REPORT on DAUSA, RAJASTHAN

28 Apr 2011

In six months, three private hospitals in Dausa district operated on 226 women and removed their uterus only to extract money for each operation. These hospitals have been working under Janani Suraksha Yojna, a welfare scheme introduced by the state government for expectant mothers. This was revealed in an RTI application filed by Akhil Bharatiya Grahak Panchayat, an NGO working in Bandikui area of the district, which alleged that doctors removed the uterus only to earn Rs 12,000-14,000 per patient. [1]

This article resulted in All in Democratic Women’s Association (AIDWA) to take notice of the situation in Bandikui, Dausa, Rajasthan where the private hospitals were flourishing. A fact finding committee from AIDWA visited a village named Bandikui within the district of Dausa, Rajasthan on 28^th April, 2011 after getting a report that there were rampant hysterectomies being conducted on the women there. The delegation consisted of three members, Ms.Ashalata, Mr.Durga Swamy and Ms.Kusum Sahibal.The committee was helped by locals. The committee conducted interviews with the private doctors from four different hospitals in that area where these operations were conducted. It was discovered that the private hospitals were making huge profits by conducting these surgeries.

Bandikui had become a hub of private hospitals with five hospitals conducting surgeries and number of private clinics. Both the nearby public health facility and the police underplayed the entire issue. The women in the area were reluctant to talk to the members. This information gathered by AIDWA formed the bases on which the Indian School of Women's Studies and Development decided to do a study on the condition of the public health system and private hospitals in Bandikui, Dausa Rajasthan after six months of the incident. The team consisted of Ms.Smitha. Nair, Mr. Ram Avatar and Mr. Rajesh Kalarivayil.

The visit was conducted from 29^th November- 1^st of December, 2011 with the following objectives in mind

To have a better understanding of the socio-economic status of the women who underwent the operation.
To understand the public health system within the area
To take an over view of the available private health facilities of the area.

Rajasthan:

DAUSA

Rajasthan, physically the largest state in the Indian Union is situated in the North-west part of the country, and has 56 million of the country’s population. The population density is 165 persons per sq. km. Rajasthan is divided into six zones covering 33 Districts, 237 blocks and 41,353 villages. The state is largely rural and 80 per cent of the population is dependent on agriculture for livelihood. Water availability is very low.[2]

The median age at first marriage among women and men in the age group of 20-49 in Rajasthan is 15 years and 19 years. The state is part of the “BIMARU” and Empowered Action Group (EAG) states and fairs poorly on the health and epidemiological parameters. The infant mortality rate is almost the same in rural and urban areas, but the child mortality rate is almost twice as high in rural areas as in urban areas. Despite substantial improvement in the coverage of antenatal care for mothers, only 4 in 10 women in Rajasthan received at least three antenatal care visits for their last birth in the past five years. Seventy per cent of the births in Rajasthan take place at home. Full immunization coverage is lower in Rajasthan than in any other state except Nagaland and Uttar Pradesh. Children’s nutritional status in Rajasthan has improved substantially since NFHS-2, but 40 per cent of children under age five years are still underweight.[3]

Brief Profile at a glance:

S.no.	Indicator	India	Rajasthan	Source
1	Population (number in lakhs)	12101.93	68621012	Census 2011
1.1	Male (number in lakhs)	6237.24	35620086	Census 2011
1.2	Female (number in lakhs)	5864.69	33000926	Census 2011
2	Birth Rate (per 1000 population)	22.5	21.44	SRS 2009
3	Sex Ratio (females per 1000 male)	940	926	Census 2011
4	Literacy Rate (%)	74.04	67.06	Census 2011
5	Blocks (number)	6428	237	As per District data
6	Villages (number)	638588	41353	RHS 2009
7	IMR	50	59	SRS 2009
8	NMR	35	43	SRS 2008
9	MMR	254	388	SRS 2004-6
10	TFR	2.6	3.3	SRS 2008

Rajasthan continues to have poorer health indicators as compared to national average with significant morbidity and mortality, especially among infants, children and mothers. One of the main reasons for this is poor public health facilities in the area, poor nutrition and lack of proper sanitation and drinking water facilities.[4]

DAUSA:

