDS), uses a three-pronged approach emphasising prevention, curative services and promotion.

 

This is done through rural and urban projects — broad-based clinics in the rural areas of Jharkhand and in Jamshedpur, focused projects such as the Mother and Child Project (MISP), and clinics which focus on specific health issues such as tuberculosis, contraception and HIV-Aids.

 

TSRDS runs 34 clinics in East Singhbhum and Seraikela-Kharsawan districts and 10 in other parts of Jharkhand. In keeping with its principle of not giving anything entirely for free, TSRDS operates a Village Health Fund. For every visit to a clinic, a patient pays a minimum of Rs2 ($0.04 or £0.02)¹, which is put into a box. So far, Rs290,000 ($6,231 or £3,774)¹ has been collected in this manner. The money is ploughed back into the community. For example, if a pregnant woman needs to have a caesarean section, TSRDS pays the hospital charges from this fund.

 

Another regular activity of the clinics is a Community Health Day, held at least once a month in each village, where women and children gather for immunisation and supplements. On these days, the gathering also serves as a forum for talking about family planning methods and other health issues.

 

Through its clinics and projects such as MISP, TSRDS especially focuses on creating village-level health cadres who can manage and deliver basic healthcare services. For example, young people go through a training of 90 sessions at TSRDS centres. These sessions cover human anatomy, basic illnesses and remedies. After being trained, the health workers are given a stock of basic medicines (such as paracetamol, vitamins and folic acid, and anti-diarrhoea tablets). They often become the first source of medication for villagers, and the first to record and diagnose common illnesses.

 

In the villages, in the absence of adequate or accessible reproductive health services, many deliveries are performed by dais (traditional birth attendants or TBAs), who have many skills. TBAs in this region cut the umbilical cord with a sickle or arrow head (in the belief that the child will grow up to be brave and courageous) and apply dung (goat droppings) on the cut cord, which leads to many infections. “We are not just telling the TBAs and auxiliary nurse midwives (ANMs) that what you are doing is wrong and leaving it at that,” Tejinder Kaur, co-ordinator of the MISP and Rishta projects, says. “We show them ways in which they can do it better.“

 

Projects such as MISP target a critical population: pregnant women and new mothers. The MISP creates village-level reproductive health providers by intensively training two women in each village. These community-based operating partners (CBOPs), as they are called, in turn become trainers. They interact with groups of 10-15 women, talking to them about health issues. They monitor such details in the village as how many women are pregnant or how many children had low weight at birth. These and other details are carefully recorded.

 

In the MISP centre in Bankatti village, a Community Monitoring Board indicates the thoroughness of this village-level data-gathering. Nine columns detail the number of pregnant women, children who are a year old, and other information. The number is not written, but marked by the relevant number of dots in each row. The details are later transferred to registers.

 

The misconceptions are many: calling the ojha (local traditional healer) to do rituals which may trigger hypertension or convulsions in the woman, believing that the new mother must not eat anything for 40 days except puffed rice and gourd, the notion that the uterus and stomach are the same, or that as long as a woman is lactating she will not get pregnant again. Another common practice is chiri daag, when the 21-day old baby is tattooed around the navel, forehead or hand with a red-hot sickle, in the belief that this will make the baby healthy.

 

In addition to the fact that the healthcare services in the villages are minimal, misconceptions add to the illnesses and mortality amongst pregnant women.

 

MISP works on changing such beliefs and practices as well as introducing new healthcare behaviour, such as basic rules of hygiene to be followed during a delivery, the types of supplements to be taken during pregnancy, vaccinations and the importance of a correct diet and rest. The project uses quiz competitions and games (such as Ludo and 20 Questions) to innovatively talk about issues such as spacing of children. Pictorial posters are also extensively used. The posters depict, for example, the danger signs during pregnancy or five basic cleanliness steps to be followed during a delivery. These are especially useful in an area where women’s literacy is low.

