Fact-Finding Report on Maternal Health in the Government Health Sector

Thursday 9th August, Saturday 11th August, Tuesday 14th August

Table of Contents:

Introduction

Relevant Constitutional Protections and Government Schemes

Data from The Fact-Finding

Main Areas of Concern and Suggested Improvements

Introduction:

Inadequate maternal health care is a serious problem throughout . Indicators such as the maternal mortality rate (MMR), infant mortality rate (IMR), malnutrition, limited access to contraception, low levels of safe institutional delivery and the unavailability of adequate healthcare all contribute to poor maternal health.

Government data from 2004 – 2006 and 2007 – 2009 shows that in particular has consistently had the second worst MMR in India.1 The current MMR is 212 deaths per 100,000 live births; the country’s millennium development goal is 109 per 100,000 live births by 2015. 2 The MMR is measured using the number of women aged 14-59 who die from pregnancy related causes out of every 100,000 live births. Uttar Pradesh has a comparatively low percentage of institutional deliveries (22%)

1 http://censusindia.gov.in/vital_statistics/SRS_Bulletins/MMR_release_070711.pdf 2 http://zeenews.india.com/news/health/exclusive/a-maternal-death-every-10-mins-in-india-un_17710.html compared to the Indian average of 41% and Kerala and Goa’s 100% and 93% respectively3, thus 78% of women are delivering outside hospitals in Uttar Pradesh.

Uttar Pradesh’s IMR is equally high compared to the rest of India. According to an India Current Affairs Survey, Uttar Pradesh had the second worst IMR with scores of 53 (2006), 51(2007) and 49 (2008) compared to Kerala’s scores of 12, 10 and 10 respectively4. The IMR is measured using the number of children under one year who die per 100,000 children. The current IMR is 50 deaths per 100,000 and the millennium development goal for India’s IMR is 28 per 100,000. The Ministry of Women and Child Development (MWCD) and World Bank formed a mapping study and created a “worst 200” list for districts in India regarding malnutrition. The researchers used the haemoglobin level of pregnant women and the weight/age ratio of children as their parameters for measuring malnutrition. Uttar Pradesh had 11 more high risk districts than any other state in India5. Inadequate access to quality, acceptable health care perpetuates these high levels of maternal mortality, infant mortality, and malnourishment.

Ghaziabad District in particular is renowned for poor hospital conditions and substandard maternal healthcare. As of 2011 it is the third most populous district of Uttar Pradesh (out of 71), after Allahabad and Moradabad6. The district has a population density of 3,967 inhabitants per square kilometre (10,270 /sq mi)7.

In addition to a large population, Ghaziabad District also has a high IMR and under five mortality rate. The IMR is 53, which is high compared to other districts, for example, the , which has an IMR of 42. The time trend of infant mortality showed that the infant mortality rate is likely to be 46 per 1,000 live births for the year 2015. However, the goal is to bring down the IMR to below 27 for the year 2015 under the MDG8. Ghaziabad’s under five mortality rate is also high at 66. This is the probability (expressed as a rate per 1,000 births) of a

3 www.nfhsindia.org 4 http://indiacurrentaffairs.org/infant-mortality-rate-in-india/) 5 http://wcd.nic.in/icds-worldbank/TOOLBOOK.pdf 6 "District Census 2011". Census2011.co.in. 2011. Retrieved 2011-09-30. 7 "District Census 2011". Census2011.co.in. 2011. Retrieved 2011-09-30. 8 http://www.iipsindia.org/pdf/a08mohanty_report.pdf child born in a specified year dying before reaching the age of five9. Clearly the government health system in Ghaziabad District is not providing adequate healthcare for the population.

HRLN therefore sent a fact-finding team to investigate the maternal health problems in the government health sector in Ghaziabad District. From what the fact-finding team could discover, Ghaziabad has 2 District Hospitals called MMG (Jassipura, Naya Ganj, Ghaziabad) and Sanjay Nagar (Sector 23, H Block) both of which are located in the city of Ghaziabad itself.

The District also has four Primary Health Centres (PHCs) but despite extensive searching the fact-finding team could only discover the locations of two of them in Loni and Dasna. The fact-finding team found the location of the seven Community Health Centres (CHCs) however which are in Mohanagar, Dasua, Garh, Hapur, , etc. There are also nine Health Posts including Sashtrinagar Karte, Nandgram, Vinjay Nagal, Shahibabad, St. Mary School, Dabur, Sanjay Nagar and Hapar Chugnee. However, this information was very hard to find. The fact-finding team were solely dependent on directions from people that worked in the public health sector as the only addresses readily available on the internet are those of MMG and Sanjay Nagar.

The fact-finding team wanted to visit a wide range of government facilities to get a complete picture of the maternal healthcare available in Ghaziabad. We visited the two District Hospitals, MMG and Sanjay Nagar, Loni PHC, Dasna CHC, Murad Nagar CHC, Modi Nagar CHC and two health posts, Sanjay Nagar and Dabur.

Ultimately, the team found that problems like the maternal and infant mortality and malnutrition are extensive in Ghaziabad because of a multitude of flaws in the corrupt government health system. For example, in just three days, the team observed major issues including lack of electricity, poor and sparse contraceptive advice and procedures, inadequate ante- and post-natal care, wide disregard for sanitation, unavailable transportation and non-reception of government cash incentives.

9 http://mdgs.un.org/unsd/mdg/Metadata.aspx?IndicatorId=0&SeriesId=561 Relevant Constitutional Protections and Government Schemes:

Article 21 of the Constitution of India guarantees a right to life. The Supreme Court of India has interpreted Article 21 to include the right to adequate medical facilities for preserving human life (Paschim Banga Khet Mazdoor Samity & Ors. v State of West Bengal & Anr, AIR 1996 SC 2426).

In this case, the Supreme Court ruled that:

(a) Article 14 – Equity before the Law: The state shall not deny to any person equality before the Law or the equal protection before the Law within the territory of India.

(b) Article 15- Prohibition of Discrimination on grounds of religion race caste, sex, place of birth or any of them. : Nothing in this Article shall prevent the state for making any special provision for women and children.

International law also includes protections for the right to health. The Convention on the Rights of Child, the International Covenant on Economic, Social and Cultural Rights (ICESCR), the International Convention of Civil and Political Rights (ICCPR), and the Convention for the Elimination of all forms of Discrimination Against Women obligate the Government of India to ensure accessible, acceptable, adequate, quality health care to all women and children.

The Government of India has introduced various schemes to improve health care. For example, the Integrated Child Development Scheme (ICDS) provides three essential services for children from age 0 – 6: immunization, health check-ups, and referral. The Government provides these services through Health Sub Centres, PHCs and CHCs under the direction of the Ministry of Health & Family Welfare.

The Government has implemented a three-tier set up for delivering health services to the Indian population. The first point of contact is a sub-centre, followed by a Primary Health Centre (PHC), and finally a Community Health Centre (CHC).

