KULGAM, INDIAN-ADMINISTERED KASHMIR – Dawn had just broken on a cool November morning in Malwan, a village in Kulgam district. Meema Ganaie, 35, recounts how she struggled up the muddy, unpaved roads filled with large potholes when she was nine months pregnant with her first child.
Walking slowly, she and her husband made the 10-kilometer (6-mile) journey by foot to the District Hospital Kulgam in Kulgam town because they could not find any transportation at that hour.
“When I reached the hospital, I had no strength even to talk,” Ganaie says. “I was almost out of breath.”
In the maternity ward, Ganaie saw that two or three patients shared a single bed, she says.
Nurses performed a routine checkup, asking Ganaie about her pain and checking her blood pressure, she says. They then told her she was not in labor and had more time for her delivery. They asked her to go home and return the next day for a blood test.
“I wept on the floor of the hospital,” she says. “But the staff didn’t pay any heed to my pain despite many requests.”
At home that night in 2011, Ganaie began to suffer severe pain, she says. Her mother-in-law asked the village midwife to visit. Within 30 minutes after the pain began, Ganaie gave birth to a baby boy.
“Both my baby and I were fine,” she says. “There were no complications after my delivery.”
Enlisting the village midwife saved the family the cost of traveling to Kulgam town, says Taja Begum, 68, Ganaie’s mother-in-law. The birth occurred at night, so public transportation was not available and the family would have had to hire a vehicle.
“We are poor people,” Begum says. “The government doesn’t provide us free transport.”
Ganaie is now pregnant with her second child. She does not see any benefit to delivering at the hospital, she says.
“I have a bitter experience of hospital care when I was pregnant with my first baby,” she says. “I gave my first delivery at home. It was normal. I don’t want again to beg in front of the hospital staff for help.”
When contacted about Ganaie’s experience, officials at the District Hospital Kulgam said they were not aware of the incident because they had not received a formal complaint and could give no details.
“I have no idea about this case,” Dr. Showkat Ali Looloo, chief medical officer of the hospital, says in a phone interview.
The federal and state governments have funded an agency to improve rural health care for nearly a decade. But the quality of health services in rural areas of the Kashmir Valley remains poor and difficult to access. The system lacks enough hospitals, clinics, medical staff and equipment, health care workers say. Officials and doctors also allege funding delays and misuse, although higher-level officials deny that criticism. The government is beginning to address the system’s shortcomings by building more hospitals in rural areas and hiring more medical personnel, officials say.
The Kashmir Valley, which has a population of 7 million, is one of three regions in Jammu and Kashmir state, the portion of Kashmir administered by India.
Each of the 10 districts in the Kashmir Valley has a district hospital, Dr. Saleem-ur-Rehman, director of health services for Indian-administered Kashmir, says in a telephone interview. The district hospital in Ganderbal district is still under construction.
Saleem-ur-Rehman’s department works under the Department of Health and Family Welfare of Jammu and Kashmir state. It is the primary government agency responsible for implementing national and state health programs in Indian-administered Kashmir.
In addition to the district hospitals, there are seven government-run specialization hospitals in the Kashmir Valley, Saleem-ur-Rehman says. These hospitals specialize in secondary, tertiary and pediatric care; orthopedic treatments; psychiatry; chest diseases; and obstetrics and gynecology. All are located in Srinagar, the state summer capital.
“The health sector in Kashmir is engaged in providing health care and medical facilities to the masses,” Saleem-ur-Rehman says in a phone interview.
Seventeen of the 23 villages in the Kashmir Valley identified by the government as “backward,” or underdeveloped, are in Kulgam district. The public health facilities in Kulgam district consist of one district general hospital, three subdistrict health centers, 27 primary health care centers and 90 subcenters.
The Indian government has established a separate agency to improve health care services in rural areas throughout the country. It launched the National Rural Health Mission nationwide in India in April 2005 and in Jammu and Kashmir state in December 2005.
“It is aimed at improving the access of rural people, especially women and children,” says Dr. Mushtaq Ahmad Dar, divisional nodal officer of the program’s Kashmir division. “The poor population should be able to have equitable, effective and accountable primary health care.”
