DMF best practices: How Bijapur started a new healthcare model

by Chinmayi Shalya

This is the fifth section in a multi-part series

The forested and tribal-dominated district of Bijapur in Chhattisgarh would not be a place where anyone would look for quality healthcare facilities two years ago. The district hospital was only semi-functional, and as admitted by the officials themselves, could provide services equivalent to a primary health centre (PHC).

More than two years since 2017, the district has turned the tables by developing a hospital compliant with Indian Public Health Standards (IPHS) where surgeries can be done, let alone regular treatment.

The district also converged its district mineral foundation (DMF) funds with National Health Mission funds to pay competitive salaries to doctors and hire them to work in the district. Accommodation and other necessary support were also provided.

“The challenge was to convince doctors to stay and work here. Competitive rates were an incentive. To ensure they are able to perform, we did everything to match up the hospital infrastructure and facilities too,” said Ayaaj Tamboli, collector, Bastar, who was, at that time, the Bijapur collector.

The story of this turnaround is now almost a fable — an example that has been emulated by other districts.

India is in the grip of the current novel coronavirus disease (COVID-19) pandemic, where public healthcare is at the forefront of response as well as spotlight for the neglect it has faced over decades.

At this time, Delhi-based non-profit Centre for Science and Environment’s latest report District Mineral Foundation (DMF): Implementation Status and Best Practices has documented some investments in mining districts on healthcare that hold the promise of improving people’s access to healthcare services.

These include hiring of doctors by various districts, upgrading district hospitals, improving last-mile healthcare access and direct benefit transfers (DBTs) to communities with mining-related disease burden.

Hiring doctors, upgrading hospitals and improving primary health access

Delivery of healthcare services is a multi-pronged problem in mining areas, with an equal dearth of infrastructure and resources as well as shortage of healthcare staff to run the facilities.

In West Singhbhum (Jharkhand), for instance, a measly 14 per cent villages have a PHC within a five kilometre radius. Keonjhar (Odisha) had a 50 per cent shortfall of doctors at the district hospital according to a 2018 assessment by CSE.

Now, many mining districts have followed in Bijapur’s footsteps to hire doctors on contracts. The first was neighbouring Dantewada where 232 healthcare staff, including nine specialists have been hired since.

West Singhbhum and Dhanbad in Jharkhand, Keonjhar and Sundargarh in Odisha also hired doctors on contract. The salaries are varied and often negotiated based on the qualification, experience and the location of posting.

“We are also trying to supplement this by hiring paramedics as well as nursing staff recruited directly from the local nursing college,” said Nikhil Pavan Kalyan, collector, Sundargarh district.

Attrition among hired doctors is about 50 per cent. However, locals say that having some doctors has been a big boon.

Mining districts are also upgrading public hospitals to ensure full compliance with IPHS norms.

Bijapur, for instance, converged DMF, Special Central Assistance or SCA and corporate social responsibility (CSR) funds to construct operation theatres, ICUs, labour rooms, pathology laboratory, blood bank etc, and a 50-bedded mother and child health centre.

Chatra (Jharkhand) is developing an IPHS-compliant hospital by upgrading a community health centre (CHC) to service Tandwa and Simaria, the district’s directly mining-affected areas.

Both these areas face a severe dearth of doctors, nurses and even medicine supply, as verified by CSE’s ground observations. Chatra has tied up with Tata Trust’s Transforming Rural India Foundation as a technical, non-financial partner for this.

“DMF can be a useful source of funds to boost healthcare in remote areas. Bijapur’s example shows that if holistic outcomes are set after due planning and gap analysis, health service delivery can be achieved,” said Raman Kataria from Jan Swasthaya Sahyog, an organisation that works on rural healthcare and nutrition in Chhattisgarh.

Other experts also concur stating that, though small, these facilities do serve to improve health access and can be consolidated further.

Odisha’s mining districts, Sundargarh, Angul and Keonjhar, have used DMF for mobile medical units (MMUs) and digital dispensary to improve first point of health contact for people in remote areas.

Sundargarh and Angul have roped in a non-profit with prior experience to run the MMUs and manage regular rounds in selected villages, ensure staff, equipment and medicines etc.

Sundargarh is operating 25 MMUs across the district, focusing on gram panchayats where there isn’t an operational PHC or CHC, while Angul is operating six MMUs in the mining-affected areas.

Keonjhar has set up digital dispensaries in three mining-affected areas — Joda, Banspal, Harichandanpur. The dispensaries are run on by Glocal Healthcare, an agency which specialises in rural and remote areas healthcare access.

The dispensaries run through a system that connects the patient with the best available doctor available online after a nurse feeds in the symptoms.

According to the consultation, the patient is either prescribed medicines or sent for an advanced referral. The dispensary also has a small lab where basic blood, pregnancy tests can be done.

The PPP model of operation has its challenges. It is tough to monitor them if they are scaled up.

Also, as health practitioners point out, they cannot be a substitute for a public health facility. However, as a measure of short-term reprieve, the initiatives have been well-received, show ground interactions.

DBT for silicosis victims through DMF

DMF is being used for DBT to help mining-affected communities, more specifically, silicosis patients and their families in Rajasthan, one of the top five DMF states in India, in a first of sorts.

Silicosis is a terminal disease caused by constant exposure to soil, silica, coal dust and asbestos, often what sandstone mine and construction workers face. State government statistics show 7,600 were certified with silicosis.

More than 28,000 are still pending for verification as of March 2020. Through DMF, Rajasthan has increased the rehabilitative aid to silicosis patients to Rs 5 lakh from Rs 4 lakh.

The state has also come up with a pneumoconiosis policy which involves families of silicosis victims under widow pension and child aid schemes, irrespective of the income bracket.

The policy asks for the creation of a pneumoconiosis fund converging DMF, CSR and other available state funds to disburse rehabilitative aid directly to patients and families.

It has also asked for a framework to mitigate environmental and health damage caused through mining through better enforcement and incentive-based mitigation frameworks, building capacity of local health centres and staff for timely detection of silicosis and generating livelihood avenues for kin of deceased, most of whom are young widows.

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