Downloaded by [University of Defence] at 01:14 24 May 2016 Health Providers in India Downloaded by [University of Defence] at 01:14 24 May 2016 (ii) Blank Downloaded by [University of Defence] at 01:14 24 May 2016 Health Providers in India On the Frontlines of Change Editors Kabir Sheikh and Asha George Downloaded by [University of Defence] at 01:14 24 May 2016 First published 2010 By Routledge 912–915 Tolstoy House, 15–17 Tolstoy Marg, New Delhi 110 001 Simultaneously published in UK by Routledge 2 Park Square, Milton Park, Abingdon, OX14 4RN Routledge is an imprint of the Taylor & Francis Group, an informa business © 2010 Kabir Sheikh and Asha George Typeset by Bukprint India B-180A Guru Nanak Pura, Laxmi Nagar, Delhi 110 092 Printed and bound in India by Sanat Printers 312 EPIP Kundli, Haryana 131 028 All rights reserved. No part of this book may be reproduced or utilised in any form or by any electronic, mechanical or other means, now known or hereafter invented, including photocopying and recording, or in any information storage and retrieval system without permission in writing from the publishers. Downloaded by [University of Defence] at 01:14 24 May 2016 British Library Cataloging-in-Publication Data A catalogue record of this book is available from the British Library ISBN: 978-0-415-57977-3 Advance Praise for the Book This excellent collection of new work begins to fill a major gap in our understanding of key features of the Indian health system: Who fill its positions, formal and informal, public and private sector, trained and untrained? What are their motivations, their ideals, and the everyday realities of their experiences? And how do these accommodate to, coalesce with, or conflict with major national health goals? Sheikh and George are to be congratulated for their initiative in stimulating contributors to such a well- constructed volume — one that will undoubtedly set the agenda for health-related policy-relevant research in India over the next decade. Roger Jeffrey University of Edinburgh This book meets a sorely felt need in health research in India. By opening up new discussion on the diverse health providers in the country, it performs a signal service to both research and policy. Both have tended heretofore to treat the concerns and realities of health providers as either obvious or peripheral. This book bids fair to change all that, with its nuanced and rich analysis of doctors, nurses, midwives, and traditional and home- based care-givers. In addressing critical issues of needs, responsibilities, supervision and regulation at different levels, the book breaks new ground in fresh and interesting ways that Downloaded by [University of Defence] at 01:14 24 May 2016 will be of interest to researchers, policy makers and health activists alike. Gita Sen Indian Institute of Management (IIM), Bangalore vi Advance Praise for the Book Sheikh and George have brought together a remarkable collection of perspectives on frontline health care providers in India, offering a glimpse into much neglected social, political, and cultural dimensions and determinants of their roles and practices. This book is a must-read for policymakers who are conscious of the human dimensions at the core of a responsive health care system, and for health and social science researchers, practitioners and activists seeking a sensitization to interdisciplinary and ‘grounded’ scholarship, with the empathetic outlook required to address India’s complex health policy imperatives. Ravi Narayan Centre for Public Health and Equity, Bangalore This in-depth examination of India’s health providers places centre stage those who are often either ignored or just seen as a problem. Yet understanding how health providers both shape patient experience of health care and the translation of policies in practice, is critical in any effort to improve the overall performance of a health system. This volume, thus, presents rich insights for India’s health policy makers — and should also stimulate policy makers and managers working in other settings. Whilst the specifics may differ, the point that health providers are central actors in any health system whose actions influence what is achieved through it, is of universal relevance. It will be an important resource for researchers and teachers in this field. Lucy Gilson University of Cape Town & London School of Hygiene and Tropical Medicine Downloaded by [University of Defence] at 01:14 24 May 2016 To Nilima and Gulammohammed Sheikh Sushila and George Downloaded by [University of Defence] at 01:14 24 May 2016 (viii) Blank Downloaded by [University of Defence] at 01:14 24 May 2016 Contents List of Figures xi List of Tables xiii Preface and Acknowledgements xv List of Abbreviations xvii Introduction. India’s Health Providers — Diverse 1 Frontiers, Disparate Fortunes Kabir Sheikh and Asha George PART I. GOVERNMENT HEALTH WORKERS: UNEASY AT THE BOTTOM Chapter 1. Government Rural Health Assistants 15 as Social Beings Asha George Chapter 2. The