Aapreshan to naam hai; Mamuli sa kaam hai; Phir bara aaraam hai. ["Operation is the name of the game; Its simple and that’s a fact; Get it done and then relax."] We saw these three lines of rustic poetry painted on one of the walls of a house in Mainpurva village (Bidhanoo block) of Kanpur Dehat district in Uttar Pradesh. We were trying to find out about the death of Kamla Devi, who had reportedly expired a few days after her tubectomy (sterilisation) operation. We asked Manoj, a small village boy, to lead us to the house of Kishan, Kamla’s husband. Kishan’s mother, younger brother and sister in law met us in a large, mud-lined open space around which were ranged different houses. We introduced ourselves and asked about Kamla.

At first the elderly woman said, "what is the use of talking about someone who is dead", and even after some persuasion we were unable to get a story from the family which had any relation to the lead we were pursuing. Most of our queries were met with evasive answers, so we went back all the way to the field offices of the NGO from whom we received our information. Fortunately, there we met Kamla’s sister who was a health worker and had come to attend their regular meeting. She confirmed that Kamla had gone for an MTP (Medical Termination of Pregnancy – legal abortion) to the local Community Health Centre. She continued to bleed because of an incomplete abortion and her uterus had to be re-evacuated at a hospital in Kanpur. She underwent tubectomy a couple of months later; soon afterwards she started bleeding once again and was taken to a hospital, where she expired after a few days.

After listening to Kamla’s story we went to the nearby village of Jarukheda where we had been told about the death of another woman, Munni Devi. Munni’s husband was not home, and her mother in law and brother-in-law were extremely reluctant to tell us very much. When Munni’s eldest son, who was standing in the group, saw our interest in the story of his mother’s death, he picked up a cycle and pedaled off to get his father, Gyan Singh. Gyan is a poor farmer, and now with the help of his mother, is raising his six children. Two years ago, when his youngest son was one, his wife Munni felt that she was quick with child. A test at the nearby Community Health Centre confirmed this, and a date for an abortion was set.

In each of the cases described here, a woman died tragically even though she followed the correct protocol. Social factors played little or no role in the deaths.
On the way out, the local Auxilliary Nurse Midwife called the couple aside and told them that she could help, and they could get the MTP done cheaper with her. At the appointed date Munni and Gyan went to the ANM's place. She said she would take 500 rupees and Gyan Singh paid half the sum in advance. A few minutes into the procedure, she rushed out and said that 'the case had gone badly' and they must take Munni to a city hospital. She refused to accompany Munni and returned the advance. Gyan Singh spent over 40,000 rupees to treat Munni in nearby Kanpur, but she never recovered from the botched abortion, and died a few days later. Operative notes on Munni’s medical reports indicated that the roof of the uterus was pierced, there was blood in the abdominal cavity, and two feet of intestines had become gangrenous. This was the handiwork of the ANM who promised her a cheaper abortion.

A third event took place just a few months ago. In April 2003 Shaila Devi succumbed to a ‘simple’ sterilisation operation in the Deendayal Upadhyay hospital in Varanasi due to ‘peritoneal shock’ and ‘mesenteric over stretch.’ In simple terms, the doctor pulled at the intestines and associated membranes so hard while conducting the tubectomy operation that Shaila went into shock and didn’t survive.

These may seem like random incidents, and in a country like ours, and especially in a state like Uttar Pradesh, these could well be commonplace. But they hold a very crucial lesson that should not be ignored. It is usual practice to blame the poor rural care-seeking individuals for not seeking appropriate and timely health care. It is a regular activity to include large components of information sharing and awareness-raising in health care projects to promote and encourage rural and poor people to attend clinics and camps. It is a common refrain that rural people have different health related beliefs and visit quacks and unregistered practitioners and don’t come to hospitals on time.

In each of the cases described above, however, a woman died tragically even though she followed the correct protocol (that is, she came to the correct government medical facility and at the recommended time). Social factors like poverty, delay in getting the person to the health centre, or the lack of proper care related to the low social value of the woman, played little or no role in these cases.

Uttar Pradesh is well known for its very poor socio-economic indicators and is clubbed together with similar states like Bihar, Madhya Pradesh, Rajasthan and Orrissa in the BIMARU group of states. What is not so well known is that healthcare service delivery is also very poor in the state. Less than a fourth of all women receive any trained assistance during childbirth, and only about one tenth of the population use public health care services. Over the last ten years or so large externally funded projects have been introduced into the state to improve the quality of service, the SIFPSA project (USAID funded) and the UP Health Systems Development Project (World Bank supported) being two important ones. Now it is claimed that the systems are improving. There are fewer vacancies and more equipment is available.

But as the examples above show, the experiences of the client when accessing this system can be very traumatic. The meaning of the term 'quality of healthcare services' needs to be expanded beyond the mere availability of medicine, doctors or nurses. It is not that these are not important, but it is frightening to think of the havoc a colossal, inept, unaccountable but active system can create, and the number of women who might lose their lives - not to the lack of health care services, but because of it!

The meaning of the term 'quality of healthcare services' needs to be expanded beyond the mere availability of medicine, doctors or nurses. An active but unaccountable system can cause a lot of damage.
India has one of the most privatised health care systems in the world; over 80% of health care expenses are paid for by individuals. Health care is also one of the most unregulated sectors. In UP, the overwhelming majority of people visit medical service providers in the unregulated private sector, as well as the informal health care providers made up of traditional and unregistered practitioners. New private-public partnerships are presented as the solution to this pathetic state - to make the state system 'efficient' and to increase its 'reach',

Unfortunately the state has not exactly covered itself in glory in regulating the private sector in health. Even where standards of care exist they are hardly ever enforced, registration of nursing homes is more often than not a very contentious issue, doctors are seldom held accountable by either their peer groups (e.g. the Indian Medical Association) or by regulatory authorities (Medical Council of India) or even through legal mechanisms such as the Indian Penal Code and the Consumer Protection Act. With an unregulated private sector and an unaccountable public sector the people of UP - and especially the women - face tough times ahead.