Can we count on our counting systems?

Can we count on our counting systems?

A shorter version of this article appeared on BMJ Blogs on October 31, 2013 under the same title.  Co-written with Himabindu G L of IPH, Bangalore.

Much of the material remains unprocessed, or, if processed, unanalysed, or, if analysed, not read, or, if read, not used or acted upon

Robert Chambers

Basic demographic information forms the basis of policy, planning and public

The Registrar General of India promptly responded with this instruction to all states. But since then...

The Registrar General of India promptly responded with this instruction to all states. But since then…

discourse.  The system through which governments record vital events such as births and deaths is the civil registration system. Defined by the United Nations as “the continuous, permanent, compulsory and universal recording of the occurrence and characteristics of vital events”, it forms the basis for identity, citizenship and civil rights. Established perhaps first by Sweden, as early as 1631,  its importance was globally recognised and more countries have worked towards establishment of efficient and comprehensive civil registration systems.



Juliet: We met, we supported and we lost…….& witnessed family getting dismantled?

Juliet: We met, we supported and we lost…….& witnessed family getting dismantled?

This is not the first time we are writing about Juliet….but this will be the last blog we can write for her. A Call from the team member took me back to memory lane…

When we first time met young Juliet (name changed) she was pregnant with severe anaemia and reluctant to go for check-up (Why Juliet is reluctant to visit Public Hospital? Then we supported her through the pregnancy to delivery (May be it was dead before seeing the world Not just during delivery in the hospital, also supported when she disappeared leaving nearly a month old baby at home.  We got a call from one of the community member saying the baby will not make it if you don’t do something…we were not sure what is that “SOMETHING” we could do at that time!

When we went to see the baby….the baby was malnourished, with severe dehydration and pic grandparents had decided to give the baby away! YES all they wanted was someone to look after that little boy. The sheer poverty and lack of social support can force people to take extreme steps….and added to that the substance abuse by all the elders in the family had not left space for responsibility and emotions. For the first time we witnessed whole community united to save little baby. After one month of intensive care at hospital, the baby was back in the safe hands of kind people in the orphanage.

Few months later Juliet was pregnant for the second time and she wanted to have another child! I was shocked and angry….our advice not to conceive had not helped. But this time she was taking care of herself and was going for regular check-up. “She is matured madam” said field team member. I was wondering with no family support, what will happen to her and the baby this time! What should be our role…many more questions while her baby was growing in the womb! But we didn’t have to do anything this time….Juliet was in critical care unit.

pic 2During a spat, a punch from her husband had caused head injury and she was unconscious in critical care unit and  husband in Jail. After few days of struggle, doctors gave up…caller from the other side said “sorry madam Juliet died”!

Few months ago Juliet’s mother-in-law also died and the community is requesting to leave her children in orphanage with Juliet’s baby! In less than two years we witnessed the whole family getting dismantled…Juliet’s baby in orphanage is doing very well, the only consolation we have. This is a story of one Juliet but I’m sure there are many more Juliet’s in our community who need support, guidance and a proper system to address social issues, which is lacking.


Dr Thriveni B S

Juliet: We met, we supported and we lost…….& witnessed family getting dismantled?

Is embracing death @ 24 so easy?

This time it was neither KG Halli nor urban health project….but Health Inc…trying to find reasons for social exclusion in Bangalore Rural district.

When we entered 8×8 single room house, Jagadish was lying on the bed. We asked how he was feeling, he pushed bed sheet aside and showed his leg…yes it was badly infected & looked scary and his hospital discharge card said Cellulitis!  He said few days ago we went again to private medical college they refused to admit me, then we went to Government Hospital, doctor said nothing can be is too late, so we came back home. I was speechless and ran out of words…just to listen from that  24yr old boy in a calm and composed voice, with no emotions saying I’m waiting for my death! I said to myself.. Is it so easy to accept death?

For a moment I forgot why we were in that house, started  making calls to friends and colleagues for help… one of the district surgeon assured to do his best. In the last 2 month, family which is mainly dependent on daily wage had borrowed Rs 40000 for his treatment, admitting him again means one or two family member loosing their  wage….where money lenders are already demanding repyment….can they really afford to give time to save Jagadish? After two days I get information that he is yet to reach hospital!!