The program acts as a mediator between the state health department and the rural population to improve the services and infrastructure of rural health services, Dar says.
The Indian government provides 90 percent of the National Rural Health Mission’s budget, he says. The Jammu and Kashmir state government provides the rest.
The state has used 9.87 billion rupees ($166 million) of the 10.49 billion rupees (roughly $177 million) the federal government allocated it through the program in 2005, Dar says. The central government has not yet disbursed funds for the new fiscal year, which are dependent on its performance evaluation of the agency that is in progress.
Kulgam district received 34 million rupees ($580,000) and spent 31 million rupees ($520,000) in the 2013-2014 fiscal year, which concluded in March, Dar says. The district spent those funds mainly on construction and the Janani Shishu Suraksha Karyakaram, or Reproductive and Child Health Program, an incentive program that targets pregnant women in rural areas.
Under this program, in addition to the free medical care at the hospital, a pregnant woman receives free food for up to three days for a vaginal delivery and up to seven for a cesarean section. She also receives 1,400 rupees ($23) to cover her travel expenses.
In 2012, 84,307 pregnant women and 14,796 newborns benefited from the program, Saleem-ur-Rehman says. From January to October 2013, 61,956 pregnant women and 15,079 newborns received medical attention under the program.
Another important aspect of the National Rural Health Mission program is the Accredited Social Health Activist program, under which a woman chosen by each village serves as a community liaison to the public health system. These women, known as ASHA workers, raise awareness of health services available in their villages, accompany pregnant women to the hospital, and encourage villagers to use government health services.
To date, the state government has engaged 10,779 ASHA workers to promote maternal health services in Jammu and Kashmir, Dar says. Workers receive 600 rupees ($10) for each pregnant woman they lead to hospital health services, including prenatal clinics and delivery.
But pregnant women say the quality of medical care at government hospitals is poor. Some women have paid heavily for failures in the health care system.
“I still remember the day of Nov. 28, 2012, when my cousin, who was pregnant, died due to negligence of doctors in our district hospital,” says Huzaifa Mir, of Malwan. Her cousin, Sheeraza Bi, was 28.
Early that morning, Mir and other family members took Bi to District Hospital Kulgam when she complained of labor pain, Mir says. They placed Bi on a makeshift wooden stretcher and carried her on their shoulders for nearly 10 kilometers (6 miles).
“When she reached the hospital, doctors delayed her treatment for almost nine hours,” Mir says.
When the doctors checked Bi, they found that the fetus had died in her womb, Mir says. Doctors told the family to take Bi to the Maternity and Childcare Hospital nearly 22 kilometers (13 miles) away.
The doctors did this because they realized Bi’s condition was serious and did not want to be held responsible for her death at the District Hospital Kulgam, Mir alleges.
“On our way to the hospital, we lost our daughter,” Mir says, speaking of her cousin’s death as analogous to a family losing a daughter.
Looloo, the only hospital official authorized to speak to the news media, says in a phone interview that he does not have any information on this case and cannot comment. Bi’s family did not file an official complaint with the hospital.
Misra Hussain, 24, says hospital services have to improve.
Hussain, of Malwan, is eight months pregnant with her first child and has decided she will not deliver at District Hospital Kulgam. She plans to give birth at home with the help of her mother and the village midwife. She is due in mid- to late June.
In March, an ASHA worker in Hussain’s village persuaded her to go to the hospital for a prenatal checkup, and the visit was distressing, she says. She had to wait in long lines.
The doctor was rude, which shocked and embarrassed Hussain, she says. This made her doubt doctors would care for her well during her delivery.
“The doctor who did my checkup told me everything is normal,” Hussain says, “and when I asked her about the next visit, she got angry and shouted at me to come when I am in labor, and then moved on to the next patient.”
Hussain’s mother, Jalla Begum, accompanied her on the visit.
"I don't want my daughter to deliver her baby at this facility,” Begum says. “The home deliveries are tension-free, and traditionally women get all the care by just being at home. The hospital deliveries are full of problems. There is no good care available at our district hospital. Our roads are mostly not in good condition, and it’s very difficult to reach the hospital.”
