Improving rural health care, one boat trip at a time

By Sophie Cousins 04 June 2015

An auxiliary nurse midwife checks a pregnant woman's blood pressure on a boat clinic in India. The boat clinic provides family planning services, immunizations, antenatal care and general checkups to hard-to-reach populations. Photo by: Sophie Cousins

More than 10 years ago, Sanjoy Hazarika heard about the death of a mother in a remote island in Assam, a state in northeast India, because she couldn’t get to the hospital in time. This led the soft-spoken professor to think: Why not bring the hospital to the people?

And he did just that.

In 2005, the Center for Northeast Studies and Policy Research, where Hazarika serves as managing trustee, realized the Indian government wasn’t going to build clinics on the geographically isolated islands along the Brahmaputra — a transboundary river flowing from Tibet to Bangladesh — and that people there couldn’t access services on the mainland.

The concept received a boost after C-NES entered into a partnership with the government under the National Rural Health Mission and also received a grant from UNICEF.

Beginning with just one boat, a few staff members and one district, C-NES now has grown to having 15 boat clinics across Assam, the state with the highest rate of maternal mortality in India.

“These people are not physically visible to the government,” Hazarika said. “Our delivery of health care has to address the different demographics of the river.”

The boat clinic provides family planning services, immunizations, antenatal care and general checkups. But the professor noticed the disparity in health care needs within Assam, noting how a Muslim minority population with large families in the Lower Assam division has better nutrition than people in upper Assam, where malnutrition rates among children are high.

‘Unique style of delivering services’

Among the major health problems Devex saw while visiting Upper Assam are respiratory issues, fungal infections and chronic diseases, such as high blood pressure and diabetes.

“We have a unique style of delivering services. No one thought services could be delivered in these areas,” Dr. B.C. Bora, who has been working on the boat for seven years, told Devex as he waited for patients to arrive after the boat docked at an island with about 200 people.

The boat clinic visits these remote islands once a month, often staying there two days at a time, regardless whether five or 200 patients are expected. In this particular instance, there were two doctors, two auxiliary nurse midwives who provide antenatal care to pregnant women under the NRHM, a lab technician, a pharmacist and a community worker on board.

One pregnant 22-year-old woman boarded the boat clinic for the first time. She’d never had an antenatal checkup and was concerned she hadn’t felt her baby kick despite being 20 weeks pregnant. A middle-aged woman from another island meanwhile came on board to have her chronic obstructive pulmonary disease checked. Boat staff has been managing her COPD for the past seven years, but Bora explained she “desperately” needs further care.

Like other patients the boat clinic treated in the two days on the river, these two women were referred to Assam Medical College in Dibrugarh, a major city in Assam, for further testing. The referrals highlight the limitations not just of the boat clinic but also of rural health care as a whole.

Perseverance, and the need to build trust

The hospital in Dibrugarh is more than four hours away from the island, and getting there is costly. For some people on the island, the boat clinic staff was their only connection to the outside world — indeed, the first time they’d ever seen a doctor.

There are also cultural and geographic obstacles, which limit the impact of the boat clinics.

During winter and especially when there is no rain, the boats cannot traverse the river because the water level is too low. Conversely, they also can’t travel when the water level is too high or during monsoon season.

Deeply ingrained cultural attitudes among villagers can meanwhile be barriers for providing health care. Many villagers initially rejected the boat clinic’s health staff, preferring to rely on the local quack instead. While they are now more trusting, changing behaviors and beliefs remain a difficult obstacle to hurdle. Despite encouraging women to give birth in hospitals, for instance, most births still happen at home.

But there have been major successes.

“Previously women didn’t know anything about their health. They used to be afraid of vaccinations, but now mothers are coming to get themselves and their babies vaccinated,” Domanyante Dasa, an auxiliary nurse midwife, explained. “I’m also seeing an improvement in babies’ hygiene. It used to be very poor and we would have a lot of cases of diarrhea but now mothers are washing their babies.”

‘A small team, big ideas and no funds’

Over the past 10 years, the boat clinics have handled about 1.5 million cases. Hazarika said the clinics reach 300,000 people on an annual basis but as he pointed out, logistical problems remain.

“We have many problems — a small team, big ideas and no funds,” he said. Forming meaningful collaborations with the government has been a problem as well, but one his team strives to find solutions to. “Without the principal stakeholder, we can’t run such a major program. This is the government’s responsibility.”

It was also difficult to select staff for such unique work, Hazarika pointed out, as it requires employees to be “pioneers and prepared to go it alone; with plenty of initiative and sass.”

So what can other health nongovernmental organizations learn from the boat clinics?

“To innovate constantly, work with the government as much as possible, build strong community relations and networks, keep in touch with people, encourage initiative and ensure service delivery,” he said.

Building strong community relations is perhaps one of the most important lessons, as is the need to protect the trust boat clinic staff has built with the villagers. Now, Hazarika notes, people understand that if the boats can’t come because of weather disturbances, for example, the health staff will still reach them at the soonest possible instance.

“At the heart of it all is a very simple thing: People have given you their trust. The most difficult thing of all was to get a sense of acceptance, to win their trust [but we’ve] found in time this has turned into support and strength,” the professor concluded.

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About the author

Sophie Cousins

Sophie Cousins is a health writer based in India. She was previously based between Lebanon and Iraq focusing on refugee health and conflict. She is particularly interested in infectious diseases and rural health in South Asia. She writes for international medical journals, including The Lancet, and for international news websites such as Al-Jazeera English.

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