It must be the frustration, helplessness and poverty forcing people accept things easily as their fate! Is it the fate which is preventing Jagadish from getting care or is our health system failed to provide care for people like Jagadish or access care? Who should be blamed for…is it the tertiary care center which did not consider worth treating him or is it so simple that we blame poverty for everything and record exclusion due to poverty??

Juliet: We met, we supported and we lost…….& witnessed family getting dismantled?

Good presentation is very important

Good presentation is very important and I apply this concept”. This is said by one laboratory technician working in a Primary Health Center (PHC). He believes that if he provides his laboratory services in a presentable way, he can earn the trust of the people. “People will come to me and they will not go to private laboratory unnecessarily where they have to pay more for the same kindof laboratory test which I can provide them free of cost”

This he is doing by simply giving the laboratory test report in a format developed by him and using the print copy of that to give report of the patients. Simple thing can make differences. He developed separate format for ANC and separate for other general laboratory test.

He is keeping all daily and monthly chart update. Well maintained registered. Neat and clean laboratory.

While talking to him and observing all these, immediately in my mind I was relating him to my recent experience with private hospitals recording system during my father’s checkup where they gave all medical records of my father in a folder and also while my friend was admitted in a hospital, nurse was visiting her after every two hours, checking her BP, temperature and putting it down in a diagnosis sheet. That time I was impressed and felt good and was thinking why these kinds of services are not available in Government health facilities.

And now when I am relating my experience with this, I am wondering if he is having the knowledge of importance of “good presentation” or good patient documentation. Why not other has this knowledge?  Are they do not know its importance and how it will benefit them? Why cannot do they do their bit like him? Is it due to they need training on it? Or they are over burden?

Anyway, I personally realized and learned from him that if I can do my bit by presenting my research work or field experience in a presentable way (through blog, article etc) and share, it can benefit the society to a large extent and also to me 

Juliet: We met, we supported and we lost…….& witnessed family getting dismantled?

Is health camp an effective stratergy

Health ‘camps’ are one of the strategies adopted by both government and non-government organizations. This literally means that a team of health professionals ‘camp’ in an area to carry out a limited health intervention. For instance, government organizes sterilization camps for women. Or an NGO organises a diabetes screening camp. Or a private hospital organises a blood donation camp. Unfortunately government pays little attention to the quality of sterilization service and tends to focus on targets. Or there are NGOs which conduct camps just as an activity, which do not yield quality.

KG Halli is one of the 198 wards in the greater Bangalore metropolis with a 45000 population, and we from IPH work with the community to improve the quality of health care in this area. Last year a grass root NGO which is working with the slum inhabitants requested our support in mobilizing the community for an eye camp. To our surprise, it was only screening without any follow up. After the camp, people from the community started asking us whether we would give them any material aid like spectacles and so on. We told them they need to ask the organizers- the hospital which did the screenings. Unfortunately they were advised to purchase the spectacles at their own cost.

Many times, a health camp run by with a private hospital becomes a business gimmick. The poor attend the camp with the aim of free check up and free treatment. When they do not get free treatment or subsidy for treatment they stop follow up. While organizing health camps follow up becomes one of the important ingredient in quality health camps.

Either targeted approach without quality services or an activity without follow up will not improve the health status of the patients and will not develop trust between the community and the NGOs involved in such camps

Therefore we to organize camps and at the same time we cannot ignore offers to organize camps when there is quality in it.

We could not say no to Doctor Santhosh Benjamin from CSI (Christian of South India hospital), when he requested us to ally with them in organizing an eye camp in KG Halli for cataract surgery. We UHT (Urban Health Team) wanted put this opportunity into best use. Hence we planned the eye camp with three phase pre health camp task, actual health camp and post health camp task.

We took up publicity through announcement in different language (Kannada, Tamil and Urdu), besides distribution of leaflets. Our community health assistants announced in three different languages. We had coordination with CSI, BBMP & UHC (BBMP run Urban Health Center), and got permission letter from BBMP to use the UHC premises for the eye camp. We purposely selected UHC to do eye camp, in order to strengthen the link between the government facility and the community. The message was eye camp followed with surgery was free.

