A small three-room delivery centre nestles amidst tall pine trees at a Maternal and Child Health Care facility. It is part of a primary health centre located in the picturesque hilly terrain of Pathisain village in the Pauri Garhwal district of Uttarakhand.
It is an uneven climb. And until a few years ago, for most women who managed the short trek to the centre, it was a depressing facility to visit. Bare walls stared back, there was hardly any equipment to assess their condition, nursing positions were vacant, and often, an Auxiliary Nurse Midwife (ANM) delivered the baby with an accompanying ASHA worker.
It is not surprising that women came here only to deliver their children. They neither availed prenatal services nor critical post-delivery care for 48 hours, both of which required them to be in the facility. Since they could not afford private hospitals or nursing homes or make it on time to the district health centre farther away, they were forced to come to the Pathisain centre, before returning home to recover.
“I am here to stay”: Brave words by a young medical graduate
In 2013, Medical-Officer-in-Charge, Arti Behl, came to Pathisain after completing her MBBS from the Government Medical College in Haldwani, Uttarakhand. She had signed the bond that mandated her to serve five years in a rural area.
Arti Behl was shocked.
She had not thought that “hill service”, even in a remote area, would be so challenging. Apart from infrastructure issues, she had to battle hostility from the locals who felt she was from the plains and could not understand their issues.
There were long-serving staff members who were used to leading an inactive, uninvolved life. They did not stretch themselves to be change agents or even provide basic services. Taking money under the table for providing medicines was not uncommon.
The local population was disgruntled and at every meeting at the sub-district level, ward and panchayat members openly criticised the dismal conditions at the Pathisain centre.
The most humiliating experiences related to how influential persons in the area expected and demanded services that were clearly outside the purview of a government Medical Officer. Or the countless times Dr Arti Behl was threatened to make medical certificates which were untrue.
Apart from work issues, what took her completely by surprise was the condition of the old living quarters. The ceiling was broken and the house had not been renovated for decades. There were bats, spiders, mammoth country lizards in the house and leopards in its vicinity. Living alone and later through her pregnancy, she would be frightened to go to the kitchen or bathroom at night, both of which were in an open yard outside the main house. She was even scared to speak on the phone or make any noise, lest she invite the ire of her co-inhabitants.
At the health centre, her youthful idealism received a shock when she realised that all essential safety norms were missing. Basic things like gumboots and gloves were in short supply, with there being no urgency to procure them. Aseptic measures, hand washing and hygiene standards were abysmally low. Deliveries were happening in an environment where there was no quality care.
When she tried to change things, she found resistance. The staff was not used to working, and any demand from her meant more work. Her tendency to spot malpractices created greater antagonism.
Although people around the area had accepted the conditions, they continued to visit the centre since they had no other option.
Arti was committed to changing these conditions since it was possible to address things and improve them at her level.
Once the old staff retired, she hired Priyanka Saini, a new staff nurse, and Sanjay Baunthiyal, the pharmacist. Slowly, the culture of the PHC began to change. The new staff was resolved to win back the confidence of the people.
“Earlier, hours after childbirth, the new mother insisted on returning home since even safe drinking water was unavailable. Now, they stay the mandatory 48 hours to avail postnatal services. They walk in more confidently, secure in the knowledge they will be cared for. Local ANM and ASHA workers are more motivated knowing they have our support,” says Sanjay.
A few years into the service, Arti felt let down when a majority of the staff left, quitting before the five-year bond ended, without even paying the penalty.
Her resolve became stronger—to not seek a transfer but stay on the premises, in the government accommodation allotted to her and manage a long-distance relationship with her husband who worked in an IT company in Noida.
Once they decided that she was going to be around, it was easier for her to bond with the community through informal counselling sessions and simple check-ups that did not need extensive equipment.
As their trust and confidence in her grew, so did services and infrastructure. Arti knew no miracles would happen and that progress would be gradual but what could change immediately was hygiene standards, a cheerful ambience, smiling faces and caring staff. She was determined to make that happen.
Surmounting odds with a quiet determination
She started by cleaning the three-room facility. From a long forgotten store whose lock had rusted, emerged tonnes of syringes, gloves, sutures and medicine stocks that needed to be checked and verified before use.
She freed up space, made requisitions for new supplies, and requested for filling vacancies of nurses, ANMs and attendants.
Next, she put in requests and followed them up with visits to the Chief Medical Officer at the district level to get sanctions for room heaters, geysers, ROs, overhead lights on the operating table, autoclave, labour tables, newborn care units, all-weather ACs, supplies of life-saving Oxytocin, IFA and calcium supplements, and medical supplies like gumboots and antiseptic solutions.
This was not easy since Pathisain had, for too long, been a faint dot on the Uttarakhand public health service map. Even though 12-15 pregnant women came in every month, it was quite insignificant in the larger scheme of things.
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Every little achievement was a victory. They got staff nurses and ANMs to assist them in providing personalised care to pregnant women.
“We try to evaluate pregnancy-related complications beforehand. The area has a high level of anaemia. The lack of adequate supplements of IFA and calcium at the facility meant that women tended to skip these. But now, we make sure that supplies are restored, and there is a flexible system which allows them to receive stocks through relatives and ASHA workers. Something as innocuous as this was not done, denying women essential nutrients during pregnancy,” she says.
Before 2013, only one in ten women received their complete antenatal care (ANC). But by the end of 2018, all pregnant women in this small hill town completed all six ANCs even if they choose not to deliver their baby at the centre.
“Complicated pregnancies are identified in time; procedural updates are carried out systematicall; partographs are maintained to help identify the moment a pregnant woman is likely to go into an obstetric complication. Earlier, in the case of any complications, patients were referred to the district hospital, which is now managed by us right here,” says Priyanka, proudly.
These measures ensure underweight babies receive full immunisation and better care. Adolescent girls are guided on nutrition much before they get married and counselled on family planning. Families are made aware of issues like stunting and wasting of newborns and infants, which is common in the area.
All this is possible since there is a 24X7 medical doctor who stays on the premises and is more than willing to look into their problems and be there for them. Dr Arti has indeed broken the culture of this government health centre.
Her biggest achievement came last year when she convinced the Chief Medical Officer to prioritise the renovation of the facility as part of the district action plan with new electrical rewiring and installation of pipelines.
She supervised the renovation of the medical facility as well as the living quarters, changing them beyond recognition.
She concludes, “My experience has shown me that the government lacks nothing. We have access to funds, resources and support. We just need the will, commitment and perseverance to make our facilities as good as any private establishment. We do not have to accept rundown, badly maintained, and depressing settings. I am happy about what we could achieve in Pathisain and I am confident that when I leave after 3-4 years, this will continue since our staff is now self-motivated.”
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On any given day, her four-year-old daughter can be found playing outside even as her husband shuttles between Delhi and Pathisain, backing his wife’s decision, taking pride in her contribution to the community.
(Written by Taru Bahl and Edited by Shruti Singhal)