A day at a Primary Healthcare Center (PHC)

This blog is part of the series of blogs on Aspur Project under the Primary Healthcare Initiative (PHI), a partnership between Basic Healthcare Services and Centre for Healthcare.

It was a hot and dry day, right around the corner from one of the summer heat waves that targeted Rajasthan. When I reached the PHC in Nithauwa in Aspur Block (Dungarpur, Rajasthan), at a little past 10 AM, day-to-day PHC activities were already operating at full-swing. This visit to the PHC in Nithauwa was part of a UNICEF program project run together by Basic Healthcare Services and Center for Healthcare at IIM Udaipur. The aim of this project was to strengthen PHCs in the Aspur block, and my field visit was the first of many such field observations conducted since. As I entered, Jitesh Ji, one of the four General Nursing and Midwifery staff (GNM), was seated right at the entrance of the Nithauwa primary health center (PHC), running the outpatient department (OPD) of the PHC. Opposite the OPD station is the pharmacy of the PHC, well-stocked, organized, and always manned.

I sat down on one of the patient seats in the waiting area, where a few patients had already lined up for their consultation with Jitesh Ji, before their consultation with the medical officer (MO), Dr. Pradeepa. The patients came, waited, underwent consultations, and were given a prescription. They then showed the prescription, or ‘parchi’, to the pharmacist through the window in the pharmacy wall and received their medicines.

No money was exchanged, and when I later asked Mamata Ji, another GNM, how much patients had to pay for consultation and medicines, she confirmed that outpatient care and medicines are entirely free of charge (since April 2022). In consultations with patients, Jitesh Ji was following a set protocol: for adults, he would note down their blood pressure and other vitals, especially for pregnant women, and for children, he would note down their height and weight.

Now, with children, height and weight measurements would be tricky. The littlest ones would squirm, while the slightly older ones would cry. In response, Jitesh Ji would ask them what was wrong and playfully scold them to get them to comply. When adults walked in, he would make small talk with them before beginning the medical consultation, asking them about their lives, their families, going-ons in the community…The exchanges, I noticed, were warm and informal, while he followed protocol. The pregnant women that came in for their regular checkups, after consulting Jitesh Ji, were sent to the laboratory further inside the PHC, right opposite the inpatient beds. On this day, Mr. Ravi, GNM, was running antenatal checkups, ensuring that the pregnant women visiting the PHC, who were scheduled for their check-ups were given their required blood and other tests, and that the results and their visit was documented in the ‘Mamta Card’, the individual register assigned to each pregnant women to monitor her pregnancy. Often to-be mothers, especially those pregnant for the first time, would be anxious about these tests. In such circumstances, Mr. Ravi, along with the family members of the mother, would calm her down, rationalizing with her that the tests were harmless and empathizing that pregnancy is, indeed, an intimidating thing!

I decided to walk around the PHC, to understand the lay of the land. Along with the OPD desk, pharmacy, lab room, and inpatient care area, the PHC also had an emergency room, a meeting room, a family planning room, a kitchen, and the delivery and childcare room. The different rooms were populated as and when required. The emergency room was usually only visited for some emergency stitching, bandaging, and injury care; the family planning room and meeting room often only used by PHC and BHS employees, and staff; and the delivery and childcare room housed all the recent mothers and newborn children, kept there for postpartum care and for neonatal monitoring. The latter, I noticed, was the most consistently occupied, while the other rooms saw an ebb and flow of patients.

After looking around the PHC and talking to different staff, I sat back down at the OPD unit to better understand the OPD processes, and to observe the every-day happenings of the PHC for the last hour of OPD consultations. In this time, many mothers walked in with their ill children, some dropped off by auto-rickshaws, while others seemingly arrived on foot. One such instance was of a mother and father who arrived at the PHC with a very young baby wrapped inside the mother’s sari, with a thick scarf protecting the baby’s head from the sun. The mother sat down next to me with the baby, while the father spoke to the PHC staff. The baby, now no longer hidden by the scarf, peeked around the PHC while in her mother’s lap. When their time came, the parents and baby made their way to the OPD table. ‘Kya hua?’, asked Jitesh Ji. ‘Bukhar, khaasi, zukhaam’, said the mother and they continued chatting, placing the wide-eyed, red-nosed baby on the weighing scale, and picking her up, poking and prodding her with little protest from the baby. After consultations with the GNM and MO, as the parents were collecting medicines from the pharmacy, Jitesh Ji turned to me and said, ‘Gudiya ko teen din se bukhaar hai’. The little girl had had a fever for three days, but her parents only just visited the PHC as they were busy attending wedding festivities in the community. Jitesh Ji’s tone was disapproving, and he made sure that the parents heard, who smiled sheepishly. With little condescension, Jitesh Ji adequately communicated to the parents that such behavior was not done. His promptness in deducing their delay in coming to the PHC also portrayed a key reason behind the smooth and effective functioning of the PHC and treatment of patients: the medical staff at the PHC is really well acquainted with and has nuanced insight into the community within which they are operating. Many are indeed from this community.

Soon after, another family of mother, father, and baby daughter walked in. Yet again, the mother used a thin scarf to protect the baby from heat, dust, and sunlight; however, she didn’t uncover the baby upon arrival. The father spoke to Jitesh Ji, who then checked the baby outside my earshot. Mr. Jitish calmly called for Mamata Ji. Mamata Ji studied the baby, undoing the scarf cover and checking the back of the baby’s neck, inside her ear. Mamata Ji then ushered the baby and the mother to the emergency room. The mother feebly protested, now looking worried, to be met by explanations from Jitesh Ji. The baby was found to have an infection in her ear and around her neck, which had turned into an abscess. It was immediately important for the nurses to drain the abscess, treat the baby’s wounds, and start her on antibiotics. The baby, her family, and Mamata Ji disappeared into the emergency room. They emerged 20 minutes later, and when I asked Mamata Ji what had happened, she narrated the explanation to me. She added, “They should’ve come a week or so earlier. But people here first always prefer to go to other healers, bhopas and such. When things get worse, only then they come to the PHC.” Bhopas can be broadly understood as traditional, spiritual healers, and therefore as practitioners of alternative medicine methods. From Mamata Ji’s account, such healers were common in and around Nithauwa and often contributed to delayed consultations at the PHC. Sometimes, these delayed consultations would lead to fatal, irreversible damage to a patient’s condition. Again, Mamata Ji’s familiarity with the area, the communities within it, and their belief system, allowed her a pointed insight into medical and healthcare decisions made by people in the community. This cultural knowledge that Mamata Ji, Jitesh Ji, other GNMs, and PHC staff possess is incredibly important in making diagnoses and treating patients. It must be valued accordingly as social and cultural knowledge, alongside the scientific medical knowledge that they have.

Mamata Ji and I began talking about her other experiences with patients and bhopas, but unfortunately it was time for a delivery. Jitesh Ji and Mamata Ji hurried away and as the heat grew stronger, OPD rush slowed down to a stop. I took another quick walk around the PHC, photographed the beautiful flowering plant behind the main gate, and sat in the quiet summer heat for a few minutes, before making my way back home.