Midwifery Role of the Auxiliary 38 Nurse Midwife Dileep Mavalankar, Kranti Vora and Bharati Sharma Chapter 3. Dilemmas and Conflicts of HIV 57 Counsellors in VCTCs Akhila Vasan and Jayashree Ramakrishna PART II. DOCTORS: VEXED RELATIONSHIP Downloaded by [University of Defence] at 01:14 24 May 2016 WITH THE PUBLIC GOOD Chapter 4. Public Sector Doctors in an 81 Era of Commercialisation Rama V Baru Chapter 5. Working with Private Practitioners 97 on a Public Health Intervention Risha Hess, Saswati Sinha and Pritpal Marjara x Contents Chapter 6. Understanding Practitioners' Responses 119 to National Policy Guidelines Kabir Sheikh and John DH Porter Chapter 7. The Dynamics of Medicos' 142 Anti-Reservation Protests of 2006 V Venkatesan PART III. TRADITIONAL AND HOME CARE PROVIDERS: THE EDGE OF LEGITIMACY Chapter 8. The Community Role of 161 Indigenous Healers Madhura Lohokare and Bhargavi V Davar Chapter 9. Traditional Orthopaedic Practitioners' 182 Place in Contemporary Health Unnikrishnan PM, Lokesh Kumar HP and Darshan Shankar Chapter 10: The Critical Role of Family Care 200 Providers in HIV/AIDS Shilpa Karvande, Vidula Purohit, Karina Kielmann, Rajendra Kale and Sheela Rangan PART IV: ADAPTING, TRANSFORMING: PERSONAL EXPERIENCE IN PROFESSIONAL SPACES Chapter 11: Sexual Harassment of Women 223 Health Workers Paramita Chaudhuri Chapter 12: Gender and Health Training of 242 Downloaded by [University of Defence] at 01:14 24 May 2016 Male Multipurpose Workers Anagha Pradhan, Renu Khanna and Korrie de Koning Poems 259 Gieve Patel Notes on Editors 264 Notes on Contributors 266 Index 275 List of Figures 2.1 Increase in PHCs and sub-centres in India from 1952–2004 40 3.1 VCT and its links with other services 59 3.2 Pre-test and post-test counselling 60 3.3 Educational qualification (masters and bachelors degrees) of counsellors in the study 64 5.1 Facsimile of Key Clinics brochure 104 6.1 The appreciative mix: explanations of practitioners’ divergent actions 136 10.1 Dimensions of family care 207 10.2 PLHIVs’ health status ‘pyramid’ 208 Downloaded by [University of Defence] at 01:14 24 May 2016 (xii) Blank Downloaded by [University of Defence] at 01:14 24 May 2016 List of Tables 1.1 Designation of field level auxiliary health staff by gender and seniority 17 1.2 Current district level government health service structure 18 2.1 Health infrastructure in a typical Indian district 39 2.2 Primary health services in one district of Gujarat — Then and Now 41 2.3 Maternal health services and the contribution of ANMs, India 42 2.4 Time allocated to maternal health and midwifery in the new ANM syllabus 45 3.1 Counsellors' experience and credentials in HIV/AIDS 65 5.1 Comparison of practitioners' Quality of Care indicators over time 110 5.2 Comparison of Quality of Care indicators between Key Clinics and non-Key Clinics 111 6.1 Study participants by hospital type and speciality 122 6.2 Thematic framework of analysis 124 8.1 Indigenous healing centres studied in Maharashtra 163 8.2 Types of healers and their characteristics 164 8.3 Characteristics of a good healer — healers' perspectives 172 Downloaded by [University of Defence] at 01:14 24 May 2016 9.1 Traditional orthopaedic practitioners in Tamil Nadu, by specialisation 188 9.2 Traditional orthopaedic practitioners — generational lineages 189 9.3 The healers categorised by age group 190 9.4 Clinical documentation of five traditional orthopaedic centres 192 10.1 PLHIV and their family care providers who participated in the study 207 (xiv) Blank Downloaded by [University of Defence] at 01:14 24 May 2016 Preface and Acknowledgements This project originated in 2006, the result of the collaborative efforts of the two editors. As doctoral scholars examining issues around health systems and health care provision in India, we observed that the treatment of frontline health providers in the available literature was insufficient, both in terms of volume and thematic breadth. The state of scholarship — fragmented, often poorly supported by empirical research, and sometimes marked by excessive abstraction and dogmatic suppositions — compared unfavourably with literature on health providers in developed nations, a profusion of learned books and articles addressing an array of sociological, political and economic issues from diverse disciplinary lenses and perspectives. We recognised a need to consolidate knowledge in this area, and conceptualised this project. Over an absorbing three-year period, we sought out potential collaborators, invited and reviewed more than 40 abstracts and chapter ideas, and worked closely with the eventual selection of authors to develop their contributions into the versions that are presented in this volume. The chapters were all written expressly for this book, and each represents a different, distinctively Indian set of experiences, perspectives and phenomena. We hope that this collection helps bridge some of the gaps that sparked our Downloaded by [University of Defence] at 01:14 24 May 2016 scholarly interest.