While sifting through updates about development initiatives by the government, either by itself, or in collaboration with the civil society, I came across some positive mentions about Mitanin, an ambitious project of Chhattisgarh government with aid of the civil society. I had lost hopes about it after Binayak Sen, who was one of the founding pillars of this concept, was incarcerated in 2005 by the state government, and so about its relevance and appropriateness in a society where state itself is playing divisive politics. Dr Sen had written a critically negative analysis about Mitanin programme in 2005 focusing on increasing state intervention and dilution of conceived approach when it all had started. So the Forbes mention of Mitanin and The Health Ministry’s Accredited Social Health Workers (ASHAs) cadre in line with ‘Arogyadoots’ of Dr Abhay Bang’s Society for Education, Action and Research in Community Health (SEARCH) and his famous ‘Gadchiroli Model’ and some other similar positive reports was reloading of thoughts about Mitanin which can be paralleled with NREGS in its scope and outreach at state level.
Mitanin means ‘friend’ in local reference. Mitanins are community health workers working at first level interface of health facilities of state for child welfare and their beneficiaries, women in hamlets. The beginning lies in Dr Sen’s work with mine workers of Dalli Rajahara which later on came up in form of ‘Shaheed Hospital’ which is separate case study. After establishing the hospital, Dr Sen and his wife Ilina moved on to work for health care of local tribal people with NGO ‘Rupantar’. To reach tribal women, they came across an innovative idea, where village women, ‘Mitanins’, where trained in primary and preventive health care aimed at checking harmful orthodox practices. These practices were largely responsible for high rural Infant Mortality Rate (IMR) and maternal deaths in the state. In one such practice, women were used to starve for five-six days after they deliver while the newborn was fed with cow or goat milk in a cloth. The initiative served its purpose and that led the state government to recognize it as a government-civil society partnership in 2000.
The Mitanin concept at a large scale was born after extended discussion involving network of community health practitioners which later on went to form State Advisory Committee (SAC) to the Chhattisgarh government on health sector reforms. This 2002 initiative was aimed at bringing about fundamental changes in state’s health infrastructure focusing mainly on rural areas as 3,818 health sub-centers each with one nurse were unable to provide outreach to around 18 million rural population of the state spread across 54,000 tribal habitations. Anganwadi system virtually failed, infant and maternal deaths and malnourishment were living stigmas. In 2003, the state government decided to appoint one Mitanin in each village.
A well laid system was put into place that envisaged selection, training and delivery modules under an autonomous State Health Resource Centre parallel (SHRC) parallel to the Health Department. Initially 54,000 women volunteers were appointed under this European Union aided and state government funded project. Also, an MoU was signed between the government and some civil society organizations like Rupantar, Jan Swasthya Sahayog, Zilla Saksharta Samiti (Durg) and Bharat Gyan Vigyan Samithi, Raigarh and Ambikapur Health Society and Ramakrishna Mission. The programme stressed especially on selection and training of Mitanins as the conveyor of the message to change was the most important link in the whole process. Mitanins were conceived to be women representatives of their respective hamlets and not villages ensuring the advantage of immediate familiarity and hence a positive note to begin the process to bring about some sort of openness among the rural and tribal women. Mitanins are trained in a unique way with aid of colours and symbols for first aid drug dispensation; for identification of dangers and risks and conveying them to upscale health care facilities for proper treatment. Emphasis is laid on to mindset change of the Mitanins so that they can bring about orientation and awareness to make their subjects willing to use public health care facilities and to do away with orthodox practices like starving women after giving birth. The training process is multilayered and runs from the top, the State Training Team of programme coordinators and subject experts, under the SHRC. The chain in between has trainers at block/sub-district level, district resource persons at block level and a field coordinator between every five blocks. All trainers and more than half of the senior trainers are women. It ensures the cohesive message flow down the line in the training hierarchy as most Mitanins belong to the orthodox and illiterate sections and hence may feel repulsive with the opposite sex, especially at the sub-district level.
Mitanins did wonderful job during initial years. Their family outreach activities targeting essential care of newborns, care of neonatal illness, nutritional counseling and counseling of mothers saw drop in negative values of major development indicators. Rural IMR came down from 85 deaths per 1,000 live births in 2002 (the second highest in the country) to 65 in 2005, almost similar to the national rural IMR of 64. The practice of starving the mother after giving birth saw a steep fall and breastfeeding for the first six months reported to be more than 80% in a 2007 report, which previously was as low as 35.1%.
But 2005 was the year of incarceration of Dr Sen and 2005 was also a year when Dr Sen seemed to be disenchanted with increasing government interference in this government and civil society partnered project. And it raised doubts for the future of the project then that still persists. He writes in his 2005 analysis of the project,
“The civil society partnership in the programme was also sought to be formalized through the establishment of the SAC. However the SAC was quickly marginalized in the decision making process, and in fact, SAC meetings have not been held at all for the last 12 months. However, this assurance was breached early in the programme. Once the State Health Resource Centre (SHRC) was properly set up and the programme got properly into swing, performance indicators took over under the aegis of an agency that considered itself to be a ‘Para-statal Body’.”
