I take this opportunity to describe what I learned during a professional visit to the tribal districts in Madhya Pradesh, India. Before I embark upon the journey I would like to describe that India with its mutiple cultures, castes and communities has a caste based hirearchy which is still alive in most urban and rural India. Infact access to socio-economic and educational empowerment are rather determined by the hirearchy in many regions despite an equity based system in the country.
This visit was undertaken to explore developing interventions and identifying potential intervention partners for sex workers reported on the Ratlam - Mandsaur- neemach trucking route on the Madhya Pradesh and Rajasthan border. This is a tribal belt and consists of a community known as the Banchadas who traditionally practice sex work since more than a 100 years.Similarly there is another community the Bedias on the Sagar- Guna- Shivpuri- Gwalior- Morena belt on Madhya Pradesh and Rajasthan border who also practice sex work traditionally. The visit report below captures the reasons and needs of the communty in this region.
I started our journey from New Delhi Airport and reached Indore on Sunday 12th August 09 at 8 pm and was joined by our local focal persons form our Madhya Pradesh Office at UNFPA.There was a night stay at Indore. This was followed by early morning departure by road on the 13th of August 09 to Jhabua – Meghnagar about 150 kms from Indore. We reached the Jeevan Jyoti Sanstha a Faith Based Organsiation (FBO) with a hospital in Meghnagar for the tribal population, catering to primary health care facilities and a few specialized facilitiesavailable. Real Medicine Foundation (RMF) has partnered with Jeevan Jyoti Sanstha (JJS) to reach out to the Bhil tribes for health, literacy related issues. RMF has supported JJS to form the ART Centre, Link ART Centre (LAC) , Network of People Living with HIV/AIDS in Jhabua and ICTC under PPP all funded by MSACS. The team was received by Ms.Kaitlyn Mcquilling from the Real Medicine Foundation and Mr.Jimmy the counselor of the Positive network of Jhabua.
RMF was founded by Dr.Martina Fulkes a pediatric trauma surgeon for post Tsunami relief. It started with clinics for Post traumatic stress, physical therapy, trauma support in Sri Lanka. It then moved to Kashmir to help the communities cope with the post effects of the Earthquake. It further snowballed from disaster to disaster and reached the high poverty zones in Pakistan, NWFP, Sudan, Myanmar, Indonesia, Peru and India. It then started developing community need based health projects like mobile clinics in flood zones in Mozambique, care for Paraplegic and Quadriplegic through special clinics in Pakistan, Microfinance based initiatives in Indonesia and other regions. In Madhya Pradesh they work in the districts of Jhabua, Alirajpur, Khandwa, Korgaon and Dhar currently on ths iesue of Malnutrition among tribals in 100 village. they have identified about a 1000 children with moderate to severe malnutrition.
In Jhabua they piloted the HIV testing in every patient attending the nutrition centre. They detected 170 People Living with HIV/AIDS and developed a network in Jhabua district. Jeevan Jyoti hospital staff was trained and sensitized in Jhabua to treat and provide care and support to the patients. Jeevan Jyoti also has projects supported by Sight-Savers International since 2002 to treat and prevent blindness and provide ophthalmic care to the rural population. They also have other projects with Help age India for the ageing population.
The Positive network Drop In Centre (DIC) is in the JJS campus. They have identified 17 Transgender and 72 MSM population in Jhabua, Meghnagar and Ranpur who are living with HIV/AIDS among the 170 PLHIV. 22 of them have succumbed as they were brought in with terminal illness. The remaining 143 are living with their families. 54 of them are on ART from the Indore ART Centre and the network organizes accompanied referrals to the ART centre on a monthly basis for regular clinical follow up, supply of monthly ART, and CD4 tests at baseline and 6 monthly intervals.
Dr.Fabian Toegel with the Clinton Foundation partnered with JJS when he was doing his thesis among the tribal population of Jhabua. He then became the technical advisor of the Care and Support program for JJS. He is part of the Clinton Foundation initiative in India which works on training and sensitization of government and private medical staff on ART and clinical management of HIV.
JJS was founded in 1989 under the Catholic Diocese of Jhabua in Meghnagar 16Kms from District HQ Jhabua in MP. Earlier their tribal and social welfare programs were conducted under the banner of the Pragati Sansthan. Their aim is to see an empowered Tribal Society freed from ill health, malnutrition, lack of education, superstition, poverty and suppression, thus enjoying the freedom and self esteem. Their mission is to initiate development programme to bring about socio-economic transformation in the lives of the people, particularly the Tribal women living in the far remote areas of the society, focusing on their health, education and income generation activities.