According to the Indian Public Health Standards (IPHS) for Sub-centres, the success of any nationwide program especially related to public health would depend largely on well functioning, acceptable sub- centres, as sub-centres are the first contact point with the community. Sub-centres are designed to provide promotional, preventative, and limited curative services to the immediate community. As per population norms, each Sub-centre should serve a population of 3,000 to 5,000 people. Each sub-centre will have a referral PHC that will provide care for a total population of 20,000 to 30,000 people. Finally, several PHCs will feed into a CHC that will cover 80,000 to 1,20,000 people.

IPHS have provided the minimum requirements (Assured Services) that the Sub-centre should provide:

15.1 Maternal and Child Health:

Antenatal care:

Early registration of all pregnancies, ideally within first trimester (before 12th week of pregnancy). However even if a woman comes late in her pregnancy for registration, she should be registered and care given to her according to gestational age.

Minimum three antenatal check-ups: First visit to the antenatal clinic as soon as pregnancy is suspected/between the 4th and 6th month (before 26 weeks), 2nd visit at 8th month (around 32 weeks) and 3rd visit at 9th month (around 36 weeks)

Associated services like general examination such as height, weight, blood pressure, anaemia, abdominal examination, breast examination, Folic Acid Supplementation in first trimester, Iron & Folic Acid Supplementation from 12 weeks, injection of tetanus toxoid, treatment of anaemia etc., (as per the Guidelines for Antenatal care and Skilled Attendance at Birth by ANMs and LHVs)

Minimum laboratory investigations like haemoglobin estimation, urine for albumin and sugar, and referral to PHC for blood grouping. Identification of high-risk pregnancies and appropriate and prompt referral.

Counselling on diet & rest, pre birth preparedness and complication readiness, delivery kit for home deliveries, danger signs, infant & young child feeding, initiation of breast feeding, exclusive breast feeding for 6 months, demand feeding, supplementary feeding (weaning and starting semi solid and solid food) at 6 months, contraception, advice on institutional deliveries, clean and safe delivery at home, postnatal care & hygiene, nutrition, care of new born and registration of birth.

Intra-natal care:

 Promotion of institutional deliveries  Skilled attendance at home deliveries when called for  Appropriate and prompt referral

(iii) Postnatal care:

A minimum of 2 postpartum home visits, first within 48 hours of delivery, 2nd within 7 to 10 days.

Initiation of early breast-feeding within half-hour of birth

Counselling on diet & rest, hygiene, contraception, essential new born care, infant and young child feeding. (As per Guidelines of GOI on Essential newborn care) and STI/RTI and HIV/AIDS

(iv) Others:

Provision of untied fund to the Sub-centres (currently Rs.10,000 per Subcentre is provided under NRHM) for facilitating the service management at the Sub-Centre.

Provision of facilities under Janani Suraksha Yojana (JSY):

15.2 Child Health: Essential Newborn Care (maintain the body temperature and prevent hypothermia, maintain the airway and breathing, the baby should be breastfed by the mother within half-an-hour, take care of the cord, and take care of the eyes, as per the guidelines for Ante-Natal Care and Skilled Attendance at Birth by ANMs and LHVs.)

Promotion of exclusive breast-feeding for 6 months. Full Immunization of all infants and children against vaccine preventable diseases as per guidelines of GoI.

Vitamin A prophylaxis to the children as per guidelines.

Prevention and control of childhood diseases like malnutrition, infections, ARI, Diarrhea, Fever, etc.

15.3 Family Planning and Contraception

Education, Motivation and counseling to adopt appropriate Family planning methods.

Provision of contraceptives such as condoms, oral pills, emergency contraceptives, IUD insertions (Wherever the ANM is trained on IUD insertion)

Follow up services to the Eligible couples adopting permanent methods (Tubectomy/Vasectomy).

National Rural Health Mission (NRHM)

The NRHM was launched in 2005 with the goal of “improv[ing] the availability of and access to quality health care by people, especially for those residing in rural areas, the poor, women and children through equitable, affordable, accountable and effective primary healthcare.” The NRHM commits to an increase in public health expenditures, community participation, and, reduction of regional imbalances and the MMR to 100 for 100,000 live births. The program created a tiered health care delivery system to guarantee, inter alia, maternal and child health services to all communities and imposed legal obligations on each entity to provide services such as those outlined below.

i. Sub Health Centre (SHC) 1. Early registration of all pregnancies, ideally within the first trimester; 2. Minimum of four antenatal check-ups: First visit to the antenatal clinic as soon as pregnancy is suspected, second between fourth and sixth month (around 26 weeks), and fourth and ninth month (around 36 weeks); 3. Associated general services such as collection of weight and blood pressure; 4. Provision of supplements including folic acid beginning in the first trimester and iron beginning in the second trimester; 5. Vaccines including an injection of tetanus toxoid; 6. Treatment of anaemia; 7. Identification of high-risk pregnancies and appropriate and prompt referral; and 8. A minimum of two postpartum home visits, first within 48 hours of delivery, second within 7-10 days.

ii. Primary Health Centre (PHC) 1. All services available at SHCs; 2. JSY implementation; 3. 24-hour emergency care including delivery services for both normal and assisted deliveries; and 4. Full coverage of maternal diseases/health conditions 5. Postnatal care including initiation of early breastfeeding and minimum of two postpartum home visits; 6. Range of family planning including contraceptives, tubal ligation, counseling and appropriate referral for safe abortion services; 7. Referral services including transport either by PHC vehicle or hired vehicle for which funds will be provided by Govt.

iii. Community Health Centers (CHC) 1. All services available at PHCs; 2. Essential and emergency obstetrics care; 3. Full range of family planning services; 4. Safe abortion services; 5. Blood bank facility; 6. Essential laboratory services; and 7. Implementation of all National Health Programmes.

20. Because the NRHM only addresses services required at SHCs, PHCs, and CHCs, District Hospitals and Medical Colleges, as higher referral centres, must at a minimum provide reproductive health services contained therein.

Janani Suraksha Yojana (JSY)

The National Rural Health Mission (NRHM) launched the Janani Suraksha Yojana (JSY) scheme to promote institutional delivery and to reduce neo-natal mortality. The JSY scheme entails specific guidelines for health care during pregnancy:10

The scheme provides financial assistance to BPL, SC, ST pregnant women who obtain antenatal care, undergo institutionalized delivery, and seek postpartum care.

Under the JSY scheme, ASHAs are assigned to every village to promote the use of health services of pregnant women. The ASHA serves as a link between the Government and the pregnant woman. The ASHA’s responsibilities include:

 Identify pregnant woman as a beneficiary of the scheme and report or facilitate registration for ANC. This should be done at least 20-24 weeks before the expected date of delivery;  Assist the pregnant woman to obtain necessary certification wherever necessary, within 2-4 weeks of registration;

10 http://india.gov.in/allimpfrms/alldocs/2384.pdf  Provide and/or help the woman in receiving at least three ANC checkups including TT injections, IFA tablets;  Prepare a micro birth plan;  Identify a functional Government health center or an accredited private health institution for referral and delivery, immediately upon registration;  Counsel for institutional delivery;  Escort the beneficiary woman to the pre-determined health center and stay with her until she is discharged;  Arrange to immunize the newborn till the age of 14 weeks;  Inform the ANM/MO about the birth or death of the child or mother;  Perform a post-natal visit within 7 days of delivery to track the mother’s health after the delivery and facilitate it in obtaining care, whenever necessary;  Counsel for initiation of breast-feeding to the newborn within one-house of delivery and its continuance till 3-6 months and promote family planning; and  Facilitate the payment of financial assistance immediately following the delivery.  The JSY also ensures that poor women receive Rs. 500 for home delivery.

