Extraordinary caregivers

Photo: Chris Hinn

"Several years into my practice as a physician at my own private clinic, my father was diagnosed with a chronic illness. I could not afford the treatment or the medicines. I had a hard time coping up with the rising cost. So, hoping that government subsidies will be able to help my situation, I applied to join the public health sector. The whole ordeal really made me reflect my role as a doctor, and the patients I should really be serving,” recalled Dr Rajesh Bhadoria.  

Dr Rajesh is the officer in charge at the District Drug Warehouse (DDW) in Badi, Udaipur. He oversees the flag bearer DDW branch of Rajasthan’s free medicine scheme in the region. For the last five years, he and his team have been making sure that benefits of the free medicine scheme reach the people of Udaipur fully. The DDW is located about fifteen kilometers away from the main city of Udaipur, laced with vast and fresh water lakes of Fateh Sagar and Pichola along the way.

Udaipur is the major city of Rajasthan named after Maharana Udai Singh of the Sisodia clan. The city of Udaipur spreads over an area of 37 square kilometers, located in the southern part of Rajasthan. Udaipur lies in midst of  the Aravalli hills and is home to the beautiful lakes with tiny islands over it. No wonder why it's one of the exciting tourist sites in Rajasthan. However, recently Udaipur has been making headlines for providing its people access to free health care.

Dr. Rajesh is one of the thousands of medical professionals involved in making the Mukyamatri Nishulk Dawa Yojana(MNDY) in Rajasthan operate.  MNDY, launched in October 2011, is the state’s free medicine scheme, providing free, generic medicines to all of its population, especially those in the clutches of extreme poverty and those marred by ill health. To implement this program Udaipur relies on 240 doctors, 122 nurses, 916 ANMs and 2381 ASHAs. Team Udaipur was awarded number one in Rajasthan for successful implementation of MNDY in 2012. Its performance can be credited to several factors like dedicated staff, effective communication between District Project Coordinator and field staff. Having strong Monitoring and supportive supervision helps them to get regular feedback from the field .For checks and balances they hold monthly review meeting of Doctors,ANMs and ASHAs. Udaipur has developed a feedback app for the patients where the patients can give their feedback. Long standing queues of patients at Drug Distribution Counters in government hospitals and vacant private medical stores with an idle pharmacist sitting over the counter across Udaipur, are two most visible impacts of the scheme.

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This would have not been possible without committed health workers on the ground, the frontline of the scheme, such as those with ASHA (Accredited social health activist) and the Auxiliary Nurse Midwives (ANM). ASHAs are the trained, community female health activists who are the interface between the community and the public health system. They mobilize people in the villages to practice healthy life practices. ANMs are appointed by the government to help communities achieve the targets of National health programmes. They work at PHCs (Primary Health Centre) and CHCs (Community Health Centre). Talking to ANMs one finds out that this scheme has reached people, however, they say people often complain that they are being asked for identity proof like Adhaar cards to avail government services ,which proves to be a hindrance in accessing the scheme.

ANM Usha Goel’s job is to tell people about various health issues and government scheme, she says "MNDY has been able to bridge the trust deficit between health workers and community. Initially when we used to tell them about some schemes, they wouldn’t trust them but after MNDY and its considerable access people have started showing faith on them .For pregnant women the scheme is very helpful, we make sure that they visit health centers at regular intervals and avail free medicine and checkups at CHCs and PHCs."

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To have the free medicine scheme really operate, there were a number of challenges to overcome, including doctors’ preferences for branded medicines along with their relationships with the pharmaceutical companies, which challenges medical societies globally. While the scheme was still incubating, it witnessed significant resistance from the doctors. Most doctors had doubts that this ambitious scheme of providing free medicine would work; many saw it as a waste of public funds. It has been almost five years since the scheme has been functional; now the tables have turned and the doctors are at the frontlines of implementation and execution.

"Medical students cannot be taught about all public heath care schemes, thus when resident doctors start practicing at the Medical College, they are inducted on the  programme for functioning of MNDY and the importance of making free and quality healthcare available to its people," says Dr Sanjeev Kumar Tak ,Chief Medical and Health Officer, Udaipur.

In India, between 1995 and 2014, public expenditure on health care saw a minuscule rise from 1.1 percent to 1.4 percent. India continues to rank low in the social development indicators because people are dying due to dearth of quality health care. In the induction , resident doctors are also exposed to the social conditions in which they will be working.

New doctors or residents are inducted  on the scheme, its mechanics as well as its purpose and goals. Because medicines are most often prescribed by resident doctors in the medical college hospitals, it is important that they are well informed about both the free medicine scheme and about prescribing generic or non-branded medicines.  Many doctors still hold the bias that non-branded drugs are of poor quality or less effective than their branded counterparts.  