The camp program began on time, as a result of two days publicity we were able to mobilize 89 patients. All the patients were registered with their name, address, with contact number for follow up. The activity went up to 3.00 pm. Out of 89, 19 were screened for cataract surgery and were given appointments by the doctor. The appointments dates stretched till 30th of May 2012.

In the midst of the camp the next door CHC (State run Community Health Center) staff wanted to ruin the spirit of eye camp, and went to the CSI doctor to tell her-“This eye camp is waste, the people from this area will never turn up, we have been conducting regular eye camp in CHC, anyway they give address and contact number but will not come”. Josphine (CHA) who followed him gave assurance to the doctor. “Since we are doing home visit and we knew all the patients we will make sure that they visit CSI hospital for surgery”.

However the patients who were asked for surgery did not wait for us to remind them. They promptly visited CSI for surgery. Out of nineteen patients 13 underwent surgery, two were sent back home because one has heart problem (he was asked to get report and letter from his doctor) and another person is diabetic (He was given medicine to control his sugar level). We are following it up with the other four patients. Both Josphine and Nagrathana met CSI doctor to ensure the visit of patients for surgery.

The eye camp program for the community has increased the trust on us and our work. The people from the community are demanding for more such programs. 

Juliet: We met, we supported and we lost…….& witnessed family getting dismantled?

What the numbers do not account for…..night beat in KG Halli

 Life has its unique ways of showing you what you might be looking for. As a purely logistic decision, it made more sense for me to stay overnight in the community centre and this gave opportunity to observe a different side to KGHalli….after dusk. Suddenly “urban” lifestyle took on new meaning for me in the context of health planning.

A walk down Tannery road at 10 pm is like walking down any other big street in Bangalore at 7pm. Like the jaws of a aging man, dark gaps where the bike workshops punctuate the shining rows of shops, many with brightly lit interiors, the city seems to swallow one up. I notice most of the people walking the street are men; the rare family, but as a single unaccompanied woman, I do not draw many glances. This is a world where anonymity is the norm. People are very occupied, earning their living. Every street corner has a hole in the wall eatery with the owner dishing out hot chicken wings from a frying hot ‘kadhai’. Large neon signs in every colour advertise “goodies” of all kinds, from clothes to shoes to accessories to ….and here we have it…. to medicines. As I strolled along, three large, glass- fronted pharmacies caught my attention, the window displays abundantly showcasing expensive and (to my mind), unnecessary products. The vitamins of old have been successfully replaced by “sugar-free” and equivalent products meant to lull the obese patient into the ‘soft’ pill option.

It is well known that many hospitals have their own pharmacies – convenience for the patient being the supposed rationale. By extension, the small clinics often have a drugstore next door. However, by a strange twist, the unstated, unpalatable truth is that the drugstore has the clinic and therefore the doctor. So it was with a great sense of curiosity that I wandered into the newly built 15 bedded hospital adjacent to the large glass fronted pharmacy. I had met the Managing Director , a twenties- something doctor when the hospital opened an hour ago, but community feedback was that it had not really take off. So I was surprised to see three patients in the ’emergency’ ward, all on ‘glucose drips’ , two of these being children. I caught sight of two ‘duty doctors’ identifiable by their stethoscopes and slightly preoccupied air. Evidently the beds are slowly filling up, although there is no permanent staff in place.

As I continued down the road I greeted an older homeopathy doctor known to me. When our team did a survey of existing service providers he had said he comes only once a week. Now, he sheepishly told me ,he comes every night between 9 and 10 pm, this is clear understanding with his regular patients.

And as I continue to walk down Tannery road, every clinic locked in the daylight hours when we have been visiting has been magically opened…with functioning health service providers. It appears they have each created their little niche with specific timings and patient profiles.

When we sit and plan the number of doctors required to serve a particular population ….24/7 services and continuity of care, my lesson from this night would be “Beware the oversimplifying standardisations… need to factor in the ingenuity of the human being in his need for survival, where he will not just meet a demand, but unblinkingly create it!’

So one more challenge to the complexity of local health systems……

Take a walk, my friend, take a walk……..