NB: the work of the ASHA or any link worker associated with Yojana would be assessed based on the number of pregnant women she has been able to motivate to deliver in a health institution and the number of women she has escorted to the health institutions.

Rural Area Total Urban Area Total

Mother’s Package ASHA’s Package Rs Mother’s Package ASHA’s Package Rs

1400 600 2000 1000 200 1200

National Maternity Benefit Scheme (NMBS)

The National Maternity Benefit Scheme (NMBS) is a social assistance scheme meant for providing some financial assistance to a pregnant woman of a BPL household. The woman must be a permanent resident of the village and the entitlement is valid up to any number of births. NMBS resulted from a court order Supreme Court order in PUCL vs UoI and Ors Writ (Civil) Petition No. 196 of 2001 dated 28. 11. 2001. Under NMBS:

 All BPL pregnant women should be paid Rs. 500, 8–12 weeks prior to delivery for each of the first two births.  The benefit under NMBS must be paid irrespective of place of delivery, and also irrespective of age.

The Supreme Court has said that the two schemes are different, and that women should have access to benefits under both schemes. In reality, they are interpreted as the same scheme and women only get money under JSY. Throughout all of our interviews in the fact-finding this scheme was not mentioned once. It was clear that some people had knowledge of the JSY scheme but no one even acknowledged the existence of NMBS.

Data from the Fact-Finding:

Based on reports from the field HRLN sent a team of health activists to investigate maternal health care in Ghaziabad. Despite significant resistance from authorities, the team visited one slum, two District Hospitals, MMG and Sanjay Nagar, Loni PHC, Dasna CHC, Murad Nagar CHC, Modi Nagar CHC and 2 health posts Sanjay Nagar and Dabur over the course of three days.

Thursday 9th August:

Shushant Lunjar Slum

Shushant Lunjar Slum is located about 4/5km away from MMG in the centre of Ghaziabad. It was a relatively small slum near the river flowing through Ghaziabad. MMG was their nearest government health facility although there were smaller private hospitals within walking distance of the slum.

Rada:

The first woman the team talked to in Shushant Lunjar was called Rada. She is a housewife and her husband, Sunil, is a rickshaw driver. Their combined family income is roughly Rs. 200 per day. The government did not give them a Below the Poverty Line (BPL) card as they did not have the correct documentation. Rada highlighted that At the Poverty Line (APL) and BPL cards are notoriously hard to obtain as registration requires numerous documents, which many marginalised families do not have. This is important because most of the time the people who are actually in need of this card do not have the correct documentation as they live in a situation where it is impossible to keep any sort of valuable documents. The result of this therefore is that the people who need these cards and their benefits the most are the least likely to get them.

Rada had just given birth to her third child. Rada delivered all her children at home. There is a five-year gap between her oldest and youngest children and she used spacing methods. Rada did not receive the Rs. 500 allowance under the JSY scheme, which the government is supposed to provide for home deliveries, as she did not realize she was entitled to this money. Furthermore, Rada did not realize that she has the option of delivering at a District Hospital and when the team asked about her health care needs, she told us that she had to travel 2km in a rickshaw to a small private hospital, at a cost of about Rs. 30 plus her medical care.

Rada received no antenatal care whatsoever. Government health workers did not register her pregnancy and neither she nor her baby received any Government mandated vaccinations. She has never been to a government hospital. Her response suggested to the fact-finding team that the general attitude was that small private hospitals would provide better care at an almost equal cost to the district hospitals who routinely charge poor people for medical care.

Rada with her newborn baby.

Sheila:

Having overheard our conversation with Rada a second woman Sheila wanted to speak to us about her experiences during delivery. Sheila’s family sells coal on the streets so she was unsure of her combined family income.

Sheila had one little girl who had just turned two but due to her particular experience with the government health centre the fact-finding team felt that it was important to interview Sheila. She had many complications with her pregnancy and the overall cost of her operations and healthcare was around Rs. 30,000. She contracted pneumonia during her pregnancy and she received no help whatsoever from government health workers. She initially went to MMG District Hospital to give birth but when she went into labour, the hospital staff made her wait for two to three hours before offering medical care. As a result, she left in order to get better attention at a private hospital. She described the conditions at MMG as poor and dirty with unclean sheets. MMG is 4/5km away from where she lives and she was not reimbursed for her travel costs. Her caesarean section in the small private hospital cost around Rs. 15,000.

Sheila also told the team that MMG is notorious for poor medical care and that it is common knowledge that most people are not taken care of and are left “lying down for hours”. She then began to detail the extent of the corruption in MMG. She said that the attendants and nurses ask for around Rs. 3000 from patients who require an overnight stay at the hospital. She also told us that in many cases, doctors do not actually treat patients. The work is left to other staff people. Doctors who do treat patients will ask for Rs. 3000 for their work.

Government health workers failed to visit Sheila for ante-natal checkups, to provide vaccinations, and to supply iron and folic acid supplements. Sheila could not get a BPL card because she did not have the correct documentation. She received no food, no medical checkups or advice during her pregnancy. Her pregnancy was not registered but she did receive a polio vaccination. Even though she went to a private hospital and was seen by a doctor she said that both she and her baby left the hospital malnourished. Her child has not been given any supplements.

Sheila with her daughter outside their home.

Main Issues of Concern and Key Areas of Improvement:

One of the key problems we found from interviewing mothers in Shushant Lunjar Slum was that they were not receiving the benefits they have been allocated under the JSY scheme for hospital or home deliveries. Furthermore, when women do go to public facilities for delivery or care, their transport is not reimbursed. In fact, these families are barred from a number of benefits because they cannot obtain APL or BPL cards. Without a government issued card, BPL families pay substantial sums for health care and services that should be free.

The fact-finding team was also shocked to learn that poor patients are illegally charged for health care in government hospitals. In life threatening situations, BPL and APL families have no choice but to provide nurses and doctors with payment. This corruption is exacerbated by terrible conditions and poor care. There seems to be a general consensus amongst the people in Shushant Lunjar that smaller private hospitals are a much safer option than government hospitals. For these families, the cost of private care matches the cost of care at free, public hospitals.

Furthermore, government health workers should register pregnancies and provide women with antenatal care as per the guidelines. Many key contributors to maternal and infant mortality can be diagnosed and addressed early. If these issues, including anaemia, are only discovered at delivery, it may be too late to save the mother or the child.