The team collected the detailed information from the interventions in Jhabua by JJS and Real Medicine Foundation (RMF) and moved to travel to Ratlam at 5 pm.
The team reached Ratlam at 9 pm in the night and halted there for the night. Early next morning the team left for Mandsaur.
At Mandsaur the team visited the District Hospital in Mandsaur to review the ICTC, STI and RH services , the Indian Red Cross supported de-addiction centre and visited the NGO intervention – Bal Mahila Vikas Sanstha running Targeted Interventions with the Banchadas initiated under SACS in April 2009.
At the District Hospital the ICTC Senior Counselor was the District Supervisor for the District AIDS Prevention & Control Unit (DAPCU). The DAPCU is part of the NRHM & HIV convergence under NACP III. IT is headed by the CMHO who supervises the District Program Officer (DPO) , an Accountant and M&E officer. It ensures the linkages between the RH and the HIV program at the district level. Under NACP 3 the 24 hour PHCs are also added with ICTCs, STI clinics. The DAPCU is a monitoring body to ensure that the staff training under RCH program is completed, supplies are in place for STI drugs, ICTC kits , condoms and other needs. The ANM, MPW and ASHA trainings and their impact needs to be supervised. The District Supervisor mentioned that in 2008 they conducted 2027 tests of which 112 reported as HIV positive. A total of 453 positive cases were reported out of 6000 tests conducted from 2002-09. The aim with the DAPCUs in place was to increase referrals for testing from the reproductive health population, ANC population, young men and women, and high risk groups. However despite the trainings the referrals from the ANMs and MPWs for the ICTC testing and STI management is not forthcoming. There are discussions on linking referrals to incentives however that is not sustainable as a model.
The ICTC counselor also informed that although there is a high concentration of the Banchada community in the district, they usually travel to the local preferred providers in the private sector. The government had a launched a scheme for the benefit for the community . However one of the past district collector's misinterprete the scheme and broke their houses. This did not go well with the community. As a result the community avoids accessing any of the district health services as they want to avoid being identified by the government.
Another interesting fact shared by the llocals was that for a girl to marry in the Banchada community the traditional system is that the boy is asked for dowry anywhere between Rs.25,000 to Rs.100,000. The girl who is supposed to marry never enters sex work. The first daughter enters into sex work as she is wedded to the local goddess Nari Mata. However due to the reverse dowry tradition, it gets difficult to get a groom for the marriageable daughter who as they can't afford the dowry. Most men in the Banchada community do not work and are dependent on the income of the daughter who is into sex work. These men are also alcoholics and opium addicts. Mandsaur and Neemach are official opium growing belts and illegal leaking of opium in the open market leads to a lot of addiction to chasing heroine in this belt. Also Extra-marital affairs are common among men in these communities.
The ICTC counselor further took the team to the UNICEF supported 24 hour call centre for pregnant women implementing the Janani Express an ambulance service, which reaches the desired villages as and when calls are recieved on the helpline. The call centre receives 317 calls per month and there are 4 people on rotation in the centre. They have 8 hour shifts but no weekly leave sanctioned in the program. They take the leave by adjusting the shifts among each other. The counselors are paid Rs.3000/- per month. The ambulance is part of the Rogi Kalyan Samiti scheme ( Janani suraksha Yojana) where Rs.1650 is the incentive for the mothers delivering in the hospital. Rs.250/- are deducted for the ambulance service from the incentive to the mother. In case of caesarean section the ambulance also leaves the mother back to home after the post-op stay.
The District hospital also runs a De-addiction centre supported by the Indian Red Cross Society. Dr.Ojha is the Centre head and he described that heroine/ smack chasing are the common addictions among the tribal’s as it is an opium growing belt. The centre has beds for admitting the addicts for 3 weeks where thy are treated with medication , counseling, yoga and provided with meals. Bupenorphin substitution therapy is used by the centre. Dr.Ojha shared that to work with the tribal communities on the issue of sex work De-addiction among men would also need to be addressed. Only then the issue of FSW rehabilitation can be sustainable for a long term.