The hospital is working to improve the conditions, Looloo says. But he cannot comment on Hussain’s experience as he has no information about it.
“We are trying our level best to utilize the NRHM benefits to benefit more and more women under the scheme,” Looloo says. “We make sure all the incentives for both ASHA workers as well as pregnant ladies are disbursed on time through checks. There is always room for improvement, and we are working hard to fill all the gaps."
Dr. Nelofar Jan, a gynecologist, worked in various public district hospitals for more than 15 years before retiring from government service in September 2013. She now runs a private practice in Srinagar but regularly visits rural areas as part of her consultation work.
She has seen firsthand the suffering of pregnant women in rural areas of Kashmir Valley, she says. Many of them cannot reach a hospital in an emergency or access health care during pregnancy or when they deliver.
Most women in rural areas deliver at home because their villages lack medical facilities and they cannot afford transportation to distant hospitals. Further, rural roads in Kashmir Valley are impassable during winter and heavy rains.
During Jan’s years of service in rural health care, she found that almost 85 percent of deliveries in rural areas took place at home. Women who deliver at home do not take antibiotics to avoid infections, Jan says. Only hospitals can provide the medical services that women need during delivery to protect them and their newborns.
“All these problems usually don’t get highlighted, as women from remote areas generally visit hospital only when there are complications,” Jan says. “Even the maternity mortality rates are not available with the health department.”
Data on the number of pregnant women accessing rural health care services is not available, Saleem-ur-Rehman says. The department is developing plans to introduce a database system to track this information.
Statistics on pregnant women’s access to health care and the negative impact of home births are sparse because most home births occur far from the hospitals where the government collects such information, says Dr. Mir Mushtaq, spokesman for the Doctors Association of Kashmir, an association of doctors from the public and private sectors working in the Kashmir Valley.
Even when a pregnant woman reaches a hospital while having childbirth complications, she may face other challenges.
There usually are no specialists available in the District Hospital Kulgam late at night, says Ruby Akhter, an ASHA worker in Malwan.
“Normally, there should be a gynecologist and a pediatrician always available in the hospital for emergency purposes,” she says. “It becomes very difficult for a simple postgraduate medical student or junior doctor to do surgeries if there are complications.”
If no obstetrician is available, hospital personnel refer patients to hospitals in Srinagar, 80 kilometers (50 miles) from Malwan, Akhter says.
Eleven doctors declined to comment on the circumstances at the public hospitals where they work for fear of losing their jobs.
There are at least three times as many small private clinics as there are government hospitals in Srinagar, says Dr. Iqbal Ahmed, a doctor with a private consultation clinic in the summer capital. But he calls it unimaginable for poor residents of rural areas to obtain care at private hospitals because of the expense.
“You are charged for everything,” he says. “Nothing is free of cost. At government hospitals, on the other hand, you may only have to buy some medicine, but everything else is free.”
Mushtaq agrees, calling district hospitals the backbone of rural health care in the Kashmir Valley.
“But, unfortunately they have turned into referral clinics,” he says. “It is quite unfortunate that rural doctors dispatch patients to Srinagar, even with ordinary ailments. That puts pressure on the entire health care system.”
Doctors should refer women to hospitals in Srinagar only when they have made every effort to diagnose or treat them without success, says Mushtaq, who works in a government subdistrict hospital in Budgam district. There is no system for tracking deaths and health complications from hospital negligence.
Staff members in rural hospitals are unjustly blamed for referring patients to the main hospitals in Srinagar, says a block development officer, a senior administrative post in the government health sector, in Kulgam district.
“We have no other option,” says the officer, who requested anonymity for fear of being fired.
This is because doctors and other medical professionals assigned to rural hospitals do everything they can to transfer to urban areas, the officer says. Urban areas, especially Srinagar, have better roads, houses, schools and services, ensuring a more comfortable living environment for medical professionals and their families.
“They spend a lot of money and utilize bureaucratic channels to have their postings and transfers changed to city hospitals,” the officer says.
Jan confirms this from her years as a doctor in the public sector.