MMG District Hospital:

MMG is the main district hospital in Ghaziabad; it is located in Jassipura, Naya Gangj. It has the only blood bank in the city and it is the highest authority in the government health sector in Ghaziabad. It is the test centre for the other district hospital Sanjay Nagar.

We were refused entry to MMG on Thursday 9th August and on Saturday 11th August. However we did manage to speak to some patients and an anonymous nurse outside the hospital.

Testimonies:

Interview with anonymous nurse at MMG:

The fact-finding team interviewed a nurse at MMG who wished to remain nameless due to the critical content of her interview. When asked about patients paying doctors and nurses at MMG for treatment she said that critical post-partum blood transfusions cost families Rs. 75 and lab tests cost Rs. 30-35. The anonymous nurse also stated that official bills are written for these costs. This symbolizes the outrageous audacity of MMG in their breach of basic human rights as the Janani Shishu Suraksha Karyakaram (JSSK) Scheme entitles all pregnant women delivering in public health to free delivery including C- Sections. This also includes free drugs, food and blood. India has been named the third largest “Out of Pocket (OOP)” funded health system in the world11.

The nurse then stated that the gate to the hospital is always closed and that in order to enter the hospital patients have to pay the guard a cash bribe. For operations, MMG charges between Rs. 3000-5000. If a woman has to deliver via caesarean section the hospital will charge Rs. 5000. The Chief Medical Supervisor, who is the manager and supervisor at MMG, doctors, nurses and cleaning staff will split the funds. For normal deliveries MMG charges Rs. 1,300 but the nurse said that if the patients are really poor then the family may barter the price down to Rs. 500.

The nurse estimates that the CMS earns a minimum of Rs. 5000 per day from these charges and that some money passes on to the Chief Medical Officer, who is in charge of the entire government health sector in Ghaziabad. The nurse also reported that the hospital’s cleaning staff regularly assist with deliveries. The nurse also explained that after delivery, the nurse will take the newborn until the parents or extended family paid the hospital.

After delivery, women do not receive post-natal care or counselling. She cited another example of this extreme negligence where a new mother required an intravenous drip. When she told the hospital staff that she could not afford the out of pocket expenses, the staff wheeled her to a stretcher into the hallway just out of reach of the drip until her family got the funds together to pay for the treatment.

The nurse described how the CMS sends employees to the PHCs and CHCs to collect money for herself and the CMO. Therefore the PHCs and CHCs have to comply in order to receive essential medical supplies. PHCs and CHCs frequently have limited supplies of essential equipment and have to purchase sheets on their own. The culture of taking cash from desperate patients has trickled down to PHC and CHC staff who also demand payment from poor families.

11http://articles.timesofindia.indiatimes.com/2012-05-17/india/31747967_1_india-ranks-expenditure-ill-health

The nurse also highlighted the poor facilities management. MMG received a grant from the government of Ghaziabad to preserve the building. The hospital staff pocketed this money. When it rains, water pours into the labour room which is highly unsanitary and impractical.

The nurse recounted multiple hospital deaths directly attributable to inadequate care, negligence, and poor infrastructure.

Interview with Patients outside the gates of MMG:

The fact-finding team interviewed two women very briefly outside the gates of MMG. Their stories corroborated the nurse’s description of the hospital’s policy of taking newborn babies away from their families until they have paid a cash bribe of Rs. 1000 - 3000.

Main Issues of Concern and Key Areas of Improvement:

A culture of corruption permeates every aspect of health care at MMG Hospital. When patients can pay for their care, they are subject to substandard care, dangerous facilities, and endless bribes. The hospital staff essentially kidnap babies until they receive payment.

Saturday 11th August:

Snjay Nagar District Hospital

Sanjay Nagar is the other district hospital besides MMG in Ghaziabad. It is situated about 5.5km away from MMG and it uses MMG’s blood bank and testing facilities. The fact-finding team were directed to their maternity ward and labour room. We immediately noticed medical waste on the counter at the nurses’ station in the maternity ward. As we were leaving the maternity ward, there was a baby lying on a table near the nurses surrounded by a protective netting layer. The team asked about the baby and the nurses replied that the baby was left in the ward and that they did not know anything about the baby or the baby’s parents. With only 15 patients in the ward, the nurses could not keep track of a seemingly abandoned infant.

Medicine Supply Room in Hospital

R.D. Yadav – pharmacist, founding member of hospital

When we went to Sanjay Nagar hospital we spoke with R.D. Yadav the head of medicine distribution in the hospital. He gave us a tour of the medical supply rooms and reported that medicine is available to both patients and the public free of charge. The hospital restocks on a monthly basis. We saw large stocks of iron, calcium, folic acid, and other medicine that is essential for pregnant women. He stated that even though the Hospital had large stocks of iron, he only gives it to anaemic patients and not all pregnant women.

Testimonies:

Sister Gogia – in charge of labour ward

When we first arrived in the hospital, four staff nurses greeted the team. Sister Gogia then agreed to talk to us; she is one of the founding members of Sanjay Nagar and has worked there for four years since the hospital opened. She gave us a brief outline of the facilities available at the hospital and the treatment for pregnant women.

The hospital is open from 8am – 2pm and the emergency room is open 24hrs a day. For ante-natal care, women come to the hospital for routine check-ups and helpful general information. When pregnant women arrive at the hospital for delivery they initially go to the Out Patient Department (OPD) for an initial check-up. Their condition determines whether they go straight to the labour ward or to the Out Patient Department.. The hospital provides transportation for complicated deliveries. The Hospital performs caesarean sections and post delivery care. Most women usually stay for 2-3 days. Later in the conversation, sister Gogia stated that post-natal care usually lasts for 4 days in regular births and 8 days for caesarean sections.

The maternity ward staff administer post-natal injections and all the vaccines are stored in the hospital. Usually a team of three to four women deliver a baby and the hospital has four doctors on call at all times for emergencies. The various lab tests needed are done at MMG and the closest PHCs and CHCs are roughly 10km away. The nurses frequently come from outside Ghaziabad, for example one sister lived in Agra. The nurses’ training is 3.5 years long.

The hospital does not have a blood bank or blood storage unit. The closest blood bank is at MMG district hospital.

The three sisters in charge of the maternity ward, Sister Gogia is on the far right.

Patients in the Maternity Ward

Geta, age 25:

The first patient we talked to had just delivered her third child. The baby was born two months premature. She delivered her first two children at home with a Dai assisting (traditional birth assistants who have received no formal training who often assist with home deliveries). There is roughly a 1.5 year gap between her children. She came directly from her house to the hospital. She did not have access to free transportation and the hospital had not reimbursed her for the travel expense. She is a cook and her husband is also in the catering business. She lives with extended family so she said it was difficult to work out her family’s monthly income.

She is not planning on having any more children so she is planning to take contraceptive pills. The hospital issued her child a birth certificate. She does not have a BPL or APL card because she did not have the required documents for registration. The Hospital had not supplied injections, supplements, or medicine and she had to pay around Rs. 1500 for injections and medicine that she purchased from private shops. She did not know about the JSY scheme and her right to Rs. 1400.

