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eeW*rt WWtu*iytutn-- - t I. ci- i, l .

\ff/est Bengal has done comparatively better in terms of infant mortality, deVV enes at medical institutions, children's full immunization, etc., yet, the incre-:: -he incidence of corrtmunicable diseasesn \)fest Bengal is a major cause of woiccording to official data, the incidence of communicable diseases n the statei:-irplv increatedbetween1995-6 and 2000-1.For all the major health indicators except infant mortality, the record-::::khand has been abysmally poor. Despire the non-availability of secondary.. communicable diseases nJharkhand (only the data for malartais available),me=lrlrts and other sources indicate , hlgh ra;teof occurrence of communicable

-ses. )falaria is a menace forJharkhand - in 2001 ftom a sample of a little abr' - rr.000 sJides, xamination results found more than 15 percent positive case:::l;na of which 60-85 percent $,ere casesof plasmodiumfalriparam a fatd,diseBoth the states suffer from absolute levels of inadequacy n terms of pu:,e-r.L-J:rervices. In rWestBengal each Primary Health Centre serves a population*--'t-4, on average. n Jharkhand this figure is 47,769. rhe government norm i:.: !p one PHC per 30,000persons n generaland per 20,000 persons n Hilly -:-lrJ areas).

The same is the case for the Heaith sub-centres. Each Sub-centre in \,:o:real serves,on average,a population of 7,104. rorJharkhand the figure is 5,6r1e government norm is to set up one sub-centreper 5,000persons for the gen,r' :opulation and one per 3,000 persons in Hilly and Tribal dreas).

-lharkhand's case s paticular\ disadvantaged for a large part of the state is c::-c \vith hills and it has a much higher tribal population Q7 percent) than W:ci.s'al (7 percent).

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5 r:wr, fn"4i af t { l i tD i05Flealth Ailments and Medical Treatment: One maior cause for concern

reliance on unqualified medical ptactitioners (JMPs) - populady known as qufor medical treatment. These quacks include unusual degree holdets @egMedical Practitioners, whose degreesare allegedly bought from various instituhomeopathic degree holders (who practice allopathic medicine); non-matricwho cannot even read the names of medicines (since they are written in Englisdepend upon the medicine dealers'guidelines (who label the medicines, for thefit of the "doctors", with the names of symPtoms of the drseases particulaicine is used for) and also some medicine shop ownefs. We have even come aman who possessesa ce*ifrcate fuom avetefinary training progfamme, but prmedical tfeatment to humans.

In Dumka the extent of such dependence is much higher - 62 percBirbhum 29 percent reportedly sought medical tfeatment from quacks. WDumka 12 percent and 11,percent relied upon the public health services andqualified doctors respectively, n Birbhum the respective figures ate 33 perce29 percent.

The main feasons for dependenceupon quacks (despite many being awtheir incompetence - in Dumka they are derogatorily caIledholdanga,holabaso on) by the poor afe (1) poor functioning of the public health servicesinabiJity to bear the cost of medical treatment at ^ pnYate qualified doctoric nursing-home/hospital.

The cost factor is very important. \fhile the private doctors are understathe most expensive sources of medical treatment, the unfortunate rca[ty is tcost of medical treatment at the public health institutions is higher than thatprivate unqualified (quack) sources. Public health services have almost ceasefree - only four percerit of the patients who visited the public health servBirbhum and 0.23 percent n Dumka got completely free treatment. In terms ting all the prescribed medicines from PHC/Hospital only 14 percent in Biand 1.3percent in Dumka have been benefited'

In sharp contfast to the popular belief (mainly of doctors and a part of mia) that rural people in generai and tribals in particular depend mainly upondoctofs, magic healers or herbal practitioners, u'e found vefy fsy, who have deurholly upon such sources.Even those who resorted to such servicesdid so duesons of financial stringency or problems of accessibiliq'to the public health s

Medical treatment not only involves high costs but also high risks becmany different forms of gross medical abuse (perpetrated not only by quacalso by qualified doctors). For example, in Dumka, the indiscriminate use ofdrips (for alrriost evefy soft of ailment) is a common phenomenon and in Bthe most visible form of abuse is over-medication (use of rnultiple antibiot

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There are also other kinds of abuse, like not exercising due care and vigilan(particularly in cases of childbirth and surgery - both in private and public instidons). One patient had to have his leg amputated due to the carelessness f the dtors and the subsequent wrong treatment meted out to him.