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A young resident doctor, Dr Mahesh, at MB Medical College said, "Initially, when I joined I did not know the importance and the need for the scheme. In college, we were so engrossed in studies and badly wanted to succeed in life and make money. But when I started practicing here at the medical college, I was moved by the poverty of the patients. People in torn clothes with feeble bodies made me realize ,in life success is just not being at the top, but serving the poor and the helpless. I do not prescribe branded medicines to the poor. I always make sure prescriptions that I write for my patients have generic medicines name, signed under my name.”

Many women in modern India still  remain in  the veils and so do their health care. They are least likely to visit the  hospitals and most likely to die without accessing proper public health care. Women have been carrying the burden of patriarchy on their bodies for a long . Free Medicine scheme has proved boon for women in Udaipur. Earlier, women who did not come to the hospitals fearing that their health will cost fortunes to the family, now very confidently enter the premises of the hospitals. One of the satellite hospitals in Udaipur has separate Drug Distribution Counter (DDC) to make it less inconvenient for women to stand in queues for their turns.

"I have come to get my delivery done ", says Shabana at labour ward in Janana Hospital, MB, Medical College who was here to deliver her second child "I am content with the facilities and free medicines they provide at the hospital. Seven years ago when I delivered my first child, things were not as easy as they are now, we had to be on our toes, if we wanted services from hospitals ,but now medicines and services are accessible in the public hospitals."

Doctors in Udaipur practice what they preach.

Last year, Dr Bhadoria's son acquired dengue fever. His situation was critical and everyone (friends, relatives, including his colleagues in hospital) recommended that he take him to a private hospital in one of the big cities. However, his faith in the public healthcare system remained unshaken. "I wanted my son to be treated in the public hospital only; his platelets were 9000 far less than required in the patient suffering from dengue. Time and again people would tell me that I was expecting too much from the system and I might have to pay the price for it. But somewhere in my heart I knew my son would be alright. At last when he was cured, my faith in public health care system was restored. I have tried setting an example for others to please trust the public healthcare system."

Sitting in one of the meetings, at the Medical College, Dr Sanjeev Kumar Tak, mentions the Hippocratic Oath. This Oath is the rite that physicians across several countries take before they enter the profession; it is a code of ethics that they need to abide by while in serving. “Through the free medicine scheme, this is what we are doing. The average Indian cannot afford to visit a private clinic.”

Challenges at outskirts of cities

Kherwara is an 80 km drive away from Udaipur. The region is dotted with terrace farms and widely-spaced houses in the Aravalli hills .Agriculture and self-employment are the main occupations of the residents of this region. Because of Improved infrastructure and its connectivity with National Highway, the PHC in the area gets a lot of cases of accidents and casualties. Roadside hotels have also lead to sex trade which has resulted in area witnessing rise HIV infection and STDs. The region faces acute shortage of doctors and the other medical staff. Most doctors are reluctant to work here, as the region has, least to offer to doctors in terms of personal growth. However, there are doctors who despite challenges in the region are serving the poorest of the poor.

Mr. Arun Meena, a Medical officer at the PHC Sulai, said that the tribal patients around the region earlier did not visit the hospitals and instead would go to faith healers to receive their medication. Due to the low literacy levels in the area; some considered illness to be an act of god.  But now they know that they can get free medicine thus they come to hospitals, especially women. Radio shows, ASHAs, ANMs and public advertisement have helped in disseminating the information about the MNDY and creating awareness regarding the scheme. This scheme has not just worked as free medicine provider, but it has brought change in the attitudes and in the thinking of community as well. Though it took some time for doctors to gain trust of the community, but once the people realized that the generic medicines provided under the scheme are effective, people frequently started visiting the hospitals. 

"Once a faith healer arrived at Community health centre as a patient suffering from diarrhea .He heard about the hospital through one of his patients who recommended that he see a doctor if he was unable to cure himself through his healing tactics." said Dr Arun Meena.

Doctor said that he himself comes from the tribal community, and has seen his community caught in the web of blind faith and suffering due  lack of awareness .He says "Twenty five years ago, people did not go to see the doctors and did not even have access to basic health care. Free medicine, this way has helped a community to get rid of the regressive custom of faith healing to a great extent."

As a medical officer, Mr. Arun's skill is not just to treat patients and give them medicines but beyond. He sees himself in a greater role as a doctor. He always asks his patients about their backgrounds, which community they belong to, and how their community is aware of the free medicine scheme. He ends his brief conversation by saying "Medicines are effective in the short run, but awareness of health options will help well into the future."

First line of defense 
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In between the CHC to the nearest tertiary healthcare centre located in the heart of Jaipur, the smaller PHC also offers another layer of healthcare provision. Dr Lakshita Jain, who is Medical Officer Incharge at Primary Health Centre in Khandi Ovari, says "I joined the service in December 2011. MNDY was launched in October 2011, the word had not spread of what the scheme was, yet and there were frequently open appointments. However, gradually people started coming to the centers. People were initially reluctant, thinking that beyond visiting the hospital they would have to travel a greater distance still to get their medicines. Now that the medicines are available at the hospital’s doorstep, patients are lining up to visit the clinics. Within three to four months of his posting, there was a tenfold increase in daily patients; from 10-20 to 100.This has been especially beneficial for children and mothers.