Geeta with her two months premature baby.

Patient who hadn’t delivered yet, age 25:

The next patient we interviewed had not given birth yet. She was eight days from her due date. She had been diagnosed as anaemic by the nurses earlier that day. Hospital staff had just drawn blood for tests and she said that she would be given iron supplements if she needed them. Her arm had a large cut on it suggesting that the blood tests had been done very badly.

She was pregnant with her first child. She had been pregnant before but due to an iron deficiency she had to have an emergency abortion at a private hospital. She was also going to undergo the “bucket treatment” to find out what infections she had, but neither she nor her family understood what the tests entailed. The fact-finding investigated the bucket treatment, but could not determine what it entails.

She is from Ghaziabad and her husband works in the technical field. They did not have an APL or BPL card because they thought they did not need them. They were unaware of any scheme that entitled her to money for having an institutionalized birth. Her pregnancy has been registered.

Her family was happy with the hospital care that she had received so far.

Patient who had recently been admitted and had not given birth yet. (Note: the unnecessarily large incision on her arm from a blood test)

Patient Megha:

The third patient we spoke to had delivered a boy on Lord Krishna’s birthday and wanted to name him Krishna. She has had four children and there has been a three year gap between each child. She is from Ghaziabad and her husband works in Rajasthan. She does not have a BPL card and she was unsure of how much the allowance was for institutionalized birth.

She delivered her child at nine months and she and her son needed injections. She had not received them because she did not have the Rs. 250 to pay for each injection and her husband was in Rajasthan so she could not access the money. She does not plan on having more children but she had no real knowledge of contraception or the services that the hospital provided regarding contraception. This woman had not received antenatal care, including injections. She would have sought out care if she could afford it.

Megha with her six year old daughter and her new baby Krishna.

Cleaning Staff

Sharbati (janitor):

We spoke to a janitor at the hospital who has worked there for one month, her main duty is to clean the ward but sometimes she is called to help with deliveries. She said that she has assisted with a number of deliveries. When asked about problems like corruption and sanitation in the hospital she answered that “only the higher ups could solve these problems.”

We asked her about costs and she said that there is an entrance fee of Rs. 100-200 to get into the hospital. She also stated that there was a governmental fee structure for medicine. For example, blood tests cost Rs. 35. This is in complete contradiction to the NRHM schemes and the testimonies of the staff nurses in the maternity wards who reported that all testing is free. She knew that after delivery urban women should receive Rs.1000 and women from rural areas should receive Rs. 1500. She said that it was the Dais who made home visits, not government health workers. She also explained that the hospital had just one free ambulance and a few other cars reserved for transporting patients.

Another Cleaning Staff member:

Another woman on the cleaning staff said that there was a lot of money exchanged between hospital staff and the media. She detailed how undercover reporters would enter the hospital and then threaten to expose the conditions and practices so the hospital pays them off. She used the Hindi words Len Den to describe these illegal deals which has connotations of the off-the-books hand to hand exchange of money.

Main Issues of Concern and Key Areas of Improvement:

The fact-finding team observed myriad problems at Sanjay Nagar District Hospital. These issues are exacerbated by corruption and an environment where poor conditions create a profit. The hospital charges patients for medicine and consultations that should be free.

Additionally, the hospital does not promote or encourage women to collect their cash entitlements under the JSY scheme. Although the cleaning staff knew about the scheme, the patients had never heard of JSY or the possibility of receiving cash.

Another major problem is that transportation services are not readily available for the patients. While some women require an ambulance in an emergency, other women cannot afford the out of pocket expenses required for travelling to the hospital.

Moreover, the team discovered very poor sanitation in Sanjay Nagar hospital. The team noticed piles of rubbish throughout the hospital, medical waste in the maternity ward, and dirty sheets across wards.

Waste and dirty conditions at Sanjay Nagar Hospital.

The hospital also suffers from staff shortages. The Hospital should ensure that trained staff assists every delivery. Untrained members of the cleaning staff should not perform deliveries.

Health Posts

Room 55 in Sanjay Nagar Hospital w/Leelamma H.V. (Health Visitor)

Health Posts are the most basic of the government health facilities. Their main role is to give vaccinations to both mothers and other members of the public. There is one such health post in the hospital itself at Sanjay Nagar where people who are not patients at the hospital can come and receive treatment.

The hospital itself also contained a health post and its main duties are providing vaccinations free of charge. Many people from outside the hospital come here for vaccinations as well. One of the nurses called Leelama said that she works in two facilities, Sanjay Nagar itself and the Anganwadi Centre and whilst working there she works in a variety of villages within the remit of those two health posts. She works on Monday, Wednesday, and Sunday in the hospital and then on Tuesday, Thursday, Friday, and Saturday in the Anganwadi Centre.

Leelama said that there are nine health posts in Ghaziabad including Sashtrinagar Karte, St. Mary School and Hapar Chugnee. She said that all the health posts are government run and funded and that she has worked in the government health sector for 22 years.

Nurses in the health post in Sanjay Nagar Hospital, Leelama is on the far left.

Dabur Health Post

The fact-finding team also visited more rural areas of Ghaziabad to get a fuller picture of health care in the district. This health post is a small room with the sole purpose of vaccinating the general public near Dabur. When the fact-finding team visited there were three nurses in the vicinity but with no patients.

One of the nurses that would not disclose her name said that the health post refers pregnant women to district hospitals and that no one gives birth there. She also said that the number of women that come per day varies from four to ten, the number of pregnant women is evidently slightly less.

The health post provides vaccinations for pregnant women but not food. She said that the injections were free and that they restock them monthly. The nurse said that there were no ASHAs at this health post as it was not rural enough.

She also said that they provide post-natal care but when asked about ante-natal care she said that people usually “engage in self care” so the nurses do not visit women in their homes.

Main Issues of Concern and Key Areas of Improvement:

The fact-finding team observed that the ante and post-natal care given at the health post is not complete under the NRHM, JSY or NMBS Guidelines. While the staff provide vaccinations, they do not distribute food as required by the JSY scheme. Also, the staff should register pregnancies and provide antenatal care to women to ensure healthy deliveries and reduced maternal mortality.

PHC Loni (26km from Sanjay Nagar District Hospital and 21km from MMG District Hospital)

Testimonies:

Talking with Dr. Kalash Chand

The fact-finding team entered the PHC at around 4pm after closing time but we were lucky to find a doctor present. We spoke to Dr. Kalash Chand who had been there for a month.

Dr Chand confirmed that the opening hours were from 8 am to 2 pm and that the facility did have 24 hour emergency care available. He said that on average there were 200 deliveries per month and five to six per day. The PHC refers caesarean sections to the district hospitals. The PHC’s ambulance has not functioned for about a year, but the doctor hopes to get a new one in September.

Their contraceptive services consist of “support and advice.” Dr Chand stated that they provide ante-natal care including injections and tablets. He also told the team that the government supplies these contraceptive choices free of cost.