Gender discrimination can be seen very cleady from the factthat 62 percentthe patients in Birbhum who remained medicall;r untreated were women. In Dumthis figure is 75 percent. Gender discrimination is also evident from the fact rnrore men than women w-ere reated in public health centres and by private qualifsources, while the maiorrry of the patients treated by quacks comprised womefl.The Delivery of Public Health Services: V/hile in Dumka all the PHCs visi*.ere ill-equipped and functioning poody (part of the premises of some PHCs haer-en become permanent shelters for different domestic animals and for the homiess,vagrants and beggats), in Birbhum no such uniformity was found. Some ofPHCs we visited have been working very well and some were not. The functionioi the PHCs, it seems,depends upon the motivation of the doctors and other heastaff. Nfhile in one PHC we had to wait fbr five hours for an interview with the Blo\fedical Officer of Health since he was completely engaged with patients (on tparticular day there were more than 500 out-patients!), in anothet PHC we found Block Nledical Officer practicing in his private chambers during wotking houThere was a board displaying the timings of his private practice (8 am to L ax'hich matched exactly with the working hours of the out-patients' department,clearviolation of medicaledricsand service ules.

Private practice by government doctors is a major phenomenon in both the d-!ncts, though less at the PHC level at Dumka (probably for the vztong reasornanv people complained that the PHC doctors spent most of their time in th:radve places, far away from theit postings). In both the districts hower,'et, alarrnajority of the government doctors posted in the hospitals engaged in privzte ptace. Often many of them were tbund at their private clinics during duty hours.

The case of services delivered at the sub-centre level by health r.vorkers s soler. V4rile in Birbhum 37 percent of the respondents acknowledged that a hea";rorker had visited their homes during the year preceding the sur-rey, n Dumka ::{ure was 26 percent. The reported visits were often made aftet very long interv- sometimes ust once a yeat.

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Despite many problems, the condition of the public health institutionsfound to be relatively better in Birbhum. N7hilealmost all the TB patients in Bitbreceived treatment from public institutions, this was not the case n Dumka, ralmost all the TB patients sought treatment from private qualified soufces.Thiits financial implications as well - in Bitbhum the averagecost of treatment fowas Rs. 1,270,in Dumka it was Rs.2,003.

In both the districts the implementation of programmes related to the prtion of communicable diseases(malaria, diarrhoea, etc.) has not been confitmeour respondents.

Implications of health ailments: The maior implication of health ailmein terms of financial loss or J,iability.While the poorest section of people (belo16,000 annual ncome) in Birbhum had to spend 18 percent of thek annual non health care,in Dumka it was 12 pefceflt. Twenty-ofie pefcent of the responin Birbhum and 37 percent in Dumka said that they had to borrow money atest rates of 50 to 120 percent per annum for medical treatment. Many were fto sell their properties - both movable and immovable - to pay for tfeatmentorder to repay loans incurred for medical expenses.

The high cost of medical treatmeflt has, in sodre cases, reversed pochanges. Such changes include mortgaging or selling of land that had been aunder the land reforms programme, working for lower wage rates against contal loans taken for medical treatment, etc. in Birbhum and the renunciation oachievements made through political movements in terms of lowering the rinterest and reducing exploitation by moneylenders in Dumka. The vicious cyhealth ailments, loans taken, loss of wages, oss of Property and poverty and his a very common rciltty for many families.Besides the financial implication, one major negative impact of health ailis on education. Many children simply carrnot attend school becauseof illnesalso a major cause or dropping out (both becauseof ill health and also becaother consequences, ike engagement in income generating work to repay loansfor health cate, engaging in farm work to compeflsate for parents'or elder\ relil lnesses. tc.).