The Change Agenda : Health

One of the sectors that I believe that needs to rework some of its strategies for implementation is the health sector. Most of the national policies for health, specially under the NRHM, though have some specific clauses for mountainous and tribal regions, there are certainly two issues that are not adequately covered in terms of policy or practice. 

The first issue is site selection for health facilities. Most health facilities (health sub-centers and Primary Health Centers) stand on lands donated by a local community member. We all know that except in few cases, often there is a need for cajoling someone into offering a plot of required land at no cost or at exceptionally low price because that is what the community is willing to pay collectively for it. So, what do you get for free or minimum cost? The minimum! Often the place is in a very vulnerable location either near a river, or on a slope or in flood prone location, as it happens in deltaic plains. Placing critical life line structures in vulnerable locations is not a right approach. This needs correction. The governments may have have to buy the land or at least a proper land area vulnerability assessment must be done before a plot of land is purchased.

The second issue is the case of vaccine packaging. Those in health sector know that most vials with vaccines for children come in doses of 10. Even in the plains where the population is much higher, it is difficult at times for the health Staff to open a vial because there aren't enough children to whom she can administer the vaccine. In the hills of Uttarakhand and in similar terrains in the country, where the population is still thinner and spread in far off places, this is much more difficult. So, either citing the policy the vaccine is not administered as the health staff cannot open the vial, or, the vaccination gets delayed, and the chances of a child not getting vaccinated increases. There is a serious need for the Ministry of Health and Family Welfare to review the policy on medicine procurement - specifically relating to packaging of vaccine vials. The manufacturers must be clearly instructed to prepare vials of 3 dozes for the hills and 5 dozes for the plains. If there are problems in production of multiple types of bottling, the vaccines can be packed in dozes of 5 per vial across the country. This would reduce wastage, improve vaccination and ensure greater results. Once the size of the vials is changed, the rules can be altered to ensure that even if there is one child, the vial can be opened so that no child is missed!

Prices with pharma companies must be renegotiated as these may try to sell hard the larger vials because they get paid based on the number of doses a vial holds.

Kedarnath : Satellite images showing pre-disaster  & post-disaster situation; In the post-disaster image (right) you can also notice the birth of a new stream!

Susceptibility and Consequential Vulnerability

As I continue to work on the Social Sector Plan for the most affected villages in five districts  of Uttarakhand, along with lots of inputs and preparatory works from my colleagues in the districts and in the State, I began to wonder about one thing. What are we really focusing on? Or rather, what are all the humanitarian agencies focusing on in their emergency response in Uttarakhand. As I kept pondering through these questions, in one of the daily mails that I share with my colleague (and mentor ) Sarbjit Singh Sahota of UNICEF, wrote " Response to Event Vulnerability will happen, but what about our response to Consequential Vulnerability?"

The people who were most vulnerable and highly exposed at the time of hazard striking them are dead and gone. Families have have lost their loved ones, bread winner, cattle, shops, valuables, almost everything ! The humanitarian agencies continue to respond with food baskets, clothes, temporary shelter, medical camps etc. There is an attempt to strengthen the emergency response system, the critical infrastructure and life line services which have been highly impacted in these districts. So, we are taking care of the "event vulnerability", i.e. people and resources who were vulnerable and have been affected by disaster are taken care of temporarily.

But what about Consequential Vulnerability -- vulnerability that is born of a disaster? People who were better off or in lower middle class, now have become poor. People who had land have now become landless and homeless as their houses and land were carried away. People who had a bread winner at home have become widows, father or motherless, orphans. People who could cultivate some grains have become paupers. Those who earned from shops and cattle have now come to seek asylum. 

The way we treat consequential vulnerabilities today will have an impact on event vulnerabilities and susceptibility of these people to disasters tomorrow.

Time the Compensation

One of the questions I have begun to ask in this assignment in Uttarakhand state is: Is the timing of giving compensation to families who have lost their houses "the right time"? Let us examine the facts. 

Usually after a disaster, immediately there is a hue and cry for compensating the loss. The governments, in order to get a political mileage and to silence the voices, immediately announce a compensation package, and at times it is even revised to increase the earlier package. In the case of Uttarakhand, each family that had lost its house got 200,000 rupees. Indeed, although the disaster had taken place on 16 - 17 June, during my visit to Pithoragarh district closer to the Nepal-Tibetan border with India as early as in the first week of July, I found that the families had been compensated. I was pleasantly surprised at that time the compensation has reached the community and people are happy that they received the money without any delay.

But this is the rainy season. People do not have much work. Most of the affected families are living on the generosity of the government which comes through free or subsidized food and some benefits given by the non-profit organizations. Today, that is about two months from the disaster, how much of that 200,000 is left with the families to reconstruct their houses? In any case with the rains continuing, the house reconstruction cannot start before October. So, how much will be left on the first day when the deprived family needs money? People eat, purchase clothes, pay for medicines, they travel and buy some utensils etc. with the same money.