Aju Devi, working at Community Health Centre Khewada, says,“As an ASHA worker, our job is to travel door to door in a community and find people who need medication, if we have some medicines available, I can give then to them. Had it not been for MNDY we wouldn’t have able to give them free medicines."

Often in cases of emergency, Doctors in order ensure that the instant medication is available to patients ,avoid getting caught in the paper work, which they do later after the help has been made .Dr Sanjeev Tak from Maharana Bhupal Medical College, says, “In cases of emergency, we send medicines without doing paper work. The last time we did that was when we had snake bite cases in the area, we believe service comes first. If someone does not want to work, one can quote any rule and get way with the work. We make sure rules do not come in between in our service. Also we do not keep phones on silent, so that we do not miss a call from somebody who really needs us."

Going beyond the distance

Some doctors in Udaipur give free consultations at their homes as well, during evening hours and on Sundays. They do it because of the willingness to serve as much patients as they can. The long line of waiting patients at Dr Rajesh’s free clinic at his old residence says a lot about how patients trust Dr Rajesh. According to his patients, he has been at the same clinic around the same time for last thirty years without traces of frustration or fatigue.  Dr Rajesh works with minimum resources. He has a hand bell that he rings to indicate patients’ turns and his prescription paper is made up of old calendars.

Women sweeper in her mid fifties arrives at the clinic. Her face is pale and body looks tired, she is here to get a prescription for her backache caused by carrying cart on her back. Another woman is there to get medicine prescribed by doctor for her husband who works in Kuwait. For his free clinic, Dr. Rajesh sent a proposal to the government asking to be allowed to have generic drugs to distribute to his patients so they do not have to go to the private medical stores. He has not succeeded in this effort as yet.

The same zeal is found in Dr Renu Khamesra , who is a Neurology  Specialist at Maharana Bhupan Hospital, she runs a free clinic at her home on Sundays from 5:30am to 6:00pm.Doctor Renu is a cancer survivor and she understands the helplessness of a human being who is struggling with the life. She says, “My own suffering made me more empathetic towards the suffering of others.”

Coping with expectations

When asked whether free medicine scheme has increased the workload of the doctors, Dr Radha Rastogi, Professor, Gynecology Department at Mahrana Bhuwan Medical College laughed and said, "Yes, the workload has increased as patients have increased at OPD (Outpatient Department). But this has also made things less hectic for us in the sense that we need not go to people again and again to tell about schemes. People come here and, along with medicines, they get to know about various schemes, which help us in achieving the targets."

The free medicine scheme has brought a lot of positives to the lives of doctors, but at the same time it has posed challenges for them, as there is a shortage of doctors in health centers across Rajasthan. Dr Radha Rastogi sums up the challenges a doctor faces with the success of the free medicine scheme in Udaipur, "Patients have started coming to hospitals in enormous numbers, and we are still not able to meet the standards of doctors-patients ratio at our hospitals."

She is disheartened by the fact that people come to hospitals with expectation of 100 percent results, people think doctors are god, but at the end of the day we are humans who commit errors, we try our level best to give best services. Often, the court gives discouraging judgments against doctors that some doctors take themselves back from taking bigger responsibilities in future.”

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Another cause of worry for Dr Radha Rastogi is that the people in the tribal areas have still not benefited fully from the scheme. The fact that home deliveries still happen there means that the communication is not happening at the grassroots level.

Dr Poonam Dharolia ,an HIV Counselor at Integrated Counseling and Testing Centre in a satellite hospital says, “Though the job has become hectic ,whenever I see HIV negative reports of my patients all my tiredness fades away .Happiness cannot be explained when we are able to save newborn from infected mother."

“Weekend breaks,” she says "are necessary to maintain personal health, as throughout the week we deal with lots pressure and depressing stories of patients. To be able to counsel patients better,  well being of a doctor is very necessary."

As the evening falls and the sun sets in the sky, Dr Rajesh moves towards his motorbike with brown bag in one hand and helmet in another to drive from home to his clinic. Dr Rajesh, while passing by one of Udaipur’s larger lakes, says, "Last time, I was here with my wife when we just had our first child. Ever since then, I have just passed by Fateh Sagar Lake but did not stop to cherish the view. My family often complains that I am not able to give time to them, but I have told them as a doctor I cannot afford to enjoy life at the peril of my patients.”

The story was produced as part of The Program for Narrative and Documentary Practice,Tufts University,to five human face to the Free Medicine Scheme of Raja than Government.(The website for the project is in making)