Dausa is located around 56 km east of Jaipur (State capital of Rajasthan) connected by NH 11 and 240 km from New Delhi. The district has a Railway station, which lies on the route of Jaipur - New Delhi and the nearest airport is Sanganer, Jaipur and is located at 26.88°N 76.33°E. It is surrounded by Jaipur, Alwar, Sawai Madhopur, Karauli, Bharatpur and Tonk. Dausa is one of the high focus districts of government of India because of its dismal health condition

Brief Profile at a Glance

S.no.	Indicator	Dausa	Source
1	Population (number in lakhs)	1637226	Census 2011
1.1	Male (number in lakhs)	859821	Census 2011
1.2	Female (number in lakhs)	777405	Census 2011
2	Birth Rate (per 1000 population)	23.75	SRS 2009
3	Sex Ratio (females per 1000 male)	904	Census 2011
4	Literacy Rate (%)	69.17	Census 2011
5	Blocks (number)	5	As per District data
6	Villages (number)	228	RHS 2009
7	IMR	N/A	SRS 2009
8	NMR	N/A	SRS 2008
9	MMR	N/A	SRS 2004-6
10	TFR	N/A	SRS 2008

Bandikui

Bandikui is a Town in Bandikui Mandal, Dausa District, Rajasthan State. Bandikui is located 30 km distance from its District Main City Dausa. It is located 76 km distance from the city of Jaipur.

The team visited the following places and took interviews at:

Private hospitals
One PHC, One CHC and the Dausa District Hospital
Mr Durga Prasad from Akhil Bharatiya Grihak Parishad – the person who filed the RTI
Testimonies of women who underwent the operation
Sub Inspector of the Bandikui police station.

Private hospitals:

The team visited Madhur Hospital, Madan Hospital and Vijaya Hospital. All these hospitals were under the scanner for hysterectomy scandal. When the team enquired about the incident that occurred six months ago each of the hospitals said the same thing that the media had hyped the entire incident.

Dr. Ramesh Vijay from Vijay hospital said

“the RTI filed by the Akhil Bharatiya Grahak Panchayat was problematic because of the language used by the RTI in which it was mentioned that we should give a list of the operations where parts of women are removed. This is why we gave a list of the uterus removal operations. After which all the problems occurred. Now we cannot run the Janani Surkhsha Yojana scheme.”

The Janani Surkhsha Yojana has been withdrawn from the hospitals, they said that they prefer it that way as they are not answerable to anybody after this and ‘will not get into trouble further’. The hysterectomies are still conducted by the hospitals. The team probed about the reason for the young women in their early twenties undergoing the operation. The officials said that these operations become necessary as these women suffer from Reproductive tract infections because they are married at a young age and lack hygienic practices. These operations cost upto Rs. 10000 and the hospitals justified this amount saying that it cost less than other private hospitals in other areas. The hospitals said that the scandal only led them to increase their prices and making the facilities more inaccessible to the women of poorer background. In the words of Dr. Ramesh Vijay from Vijay Hospital

“ Why should I charge less from the women, the media hyped the issue when there was actually none. Now I run my business as I want, so there are some women who cannot access the facilities. It is not my fault but other people who hyped the issue for nothing”.

The team enquired if the hospitals refer the patients to government facilities, rather than conducting the tests. To this Dr. Rajesh Dhahar from Madhur Hospital replied

“The women do not trust government hospitals; even now there is no gynaecologist in the CHC of the area. Why should we stop the women if they want to go, but it is the women who realise that we offer better services than the government hospitals”

Overall the hospitals never refused information to the team but all seemed to have the same answers to all the questions. All the hospitals were filled with women from different places and the operations still continued at a rampant rate. Next the team visited the police station at Bandikui

Bandikui Police Station:

At the police station the team met Inspector Tejraj Singh to enquire about the developments after the case had been registered against the private hospitals. The inspector was dismissive about the entire incident saying that there was no actual case it was only the media that hyped the entire incident. He also said that there was nobody who had put forth a complaint against the hospitals after all the hype. He said that the case had died down in the local media immediately and it was only the ‘english’ media that created all the paraphernalia around the case. Around ten minutes into the interview Dr. Rajesh Dhahar from Madan Hospital visited the police station saying that there was a case that he had to talk to the inspector about, the entire conversation was then taken over by him. He and the inspector reemphasised that there was no case and it was only a money minting process by the NGO who filed the RTI and media was fooled by the entire thing. The team also visited the government facilities in the area

Government Facilities:

Kundal PHC: The Kundal PHC had eight sub centres under it. The doctor was asked about the facilities it offers to women. He explained that ante natal registrations take place for women and they are provided with iron folic supplements. When asked about the hysterectomies the doctor said that they are still common in the area but there is nothing the PHC can do about it. Usually the patients go to the private hospital from the beginning. He said that even if the women choose to come the PHC there are no proper facilities at the PHC to help the women. The best they can do is to refer the women to the district hospital at Dausa as the CHC at Bandikui does not have a gynaecologist.