For post-natal care, women usually stay at the hospital under the supervision of ASHAs. He said that overall satisfaction was good but that they have a shortage of staff and equipment.

The fact-finding team then questioned Dr. Chand about the problems in his facility and the poor conditions. The fact-finding team noted that the hospital is extremely dirty. Rubbish surrounded the hospital and the conditions inside the hospital were equally unsanitary. Dr Chand stated “This is not a hospital. This is a house of disease. The conditions are so bad that if a healthy person came they would leave ill.”

Next, Dr. Chand described the large range of problems this PHC in Loni and other government health facilities experience. Firstly, the state government does not implement the NRHM protocol. For example, the PHC should have six doctors and specialists, which is not the case. Secondly, there is a shortage of staff, funds, equipment, and quality medicines. In addition, Dr. Chand stated that the conditions are stagnant and that no progress has been made. He said that the government has no real intention of improving conditions with regard to medicine and equipment and that these problems are rife throughout Ghaziabad and Uttar Pradesh.

When asked how to solve the corruption, he said we must transform ourselves and that is the only way that we will see change. He said that “no treatment happens here” and that they must “give medicine and put on a show” but that the “government hospital is nothing but a farce for the government to look like it is doing something.” He said that the government is not improving the facilities because it is in their interest to maintain the status quo. According to Dr. Chand, government ties to pharmaceutical companies and the private healthcare sector ensure substandard health care for poor Indians. This connection obviously affects drug supplies, and decisions about what medicines to buy and which pharmaceutical companies to deal with. He also stated that all directions come from the Chief Medical Officer (CMO) called Ajay Agrawal including what medicine is distributed where. Dr Chand even went as far to say that doctors are directed to prescribe ineffective medicine or the wrong medicine so patients end up spending more money.

The fact-finding team asked about the media corruption after it was brought to our attention in Sanjay Nagar DH. Dr Chand that it is very common for big newspapers to walk into a facility and demand bribes so that they do not expose the horrific conditions they find.

The fact-finding team talking to Dr Kalash Chand.

Nurse Sangeeta Chopra

We then met the staff nurse Sangeeta Chopra. She has been in this PHC for nine years. Until very recently she was the only staff nurse at the PHC. Inevitably this meant that the hospital did not have an available staff nurse 24hours per day. Now there are two nurses ensuring 24 hour care.

Sangeeta said that she delivers babies without additional assistance from a doctor or midwife. She stated that the PHC does not provide ante-natal care.

The PHC holds family planning camps every Tuesday. A camp is set up by staff from MMG district hospital to perform laparoscopic tubectomies. She also stated that it is generally not that difficult to get a BPL card and many people do get them but those who struggle are usually the poorest.

Patient, Soni

We then spoke to the only patient in the maternity ward. Soni was pregnant with her second child. Her first child is four. Soni delivered her first child at home with a dai. The government did not provide her with antenatal care, delivery assistance, or post-natal assistance. She did not receive a cash incentive after delivery. For this delivery Soni expects a higher standard of care from the government facility.

The hospital covered the costs for her injections and transportation. After her child is born she will undergo a tubectomy as she is not planning on having more children.

The only patient in the PHC at the time of the visit, Soni. She had just started the labour process.

Main Issues of Concern and Key Areas of Improvement:

The fact-finding team was impressed with Dr. Chand’s candid account of corruption in the public health sector. Clearly, corruption is a major contributor to inadequate and unacceptable health care in Ghaziabad. The fact-finding team learned that key shortcomings including poor sanitation, limited supplies, and inadequate staff are all contributory problems stemming from lack of motivation and corruption. The fact-finding team found that the corruption spreads throughout all levels of the health sector from cleaning staff to the CMSs and CMOs. Shockingly, corruption directly impacts diagnosis and treatment. Intentionally misdiagnosing ailments and providing patients with expired medicine to earn additional money from marginalised hospital patients amounts to negligence and is a significant concern.

The dirty labour ward at Loni PHC.

Stagnant water and rubbish surrounding the PHC.

At the patient level, the fact-finding team’s main concern is the fact that the JSY money does not reach women. At the same time, hospital staff, including guards, pharmacists, nurses, and doctors, demand fees at every step of delivery from arrival to discharge. Poor families who cannot obtain a BPL or APL card cannot make up for these substantial out of pocket expenses.

The media also perpetuates this corruption by accepting bribes to remain silent on government corruption and the abhorrent hospital conditions.

Ultimately, this corruption impacts the most marginalised Indians who are forced to scrounge for money and sacrifice their basic dignity for substandard medical care.

Tuesday 14th August:

Dasna CHC (11.5km from MMG District Hospital and 9km from Sanjay Nagar District Hospital)

On the road to the CHC the fact-finding team passed private hospitals and many chemist shops. Upon arriving at this CHC, the CMS, Dr. Hari Dutt, referred us to the CMO, Ajay Agrawal, who gave us written permission to view the CHC.

Facility: When the team first visited, there was no electricity or running water in the facility. Upon returning with the CMO’s permission, the fact-finding team learned that electricity had just been restored to the facility. When we asked to use a washroom, we were shown to a private washroom in the nurses’ quarters. We did not see the patients’ washroom.

The CMS gave the team a guided tour. At the same time, nurses visibly slipped, away to clean the labour room before we entered. When the team reached the delivery room, evidence of the nurses’ last minute clean up was clear; a woman who had just given birth had been changed into a salwar kameez, and there were bloody sheets in a bucket beneath her delivery table. There was another bag containing medical waste and dirty clothes in the corner of the room. During the tour, a staff member constantly stood in front of the bag blocking this particular area from the camera. The team saw fresh blood on the floor.

The labour ward in Dasna PHC after the mother had been dressed in new clothes and the room had been cleaned before the fact-finding team could see it. (Note: the bloody waste on the floor)

Testimonies:

Talking with Staff Nurses, Dara & Babita

The team spoke with two staff nurses named Dara and Babita. Babita has been working at this facility for a month, after being transferred from Lucknow. Her main duty is delivering babies, and she said there are anywhere from zero to seven deliveries a day. She stated that one nurse performs the delivery alone. She said the nurses work every day, and have day or night shifts. Babita said there are three nurses working at this facility.

When asked about ante-natal care, she said that the facility does not provide regular ante-natal care, unless a pregnant woman has complications and visits the CHC for care. Babita stated that because most women do not receive antenatal check-ups, anaemia and abnormal bleeding are the most common complications. She stated that folic acid is given to pregnant women before delivery, but that most women are negligent and fail to take the medication.

She said that most women go home the same day that they deliver their baby. After the delivery, the CHC provides women with free medicine.. She said these medicines come from a government supply and include folic acid and vitamin supplements.

Babita said that around 150 ASHAs work with this facility. Babita said the ASHAs give pregnant women as much guidance as possible. ASHAs run the family planning and provide women with condoms and information about sterilization. The CHC does not provide sterilization services. When complicated cases are transferred from the CHC to the district hospital, ASHAs receive Rs. 250 for transportation costs.