The team then proceeded to meet the NGO Team of Bal Mahila Vikas Targeted intervention among the Banchadas in Mandsaur. The NGP had a Banchada community member working as a peer educator and who shared a lot of details regarding the community. The NGO is a NACP III based TI project intervention in about 22 villages in Mandsaur. The NGO workers started with baseline mapping in Mandsaur and Neemach and are now concentrating their work area to only the Banchada community in Mandsaur. They have 1 counselor, 3 Out Reach workers , accountant, peer educators and Program officer. The NGO informed that in Ratlam another NGO called Samarpan was working with the communities. The population in Banchada identified was 600 FSWs among 5000 Banchada families distributed in about 30-32 FSWs per village. Most visit quacks and other private Health Care Providers (HCPs) for their health needs. During the HCP mapping the NGO identified the most sought after 20 HCPs most of them being Registered Medical PRactitioners (RMP), quacks and one of them a Gynecologist and paediatrician. They ahve had advocacy meetings with them. They further plan to train these HCPs on STI syndromic management by MPSACS. The Banchadas mainly visit HCPs for health needs of the mother and children.During the baseline community needs assessment, the Banchadas reported a demand for condoms and STI care, Reproductive care and education for children. Soem young genderation also expressed the need to come out of sex work and have access to alternate income genderation programs and or educate their children so that they can give them a better futire.
The team asked the community members the origin of sex work on how do the community members seek information/ gain knowledge.The NGO team mentioned that through the clients and exposure to television are the main sources of information for the communityi. No newspapers reach as only 1% are literate in the community.The Banchadas of the younger generation have seen some education and are now ready to get out of this practice but the mothers and grandmothers resisting their exit.
The peer educator mentioned that, Banchadas were actually Rajputs and the women were sent by Rajput kings to the military base in Mhou, to get access to the military secrets. That is how the FSW trade started and the families of the FSWs started enjoying special privileges of the Rajput kings due to their special status as secret informers. Thus its more than 100 year old tradition. It was also encouraged by the traditional practice of marrying the first girl of the family to the Goddess Nari Mata. Thus the men celebrate when the first born girl attains puberty and is considered the bread winner of the family. The men act as pimps.
The team asked the NGO if they would be fine with other NGOs / CBOs being set up in Neemach and if it was ok to approach MP SACS to plan interventions there so that the Ratlam, Mandsaur and Neemach trucking route would be covered completely. The NGO was keen to welcome other NGOs working in Neemach and was also looking forward to technical support from other partners to improve the quality of their interventions. The NGO was not visited by the TSU for any monitoring visit so far and needed monitoring support. They also needed more information on Condoms as some FSWs had heard about them and were demanding them as well.
The team then proceeded to Indore from Mandsaur at 2 pm to catch a flight to Bhopal. Due to the bad roads and rains the team was taking double the estimated time to cross the destinations. The team reached Indore by 7.30 pm. The flight was delayed by more than 2 hours as it was a connecting flight from New Delhi- Indore- Bhopal –New Delhi. It was also delayed by congestion in Mumbai.Although the roads were bad the greenery during the rains made the drive more than tolerable.
The team reached Bhopal at 11.00 pm. Next day by 10 am the team proceeded to meet and discuss the possible strategies to be put up to the MP SACS while meeting the team there. The team then had a very fruitful discussion with the MPSACS.
At Bhopal we finalised our strategies with the Real Medicine Fooundation and proposed the activities to the MP State AIDS Control Society.
The trip ended with delays at the airport and we reached New Delhi from Bhopal by 12.30 /1.00 am on the 15th July 09.
The key points for learning/ scope for UNFPA in MP SACS are mentioned in the Summary below:
There is scope for innovative interventions among the Bedia and Banchada communites for HIV prevention, care and support activities. The activities to be designed should be sustainable and community based rather than lead by NGOs. However, NGOs need to be partnered with locally to provide technical support for monitoring and evaluating the quality and impact of the interventions.
UNFPA proposes to take the lead in developing this with the potential partners RMF and JJS and the proposed intervention would be put up to the Local SACS in the next one month for both the communities. However, since there are other factors local partnerships need to be developed to address the opium and alcohol addiictions with the men of the communities, the other needs like school education and reproductive health needs of the community need to be addressed as well. Also there is a need to explore the interventions with the clients of the sex workers- truckers and migrants on the route through various partnerships at the SACS and local NGOs and private partners. Thus a holistic approach would be needed to sustain these interventions.
UNFPA proposes to develop the FSW CBO interventions and llink up RH,STI, HIV prevention, care, support interventions in the program. We further will ensure availability of male and female condoms in the program as well. Other link ups with local socio-developmental packages will be developed within the program.
We will keep the AIDS competence community posted on further progress with this initiative and welcome more suggestions to develop this challenging intervention.
I will also add up the photographs of the field visits to this blog shortly.