The two decades of conflict in Kashmir have also stretched staff thin, Mushtaq says.
“There are so many casualties due to killings and injuries so that the entire focus goes to deal with those emergencies,” he says.
Jan says this prevents women from accessing maternal health care services. Most patients in government hospitals are being treated for gunshot wounds and tear gas injuries.
“Maternity health has been affected badly,” she says. “It becomes very difficult to reach out to the rural women who suffer from maternal health issues due to the rampant strikes and volatile nature of the place.”
There is a dire need to add hundreds of doctors, paramedics and nurses to upgrade the rural health care system, she says.
“We have to equip the district hospitals with latest equipment and then employ enough people to operate the equipment,” she says.
Shabir Ahmad Khan, former state health minister of Jammu and Kashmir, addressed the region’s shortage of medical personnel at a media conference in September 2013.
“The state hospitals are facing a shortage of 6,000 employees, including doctors and paramedics,” he said. “At present, Kashmir has 1,279 available doctors, and the number of paramedics is greater than the doctors.”
Saleem-ur-Rehman confirms that the shortage remains an issue.
“There is a dearth of doctors as well as other hospital staff in various health care institutions of Kashmir,” he says.
Officials and doctors also debate funding delays and misuse.
A data manager, a position responsible for managing the database of records for the National Rural Health Mission at a public hospital, also requested anonymity for fear of being fired.
“Under the Reproductive and Child Health Program, we don’t get funds on time,” the data manager says. “For example, we received the pending amount two days before the end of the financial year in March.”
This was the allocation of funds for the entire fiscal year, which ended March 31. Programs suffer because of funding delays, the data manager says.
“But at the 11th hour, we get pressure from higher officials to spend the money so that audits are properly maintained,” the data manager says.
Dar does not deny that funds get delayed.
“But the delay is not from our side,” Dar says, attributing the problem to the Indian government.
The bureaucratic process takes a long time and involves many departments and internal audits, he says. This causes delays for all National Rural Health Mission programs across India, including those in Jammu and Kashmir.
An official from the Public Relations Department of the Ministry of Health and Family Welfare headquarters in New Delhi, the capital of India, denied the delay in disbursement of funds. The state government blames the central government for its own performance failings, he says.
The official declined to be named under orders not to comment on controversial issues following the recent formation of a new central government.
Misspent resources pose another challenge to the health care sector, Mushtaq says.
For example, the government wastes money renting privately owned buildings to house clinics and building new structures instead of improving infrastructure and equipment within existing public buildings, Mushtaq says.
“It doesn’t make any sense to construct new buildings when the already established units are not well-equipped,” he says.
Dar denies any misuse of National Rural Health Mission funds.
“As per the requirement, new hospitals are being constructed, and we are also working to strengthen the already-established hospitals,” he says.
The government is addressing these challenges and shortcomings by recruiting new staff and expanding medical infrastructure in rural areas, officials say.
Saleem-ur-Rehman is the highest official responsible for improvement of all programs funded by the central government in Indian-administered Kashmir.
“We are in the process of recruiting doctors,” he says.
Dar says officials in the National Rural Health Mission program are working hard to improve its services, though he could not elaborate on specifics.
Between December 2005 and November 2013, the National Rural Health Mission added 4,958 medical professionals to the state health care system, according to the Jammu and Kashmir government’s 2013-2014 Economic Survey. Eighty percent were paramedics, and 20 percent were physician specialists, general doctors and nurses.
Construction of more hospitals is ongoing, Saleem-ur-Rehman says. The government has not finalized the number of new hospitals it will build, but it plans to build a new pediatric and maternity hospital in Srinagar and upgrade existing hospitals.
Pregnant women such as Ganaie say they would welcome improved medical services at state hospitals.
“At present, I don’t see any benefit from the hospital delivery,” Ganaie says. “But, if there would be good services, where both the mothers as well as children can lead happy and safe lives, I am sure we would be happier to give birth to our babies in hospitals.”
GPJ translated some interviews from Kashmiri and Urdu.
Taja Begum and Jalla Begum are not related to each other. Dr. Nelofar Jan and Rosy Jan are also not related.