Human resources for health are a critical building block of every health system. In India, the health system has struggled with the shortage and inequitable distribution of human resources, including the challenge of attracting and retaining health workers in remote settings. This blog, on the lives and work of crew aboard a mobile boat clinic, illustrates the intrinsic motivation of the health workers and support staff in delivering services to one of India’s geographically remote and challenging areas, the Majuli Islands in Assam, and the impact of such motivation on the quality of care.
Against all adversities
The north eastern state of Assam is home to the world’s largest riverine – the Majuli Islands. These islands on the river Brahmaputra (one of the world’s largest rivers) are accessible by boat from districts like Dibrugarh and Jorhat on the mainland, in upper Assam. It can take between a few hours to nearly a week to reach these islands, with uncertain access to-and-from the islands during bad weather, or the monsoons, severely impacting access to health services for the islanders. In order to address the challenge of physical access to health services, in 2005 the Centre of North East Studies (CNES) decided to use a local innovation – that of boats to provide health services to people on the islands.
Over the last decade the innovation was scaled up with support from multiple stakeholders including the National Rural Health Mission (now National Health Mission) and UNICEF. The locally made boats house a crew which typically comprises of a district programme officer, 2 medical officers, 2 auxiliary nurse midwives, 1 general nurse midwife, 1 pharmacist, 1 laboratory technician, community workers and boat crew including a cook and captain. The remote location of the islands mean the crew often stay aboard from between 2 days to a week, sharing rooms and a toilet. Habitation is often a 2-4 km walk from the shore – which on sandy terrain, carrying laboratory equipment and medicines, can be a challenge. In the dry season, the water levels recede, leading to a wider shoreline and water levels so low that the boats can’t reach the shore, therefore fragile country boats are used to access the islands from the river, with a longer walk, exposing the crew to snake bites, leeches, allergies etc. During the monsoon, crew can be stranded on the islands (as happened last year), and need to be airlifted to safety. Community workers, or the Accredited Social Health Activists (ASHA) conduct outreach programmes prior to a visit by a boat clinic informing villagers of the health camp. The camps provide essential health services, including nutrition, immunization and essential maternal and child health services. Laboratory services are offered on board; referrals are made for more serious cases.
Teamwork and Companionship
The camaraderie and dedication of the boat clinic crew is a testimony to the role of teamwork in delivering health services. Crew members tend to abide by their schedules and designated role. Food needs to be cooked and served on time, tents need to be pitched, and equipment needs to be carried long distances. Teamwork ensures a synchronicity which can have camps set up and dismantled within 15 minutes!
Female nurses often bring their offspring onboard these trips, and team members pitch in to help, taking turns for childcare. After a long day’s health camp, crew members find time to have fun, fish, play football, cook, or swim. Often doctors use spare time on the boats to study for exams. The companionship and time in nature, a friendly environment and crew are probably some of the reasons for the contentment, and dedication of the boat clinic health workers.
Distanced from their families, surviving on the river for days on end with limited resources including water for bathing, not to mention life on a river which can be dangerous during the monsoon season – and yet, despite the hardship of life on a boat, the crew members are cheerful and passionate about their work.
Bond with Patients
The friendly rapport between the community and doctors is evident. From my observations while attending health camps across islands, the commitment of the medical officers, nurses, laboratory technicians and pharmacists to the wellbeing of the patients was crystal clear. Most knew their patients, and communicated with them as though they were family.
One of the islands had a lady who had delivered a baby at home in the presence of a midwife just a few hours prior to the boat clinic arriving at the island. The mother was struggling to feed the child; over the next hour she was coached by the nurses as to how to feed her baby, bathe her and most importantly how to cradle her. It was magical watching a mother feed her baby for the first time and the easy relationship of the mother with the nurses who had been monitoring her pregnancy through the health camps.
Children would race up to the camps, walking up to the doctors with naughty smiles on their faces as they picked up their packets of ORS (Oral Rehydration Salts) – delighting at the sweetness of the ORS, reminiscent of glucose (a sweet powdery substance commonly used to prevent/treat dehydration) readily emptying the powder onto their hands and licking it up, while waiting for their family members to finish their checkups. The doctors sometimes use this as an opportunity to check children for anaemia; children below the age of 5 are given Vitamin A drops.
Nearly the entire crew shared a work ethic very different from common perceptions on the public health system. When talking about maternal and infant deaths, they put a face to these names so they ceased to be just numbers to them but actual people, whom they had spent a specific amount of time with. The pain with which an ANM or a Medical Officer would talk about a pregnant mother who died due to heart failure, despite their instructions, spoke volumes about their involvement in a patient’s life. It’s no wonder that patients are seen waiting expectantly at the shores of their islands for the clinics on the scheduled days. They believe in these doctors and nurses.
Discussions on human resources for health need to focus as much on hardware (numbers, distribution, training, salaries), as on software (passion, teamwork, emotional connect with patients), while acknowledging, clearly, that there are links between both. The medical crew’s stories convey that no amount of discussions on universal health care will be helpful unless these are driven by instituting a responsive and responsible culture of care. The experiences of CNES’s medical crew are an inspiration that needs to be told and retold.
Note: This article is based on an independent study by the author during May and June 2016. The author is grateful for the guidance of Prof. Arima Mishra, and facilitation of fieldwork by the C-NES team.