“Moreover, once the power elite in the government and outside it realized that the Mitanin was a handy new source of patronage within the village, they quickly took over and occupied all the vacant spaces in the implementation of the programme.”
“Within a year of the establishment of the new state, a very large number of new NGOs crawled out of the wall to serve as vehicles for the hegemonic aspirations of the existing elites. This nexus exerted great pressure to rapidly expand the programme.”
“As a result of this expansion, the focus shifted away from the rights based approach to one that concentrated on technical milestones. This destroyed whatever possibilities were left in the development of an approach based on a realization of the right to health care.”
“The para-statal Body, which quickly became a “quasi-statal body” implemented this total perversion of the original concept of the Mitanin.”
This analysis cannot be dismissed as it comes from someone who, more than anyone else, has the ground experience of health care practices in a typical Chhattisgarh situation and who is one of the pioneering beacons of the Mitanin programme. It was enough to sadden anyone who believes in dynamism of state-intervention-free social projects irrespective of whether the government is funding it. Government at best can monitor it and that too should be done through independent auditors. Dr Sen’s observations came at a point when the Mitanin system was well in place and the need was to rope in more and more initiatives under it. Instead, what took place is a systemic problem. Main concern is the outcome in the long run now. A project of caliber of Mitanin has always the long term goals set on the wheel with short term intermittent sub-goals. If the project is still generating positive reviews and progressive results, it may have twin possibilities.
First, it may be that the rot just has started, and it will take some time for results and productivity to go haywire and whatever progressive outcome that is coming in is a result of the good foundation laid in initial days. This one is a detrimental scenario, as it would result in total collapse of the system once the rot has reached to a sizeable proportion of the centre point of the delivery process, the Mitanin, given the pathetic and chaotic state of rural and tribal population in the Naxal violence hit Chhattisgarh. A project like Mitanin can only succeed if it can ensure a sustained, smooth and direct communication channel between the Mitanins and their target subjects. It Mitanins become a pawn of political patriotism and therefore factionalism, it will not be long before they would loose the social confidence and respect they have earned in the process, and that would be the beginning of the dead end for this ambitious project.
The second case is: the political interference is failing in its goal to make a patronage base among villages by acquiring loyalty of Mitanins. Mitanins are unusual volunteers. These women are collective groups of mostly poorly literate or illiterate hamlet dwellers. They are not paid for what they do. It is again one of the innovations of the Mitanin programme. It insulates Mitanins from the underlying corruption that might have imbibed into the system owing to the political patronage proposition as well as acts as a bypass avoiding the possible recruitment and bribing racket that would have taken shape if the Mitanins were paid workers. This leaves Mitanins with what we can say a saving grace, something we would like to deeply believe in and fiercely promote, as a motivating factor to keep engaged in their work. It is that honour, the precious commodity for a poor rural woman, that she earns in the process and which leads to her ascension in the larger social sphere of activism and a recognition that might thwart any political interference as she will try to protect her honour, her independence, her social status, confidence of her social sphere at any cost. What Mitanins did in Koriya, can be seen as a precedent in this direction. Anganwadi and primary health centers were in poor state and child heath care was almost gone. Mitanins in the region sent complaints to the district collector. They approached Supreme Court commissioners and wrote to the state government when no action was taken. The result: action was immediate. And Koriya is not the standalone case, they are swelling in numbers. Mitanin officials maintain over 10,000 complaints have so far been filed by Mitanins against the erring public health centers. Moreover 5000 of the Mitanins stood in the Panchayat elections and got elected. No doubt, Mitanins have achieved a great feat in a small time frame. They have been a contributing force in improving major health indicators of child and maternal health in the rural Chhattisgarh. A report by the British medical journal The Lancet observes, “Much of the improvement in child survival rates in Chhattisgarh undoubtedly relates to better health-seeking behaviour and childcare practices. The initiation of breastfeeding during the first two hours after birth increased from 24% of live births to 71% of live births, and the use of oral rehydration salts in the management of diarrhoea in children younger than three years increased by 12% in the two weeks before the survey,”, it goes on to add, “Overall, the state has seen the number of underweight children fall from 61% to 52%. In addition to this, immunisation has increased from 22% to 49% in the 1-2 age-group.”
We all would like to believe in this second possibility case if the Mitanin programme is still delivering despite fears of Dr Sen. We would love to see the slogan of a Mitanin “Swasthya Hamar Adhikar Hawe” (Health is Our Right) echo just not in voices of present day 60092 Mitanins of the state but in many more voices of the subjects of the programme. We would like to have the popular radio programme ‘Kahat Hai Mitanin; again and again to spread the message. This violence torn state needs many more healings and a successful and sustained campaign like Mitanin would be nothing more but just one healing touch in the wave of many scars left by the Salwa Judum experiment. If Dr Sen’s mention of ‘para-statal’ and ‘quasi-statal’ bodies is acquiring a shape more and more regular with passing time, we would pray to see Mitanins out of their sphere of influence. Expecting this is a bit unusual, but, then, nothing else would do.