Bandikui CHC: The team talked to the Paediatrician of the CHC Dr. J.P Varma. He was asked about the facilities the CHC offers to women. He said that there were child births that take place that at the CHC. When the team enquired that how that is possible without a gynaecologist being present at the CHC. He mentioned that a team of the nurse and the paediatrician take care of that. There were atleast hundred and eighteen deliveries that took place in the month of November and if there were any complications the women were either referred to the district hospital or most women prefer to go to the private facility in the area. At this point the interviewer asked about the hysterectomies that took place. The doctor also dismissed the entire incident as‘media hoopla’. He said that there is nothing the government facility can do if there are operations are being conducted as there are no good government facilities in a hundred kilometre distance. He ascertained that he is aware that the operations still continue but there is nothing they can do it as the facilities at the government facility are in a poor condition. He also said that he feels that private facilities are actually providing a service they cannot offer. When asked if there was a move to improve the government facilities after all that happened at Bandikui. He said

“there has nothing been done about it. The administration knows that there are no facilities here. They do not need a scandal to know about the problems in the government facilities. They already know everything but they don’t do anything about it.”

He actually raised his voice stating that there is nothing the doctors can do at their level if they are no changes made from above.

Dausa District Hospital:

The team visited Dr.Sarita Mina from the Dausa District Hospital. She talked at length about the facilities at the district hospital. She raised issues about the lack of operative facilities, shortage of staff and lack of post operative facilities. She mentioned that the women only came to the hospital after the condition had become serious. She said

“Many women face a lot of reproductive tract infections (RTI) at a very young age. They come to the hospital after the condition has become complicated. Many times they do not come back for follow ups because it is very expensive for them to keep returning to the district hospital as it is very far”

Akhil Bharatiya Grahak Panchayat:

The team visited Mr. Durga Prasad from Akhil Bharatiya Grihak Panchayat(ABGP). He explained that the entire case came to his notice because he was a counsellor for Pre-Conception and Pre-Natal Diagnostic Technique (PCPNDT) act. He heard the talk about case of rampant hysterectomies taking place at the private hospitals in Bandikui. It is then he decided to file a RTI which he did with the help of Human Rights Legal Aid. The language used in the RTI he said was specifically written so that they could get precise information about the number of operations being conducted on women. He further explained that women from lower castes were being targeted. He explained

“I was surprised to discover that the maximum number of women who had been operated on in the last two years were women from four castes namely Gujjar, Mina, Mali and Birwa who are from the surrounding villages and illiterate. The doctors coax the women into believing that they have no other option but to undergo these operations. The hospitals are expensive and charge upto Rs. 10000 for an operation It is a racket where there are people at the PHC who are paid to get the women into the private hospital. Each women they bring these ‘agents’ are paid a specific amount. It is for this Rs. 10000 that these women are tortured and endure so much pain.”

The RTI results were directly disclosed to the media as they were not sure how the police will respond to them. According to Mr. Prasad the local media did not give the issue the required attention and it was the national media that actually brought the entire scandal to the public. When asked about the probes after the results came forward. He explained

“There was a three member set up by the government led by Mr. O P Meena, Chief medical and health officer, Dausa,. This committee never sought explanation from the women on the list; they only talked the women whom the hospital asked them to speak to. The report was released by the committee and all they said was that the public health facilities are not good and another recommendation was that there should be a gynaecologist made available at the CHC. But that recommendation won’t solve any problems. They have done nothing to stop the racket between a government hospital and the private hospital.”

The report was rejected by the ABGP and they wrote to the government about the lack of work done by the probing committee. This resulted in the government setting up a second committee who have not revealed their findings till now. Mr. Prasad was also probing the issue at an organisational level and will be soon releasing the findings to the media.

Testimonies of Women:

The team members took the testimonies of three women who had undergone the operation. It was one most difficult interviews to conduct as the women were never available alone, there were men who were always interrupting and answering the questions for the women. The female member in the team had to take the women to a different room (whenever possible) and try asking them the details.