 

The CBOPs also disburse a delivery kit (provided by the state government, which contains a new blade, soap, clean pieces of cloth, etc) and ensure that it is used. If a delivery requires hospitalisation, the CBOPs, in consultation with TSRDS-MISP, arrange for transport and money, identify an appropriate nursing home or hospital and an accompanying person. The CBOPs collect Rs5-10 ($0.11 or £0.06 – $0.21 or £0.12)¹ per month from the women (depending upon their ability to pay), which goes into a common fund for medical emergencies. In meetings with groups of women, the CBOPs also initiate discussions about such issues as domestic violence, dowry and women’s legal rights.

 

In Bankatti village, as in other villages, TSRDS uses the government anganwadi (a centre providing basic healthcare) centre as its MISP office. Not only does this avoid duplicating building permanent structures, it is also a place the women are familiar with when they come for ICDS services.

 

About 50 women and children are at the Bankatti MISP centre when we visit; the women talk about how things have changed. All of them are now clearly very well-versed in safe pregnancy and safe delivery practices and the importance of post-natal care. One woman talked about how, in the past, they fed their babies goat’s milk but now know the importance of breast milk; another talked about how when her son was born, the dai used an old blade and applied goat droppings on the cord. “Now nobody does this in our village,” she says. Some of the women talk about contraception and spacing. Renuka Mahato, for example, had her first baby in 2001 and the second one only in 2007.

 

Many of the babies at the centre are wearing beads on a black string tied around their waist. Lakhsmi Mahato, one of the mothers, explained that the beads marked the number of vaccinations the baby has received — an innovative way to keep count in an area plagued by low literacy.

 

Nupur Rai, a community-based health worker, talked emotionally about one of her special cases: a baby girl, who only weighed 500grams and was born to a 15-year-old mother. “She only slept wrapped up on her mother’s chest,” Ms Rai recalls. “At two months, she was 850grams; she got rickets, had to be given medicines, massaged. At one year, she became 2kg; till the age of two, she could not walk.” The girl, Malati, is now a lively seven-year-old. She shares a very special bond with Ms Rai, who visited her home every day when Malati was a baby. “I would go to the village in fear,” Ms Rai recalls, “wondering if the baby had died. I’d ask before entering, is she still there? This girl is one of my best rewards.”

 

Although the MISP’s target group is pregnant women, lactating mothers and mothers of children under two years, it has an important secondary target group: husbands, mothers-in-law and community members because, as Dr Kaur says, “How much ever we may talk to the women about health, it will not ultimately work if the mother-in-law and husband are not involved. So we extensively interact with them too, as well as with the entire community and with other NGOs working in the area.”

 

The changes brought about are also evident in the government health machinery. Due to TSRDS’s backing and because the women in the villages are now better informed, they demand better healthcare services. “If the ANM is not coming regularly, we know how to complain to the primary health centres,” Renuka Mahato from Bankatti village says. The single primary health centre in Ghamaria is more regularly visited by doctors, more medicines are in stock, and the auxiliary nurse and midwives have become more regular in their rounds of villages.

 

The third major type of activity in the health and hygiene basket is a focus on specific health issues, such as tuberculosis, HIV-Aids, and contraception. The Family Welfare Clinics (part of the 34 clinics) focus on contraception and sexually transmitted diseases.

 

On certain days, the clinics turn into a TB control centre. The disease is especially common here; it spreads fast in crowded homes, with low levels of nutrition and sometimes high levels of alcoholism. The clinics test the patient for TB, register the case and give a standardised nine-month course of free medication, as prescribed by the government’s Directly Observed Treatment, Short course (Dots) programme. Often, treated and cured patients become motivators and educators for others.

 

The Khushi project of TSRDS’s health and hygiene basket also focuses on HIV-Aids and STDs. It runs the Khushi clinic in Transport Nagar (a parking spot in Jamshedpur for the hundreds of trucks that come to this industrial hub). The Khushi clinic uses games and posters to inform truckers, many of whom in turn inform their colleagues. Mohammed Naushad, a truck driver from Jaunpur, says, “In the beginning, we would just ask for an injection to cure us. Now we know about prevention; we have changed our behaviour in many ways. And we help others. If a driver or his helper is sick, we bring him here. We show others the right path.”