Babita said that women do not use APL or BPL cards at this facility. As per the JSY scheme, rural women who deliver in the facility receive Rs. 1400, and urban women receive Rs. 1000. Babita said that women who deliver at home do not receive any money.

Patients with HIV or an STI are not treated at this facility. The CHC refers these cases to the district hospital.

When asked how the facility could be improved, Babita suggested that caesarean sections and sterilization should be performed at the CHC.

Nurse Babita

Talking with Chief Medical Supervisor (CMS), Dr. Hari Dutt

While touring the facility, Dr. Dutt confirmed that the facility does not perform caesarean sections. He said the facility has one female doctor, but no gynaecologist. Dr. Dutt told the team that staff nurses do the deliveries, and that the CHC performs around 150 deliveries per month. He said that the cleaning staff are not involved in deliveries. While the nurses told the team that women leave the facility on the same day they deliver, Dr. Dutt contradicted the nurses and stated that women stay for 48 hours for post-natal care.

In the labour room, Dr. Dutt showed us a metal tin with vials of “emergency medicine” for complications during delivery. He explained that the medicines come from Lucknow, then go to the CMO, and then are distributed by the CMS pharmacist named D.V. Singh. Dr. Dutt said D.V. Singh chooses what medicines are distributed throughout the CHCs. Dr. Dutt said this facility receives its medicines from Sanjay Nagar District Hospital. The fact-finding team could not examine the medication supplies, as the person with the key to the storeroom was not in the hospital.

Dr. Dutt explained that this facility used to be a PHC, but was transformed to a CHC due to a population increase. When asked about what could be improved about the facility, he stressed the need for more staff and reliable electricity. He stated that they need three ward boys, more than one sweeper, and more staff to provide 24-hour emergency services. There is currently only one permanent staff nurse. He said the facility needed a general surgeon, someone to perform ultrasounds, and more staff for the operating theatre.

Interview with patient – Monica, age 22

During our tour of the facility, we met a patient named Monica who was lying on a bed and beginning to feel contractions. We asked to interview her and the CMS and other staff members remained in the room while the team spoke to Monica. The fact-finding team conducted the interview with seven government employees in the room.

Patient Monica after she had been given fresh bed sheets when the fact-finding team had been given a tour of the hospital. (Note: the dirty bed side table and bucket)

Monica shared with us that she is pregnant with her first child, and has been to this facility for check-ups during her pregnancy. She has taken calcium and folic acid. She met with an ASHA during her pregnancy who suggested vaccinations. She has not received advice or information regarding contraception. Her pregnancy was normal.

Monica is a graduate student studying English literature and sociology, and her husband is a chemist. Their income is around Rs. 15,000 per month. Her in-laws live in a village near the CHC, and they brought her to the facility. She hopes to have another child in the future.

She said she has an APL card that was not difficult for her to get. At this point, the CMS interjected that BPL cards can be difficult to get.

Main Issues of Concern and Key Areas of Improvement:

The CMS of Dasna highlighted inadequate staff, electricity, and water as the main problems in this facility. The fact-finding team also noted that these essentials were missing. In addition to deficiencies in basic infrastructure and staffing, the CHC fails to accurately implement key requirements under the NRHM. For example, the CHC does not perform caesarean sections or facilities for HIV positive patients. The facility does not provide transportation for referrals to the District Hospital and HIV positive patients will have to travel up to 20/25km to get to a hospital for treatment.

Murad Nagar CHC (15km from Sanjay Nagar District Hospital and 19km from MMG District Hospital)

Upon arriving at Murad Nagar CHC, a man who normally supervises tuberculosis (TB) patients told the team that they could not enter the CHC. We showed him our written permission from the CMO but he said that the CMS had left and that he was not able to let us in without permission from the CMS. We called the CMS who said he was in the CMO’s office and would return to the CHC later that evening.

The CMO actually referred the fact-finding team to this CHC. The team thought it was highly suspicious that the CMS happened to be meeting with the CMO when we arrived. .

The team noted many stray dogs wandering in and out of the facility.

Testemonies:

Due to our inability to enter the Community Health Centre we interviewed various people outside the hospital.

Interview with ASHA

The team spoke to an ASHA who had just assisted with a delivery. She said that her main duties were looking after pregnant women including managing their food intake and ensuring they get two tetanus injections. She said that she gets paid Rs. 600 per delivery and that 150 ASHAs work under this CHC. She said the training to become an ASHA lasts a week and that ASHAs have several follow up trainings. The ASHA said that she does two to three deliveries per month and that she assisted with three in May, three in June, and two in July. Her post-natal duties include BCG (tuberculosis) and hepatitis vaccines. She said that she provides whatever is “asked for” with regard to contraception and that she does not deal with HIV patients as they are sent to district hospitals.

Interview with Patient

We spoke to another patient outside the hospital who had just given birth. The hospital staff discharged her from the hospital because the next day was a holiday. She received her Rs. 1400 allowance under the JSY scheme.

Interview with TB Supervisor:

The team briefly spoke to the TB Supervisor who denied us entry to the CHC. When asked about what happens after operational hours he said that nurses are available to help with deliveries but that doctors leave the facility. He also said that ANMs provide immunizations.

Interview with ANMs named Gayahi, Derit and Krishna

We also met three ANMs outside the hospital. They said that most women come for ante natal check-ups and that there is a female gynaecologist on staff. The ANMs provide tetanus injections for pregnant women. They also look after family planning, meaning male and female sterilization. The ANMs travel 16km for field work and the hospital does not reimburse their expenses. They also said that women do not receive Rs. 500 for home deliveries. They did confirm, however, that the facility provided Rs. 1400 for institutional births to encourage women to deliver at the CHC. The CHC gives a new mother a check on the day she delivers. The ANMs added that ASHAs have made significant contributions to health care in the district.

Main Issues of Concern and Key Areas of Improvement:

As with the other PHCs and CHCs, Murad Nagar does not provide healthcare for HIV positive patients. These patients have to travel to Sanjay Nagar or MMG for treatment.

Another major concern is that the ANMs were not reimbursed for their travel, which dramatically reduces their wages their motivation. The number of ASHAs also needs to be greatly increased as the supposed ratio is one ASHA per 1000 patients.

Talking with private chemist outside Murad Nagar

Praveen Tyapi

Because the fact-finding team could not visit the CHC, we decided to talk to the owner of the medical shop on the same street. He had knowledge of the Janani Suraksha Yojana scheme, which establishes the one ASHA per 1,000 people guideline. He said that the ASHAs do pre and post-natal immunization for free and that the government provides folic acid. He also said that around 10 pregnant women per day come to buy folic acid and about four of them also buy protein supplements. He said that calcium costs around Rs. 20, Protein-X costs around Rs. 165, and a pack of 15 folic acid/iron supplements costs around Rs. 70.