Case one

Name- Vijayanta[5]

Age-33

Caste -Gujjar

Education-Has not gone to school

Children-Two

She was married at the age of seventeen. The hysterectomy was conducted at the age of 28 years. She first visited the Dausa District Hospital with intense bleeding and stomach pain, where she was informed of cyst in her stomach. She underwent an operation for the cyst. But the bleeding persisted for which she went to the government hospital in Jaipur. She said

“the doctors were not at helpful, everything in the hospital was confusing and nobody would explain anything to us properly. It is then my husband decided to go to a private facility. We have to work in the fields or we lose our wages, always going that far was not possible. Then we went to Madhur hospital where the doctor told me ‘mere bachedani me kharabi’.He told us that the only possibility of me getting free of this pain was to have an operation done. We agreed and we have had no problem since then. We will never go to a government hospital again they don’t treat us well”

It was never explained to her why she needed the operation and it cost her Rs.10000 to get the operation done. It was expensive for them but they preferred to get it done in private facility as the doctors in the government facility were not helping them. She faced side effects such as severe back pain, hot flushes, sudden loss of sensation in hands and legs. They did not visit the doctor post operation because it meant loss of more money for them. It was not only her, she knew many women who have undergone the same operation

“In my community only there are many women like me. They all go to private facility. Nobody trusts the government hospitals. But it is ok after the bachedaani is removed there are some side effects but it is ok, we bear so much pain then this is also ok to bear”

When asked if she was aware of the incident that happened six months ago. She replied

“that what happened was all wrong, the doctors are trying to help us. If we have problems what can they do.”

Case Two

Name- Jammuna[6]

Age-she does not know

Marriage- she was married at very young age

Education- None

Caste – Mali

Children- Two

Jammuna does even remember the age she was married at, she remembers being a child during that time. The first thing when asked about her operation she laughed it off saying everybody gets the operation done. There were other women who agreed with her. There was one person in the group with Jammuna who said that she was having frequent and prolonged bleeding and she may also have to get the operation done soon. Jammuna had severe side effects after the operation which everybody thought was ‘normal’. The doctor at the private facility she attended told her ‘bachedaani kharab hai’ and it was in her best interest to get an operation done. That was all she was told. The operation cost her Rs.10000. None of the women trusted the government facility and said that they do not prefer going there. Nobody had heard about the scandal that happened six months ago.

Case three:

Name: Kamala

Age-Does not know her age

Caste -Gujjar

Education-Has not gone to school

Children-Two

Kamala was very confident and forthright to talk to; she asked the interviewer a lot of questions before she agreed to answer any. She wanted her children to study so they can explore and see the world more than her. She had undergone the operation in Madhur Hospital whom she had approached after two years of treatment in a government hospital. This treatment was for prolonged bleeding and pain the stomach. She asked

“how much bleeding should I bear, I kept taking treatment but there was no use. When I went to Madhur all they told me was I needed the operation and I agreed. I still have a lot of pain in my lower back, and sometimes I sweat a lot with heart palpitations. But that is something that I have to bear with, there is no way out. Many women I know have same problem, many women have undergone the operation. It is our fate only.”

The interviewer had interacted with many women other than who had not undergone the operation. There was a general sense of mistrust to go to the government facility, as there either no facilities, a lot of time was wasted at the government hospital and the behaviour of the staff was not good to them.

Conclusion:

In the two day visit the team visited a number of people; the women who underwent the operation mostly belonged to the lower caste. The women had all visited the private facility either after visiting the government or had directly gone to the private facility. The women did not trust the government facility. The government hospitals were ill equipped, short of staff and sometimes they were badly behaved. The private facilities were all packed with women from different parts in the area; there was hardly place to move in the area. The doctors in the private hospitals were very cautious when talking to the team; they did divulge any information that was demanded by them. The information was well rehearsed as every hospital seemed to give the same answers, they all answered in the lines that they were trying to do good and, make necessary facilities available to women. The government scheme being withdrawn was seen as a boon as they would not be answerable to any other RTI’s filed.

This situation in Bandikui is like a vicious circle where the worst sufferers are women. They are forced to use the private facilities even if they are expensive because of lack of public facilities in the area. The women have a very casual attitude towards their health, which stems from patriarchal system where the women and their health are always considered secondary.

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