This takes me to the first question: Is the timing of giving compensation to families who have lost their houses "the right time"? Or, should the "housing compensation be better timed?". One option I would propose is the following (an idea I shared with a few and later I wrote to Eilia J. in Care India yesterday, to share my opinion. 

Hon'ble Chief Minister of Uttarakhand gives compensation 

I would propose that the government gives the money in 3 or 4 installments; and all installments should be paid as advances (unlike in Indira Awaj Yojana where money is retroactively paid). This might have some force on the families too to take responsibility for the money and the house, while at the same time help in standardizing, completing the housing, and improve the the Cash Transfer mechanism as well.

If given in one time advance, it looks like the government has given the compensation, and it has technically washed its hands off! A longer term engagement by splitting the money will also give space for more dialogue on land rights, land usage issues, environmental concerns, risk prevention and management etc. 

May be it is time to rethink some of our compensation policies.

Working with Body and Mind

On 21 July, on arrival I checked in into a hotel on Rajpur road with a bit of bargain, after they agreed to give breakfast and dinner as complimentary for Rs. 1,500 per day. My room was in a corner, with very little light coming into the room. The pressure of work was catching up on me. On 22 July, Monday we had the initial orientation with Sarbjit ji leading it. On 24th we were busy in the morning at a Coordination Meeting called by  Sphere India and State Inter Agency Group at Hotel Aketa. Mr. G.Padmanabhan joined us in the afternoon, as we were told that GP (as we fondly call him) would be staying with us as an expert guide on the part of UN. So, that is going to be my biggest asset as I can count on his wisdom and experience.

We were given 10 days time to complete the first part of our task: clusterization of affected villages and prepare a Social Sector Plan for five districts. By the second day I could feel the heat of work, as I found that there is vast difference in the quality of people I had at hand. It was getting tough each day: there were several meetings lined up each day at the state level with various departments, break the grey cells to plan how this Social Sector Plan would look like, and coordinate the six district coordinators who had come with various experience, culture, educational level etc. And, as myself was unsettled, I was really wondering if I fit into the shoes.

In the second week, on Saturday and Sunday (27th & 28th) I took some time off and went around searching for a cheaper and better place to stay. It was certainly a frantic search, as I saw whatever little money I had was getting eroded day after day. At last I found a place "Butola's"--a new guest house just two months old. The rooms were clean and tidy, the room was bright, and even I had a bit of sunlight into my room at different times of the day. Though the place was about 5 km from the Secretariat (the headquarters of the Uttarakhand State Administration) from where I am working currently, it was well connected by road. And it was just about 2 km from my colleagues P.D.Mathur's home. So, at last I shifted there at Rs. 3,500 per month, and with additional 2,500 for breakfast and dinner. Since I found that the food is not worth it, after two weeks, I opted out of the dinner package and kept the breakfast only.

Once I got settled, I was now able to focus better on work. By 30th July I cracked the idea of how to make the Social Sector Plan, and started working on it. But, because the data was not coming from the districts, it kept dragging eternally, and by 15 Aug, we could complete just 3 of such plans. Two more are still pending.

But in the meanwhile, I have been able to get into lot of networking with several departments of the government: Women & Child Development Department, Education, Health and Disaster Management - to be specific. I also found some not so frequented sections to come around and help me. I took assistance of the GIS section in the Disaster Mitigation and Management Center and the NIC cell within the Secretariat to help me with several information or to validate certain information. 

I also grew in good friendship with GP, Sarbjit ji, Shachi, Rahul, P.D. Mathur, Shailesh, Divya and Aashima. Aashima left the team due to personal reasons after a three week stint here. I also got some new friends in the government: Mr. Sudhakar, Mr. Badauni and Ms. Suman. Things are shaping up for better. I have a hope of completing the assignment on a high, though I have to work long hours that take a toil on my body and at times on mind.

Note: Indeed in the second week, I was so stressed that I took a stress test and other tests relating to heart just to check if I am fine. Or, else I should quit this place. But, luckily, my system was able to take it and move on.

The Journeys

On 7th we traveled from Munsiyari to Pithoragarh. On way we were informed that due to bad weather helicopters won't be flying, and so we will have to come by road. Noting that the roads are in extremely bad conditions and we were really up in the mountains, we knew that we would be having some real long travel. Bharati, one of our colleagues wasn't feeling well. We gave an avomin so that she would not vomit on the way, and we reached Pithoragarh at about 1.00 pm. We had lunch and we traveled again, crossed Almorah, and traveled further West, and at last stayed in a little town on the way as it was already 9.30 pm, and it wouldn't be safe for us after that. Our driver, Mr. Neeraj had been driving since morning 7.00 am from Munsiyari. On 8th morning at 7.00 am, as it continued to rain we left for Dehradun and reached at 4.30 pm. This was really a very long drive. 

On 9th & 10th, we continued with preparations of our reports, and on 11th I traveled back to Delhi, and then to Kolkata. My friend Tanaji was kind enough to allow me to use a car to reach home at night itself. I had three students from Seattle with whom I had planned to have dinner. So, on arrival in Kolkata I traveled to Tung Fung and had a good dinner. Then proceeded by car to Bolpur.