He also told the team that the CHC experienced medicine shortages. The chemist intentionally stocks extra drugs in anticipation of CHC shortages. When asked about his own children he said that his daughter was born in a private hospital in Modinagar because his wife has a rare blood type of B- and had hypertension. He also said the only blood bank in the Ghaziabad District is in MMG. He added that the ambulance in Murad Nagar is regularly functioning.

Modi Nagar CHC

(23.5km from MMG District Hospital and 18.7km from Sanjay Nagar District Hospital)

There were signs both here and in Murad Nagar CHC advertising that women giving birth in the CHC would be compensated Rs. 1400 or Rs. 1000 under JSY.

Sign outside Murad Nagar PHC detailing the benefits available under the JSY Scheme.

Testimonies:

Talking with patient Jamila – Gulshan

Jamila had just delivered her third girl; her first daughter is three and her second daughter is two. She received an allowance of Rs. 1400 and free injections. She did not receive ante-natal care. Her first child was born at home. Her second daughter was born at the CHC and she was pleased with the care she received. She had been given pain killers and the ASHAs came regularly to check on her. She said three people were present at her birth; one ASHA, one nurse, and one doctor.

Jamila with her newborn daughter on a bed with no sheets.

Interview with an ASHA named Sadhna Tyapi

Sadhna primarily works with another CHC, so she rarely visits this PHC. There are around 150-200 ASHAs where she is stationed. Sadhna receives Rs. 600 per institutional delivery. For post-natal care she advises mothers to immediately start breastfeeding and ensures that women breastfeed every two hours. She also provides counselling on sterilization.

When asked about the improvements that could be made to the hospital, Sadhna said that the lack of electricity was a major problem. She said that the hospital frequently functions without lights and that the staff perform deliveries by candlelight and mobile phone light. She explained that she had been an ASHA since 2006 and that sometimes the allowance for mothers reaches them late but if so the ASHAs take it to them.

Interview with staff nurses, Shaeda Gautam, Dorris Anderson, Sunita

The fact-finding team then spoke with three staff nurses who worked in the labour room. The CHC delivers around 50-100 babies delivered per month. The CHC employs three post nurses, five general doctors, and no female doctors.

The CHC performs normal deliveries and refers complicated cases to the District Hospital. The nurses said that post-birth they make hourly checks on patients and make sure that each woman has accurate copies of their medical records. The CHC employs a Dai who has been at the facility for 1.5 years. Two ANMs work permanently at the CHC and a third works on contract.

After the fact-finding team asked to take photographs of the ward one of the nurses said to a patient: “why are you laying on that bed with no sheet, they’ll capture it in the photograph.” The nurses clearly want to project a positive image of the CHC regardless of the reality in the wards.

The staff nurses at Murad Nagar PHC Shaeda Gautam, Dorris Anderson, Sunita with ASHA Sadhna Tyapi on the far left.

Main Issues of Concern and Key Areas of Improvement:

During the first 30 minutes in the CHC, the fact-finding team did not speak with a single staff person. Accordingly, the team photographed the highly unsanitary conditions in the Murad Nagar CHC. We found bloody sheets from old operations and generally unclean wards.

Bloody sheets from an old operation.

The dirty labour room in Murad Nagar PHC.

Delivery implements resting on dirty sheets in the delivery room in Murad Nagar PHC.

Dirty monitoring equipment and a bed with no sheets.

Finally the unreliable electricity supply constitutes a major concern. Practicing medicine in the dark is not safe for the patients or the staff at the CHC.

Main Areas of Concern and Suggested Improvements:

In order to improve maternal health care the state must provide effective solutions for maternal mortality, infant mortality, malnutrition, access to contraception, and safe institutional delivery. Although the NRHM attempts to address these issues, However, there are so many flaws in the government healthcare system that cause these problems throughout hospitals in Ghaziabad:

JSY Benefits: Based on the fact-finding team’s interviews, it is clear that many women do not receive their JSY payments. Inadequate disbursement could be the result of poor distribution techniques, inadequate advertisement, or corruption.

Corruption:

The fact-finding team uncovered widespread corruption at every level from the cleaning staff up to the CMO Ajay Agrawal. Patients are unnecessarily charged for medicine, overnight stays, entrance to the hospitals and even bed sheets. Furthermore, there have been several incidents described where babies have been taken from parents who were unwilling to pay for their treatment and that they are not returned until they have been.

As a result of widespread corruption, poor people go to smaller private hospitals because they provide better healthcare for a similar price. The Doctors in the government hospitals are instructed to misdiagnose patients and prescribe faulty medicine so that poor patients pay high out of pocket prices and generate income for the hospital staff. The fact-finding team were also told that the link between the pharmaceutical companies, the private sector and the government means that it is their interest to keep these horrific conditions. The media is complicit in this culture of corruption.

Testimonies form Dr Chand and the anonymous nurse from MMG corroborate this corruption first hand.

Sanitation:

Unsanitary and unhygienic facilities are the norm throughout Ghaziabad. The fact-finding team found medical waste, general waste inside and outside the facilities, old bloody sheets from operations and fresh blood in labour rooms. The unsanitary conditions simply do not provide an environment which is suitable for recovering from illness.

Ante-Natal/Post-Natal Care:

Government health workers largely fail to provide women with any sort of antenatal health care. The health posts provided vaccination, but health workers from the PHCs and CHCs rarely assisted women before delivery. There is virtually zero post-natal care in any facility that the fact-finding team visited.

Lack of Staff:

The fact-finding team found that not a single facility had adequate staff. In this context, members of the hospital cleaning staff deliver babies, women are left without medical attention, and newborns are left in patient wards without adequate supervision.

Transport:

There is little or no transportation for patients to travel to, from, and between facilities. The most marginalised members of society cannot safely or quickly travel to or between facilities, endangering their lives.

APL Cards/BPL Cards:

The fact-finding team consistently found that women struggled to obtain an APL or BPL card because of the difficulty in obtaining the necessary documents.

Contraception:

Government health workers provide very little advice to women about contraception, especially regarding non-permanent spacing methods (oral contraceptives, condoms, copper-T). For public health workers in Ghaziabad, family planning is synonymous with female sterilization. As per the NRHM guidelines, state that even Primary Health Centres should offer a range of family planning including contraceptives, tubal ligation, counselling and appropriate referral for safe abortion services.

Lack of Electricity in PHCs and CHCs:

There is a serious lack of power and water in the PHCs and CHCs. Women have no choice but to deliver their babies by candlelight. While the government has taken strides to promote institutional delivery, it has failed to ensure a dignified delivery for all Indian women.

HIV+ Patients:

CHCs and PHCs automatically refer HIV positive patients, whose transportation is not covered by the government.

ANMs and ASHAs:

Overall, facilities lack adequate numbers of ANMs and ASHAs. The state has failed to ensure one ASHA per every 1,000 people. Hospitals fail to reimburse ASHAs for their travel and ANMs do not receive adequate supplies or vaccines.

Neither ANMs nor ASHAs provide thorough antenatal care to women in their jurisdiction.

Fact-finding conducted by: Charlotte Weston, Laura Shoaps and Shaneka Davis