Tackling health loans and modern slavery as a community in Bihar, India

1 August 2017

‘We need to change our own mind-sets to become less dependent on medicines,’ concluded the wife of a bonded labourer in northern Bihar we met last week. She is one of the members of a local action research group on health and loans with whom we work on research on modern slavery in North India. Her group wants to work on health because health expenses are the main reason why families take loans and end up as a bonded labourers. Many men in this mostly Muslim village have migrated to different parts of India and other countries to earn money to pay off high-interest loans that are taken, among other things, for C-sections, treatment of tuberculosis (TB), diabetes and respiratory infections in private hospitals. Their journey is paid for with another high interest loan with monthly interest rates between three and ten per cent. Several make the journey in bondage, guaranteeing the payback with their labour until they have paid the loan and the interest back, leaving the women to take care of households riddled with multiple debts.

Why villagers turn to private healthcare and money-lenders

Many villagers either choose or feel forced go for expensive treatments at private hospitals or clinics. Women report long queues for state-run healthcare, rude staff who need to be bribed, prescription of medicines that are not easily available, and a general feeling that doctors treat only those who either have money or social standing. These women also prefer the medicines they get in a private hospital better than medicines prescribed in the government system. Their concerns about the quality of government health services and medicine prescribing practices are grounded. A review by WHO of essential medicines - one of the cornerstones of public health for the poor - in India found an improper selection of medicine like the inclusion of a nearly obsolete medicine.

Private healthcare is not cheap for the working poor in Bihar. A C-section delivery in a private hospital can cost up to Rs 40,000 while the daily wage of the villagers is between Rs 150 and Rs 200 per day for irregular work, well below the state’s minimum wage of 237 rupees for unskilled labour. TB treatment using Direct Observed Treatment Strategy (DOTS) is free through the Indian government system but can costs tens of thousands of rupees in a private clinic. Like many villages in India, this village has credit and savings groups but these are not meant for emergency expenses. ‘If it’s Rs 10,000 we can approach the credit and saving group but for such a big sum, only the money-lender is there,’ explains one member.

Collective action and changing behaviours

When the group started, women complained amongst each other about their own stories or about people they knew. But they were not yet confident enough to take action. They felt services in government hospitals were lacking and had raised their concerns with doctors and nurses at an individual basis. Through gradual discussions in the group, they decided on the need to collectively take action. In December 2016, the group approached health authorities in the district hospital. In January 2017, they met with the public grievance redressal cell at the district level and raised their complaint. To their surprise, they were assured by the hospital in charge that if they faced a problem or if anybody asked for bribe, they could directly reach out to the person they spoke with or place a complaint in the grievance box. As a result, more women said they had started to visit the government hospital. They also have less complaints about the medical treatments and staff behaviour when they go.

Today the group is more confident about their ability to demand the services to which they are entitled. There is room for disagreement and differing opinions within the group, yet the members have a clear sense of the group’s purpose. They now feel they should share their knowledge with other women like them and expand their group with government supported health staff such as the ‘ASHA workers’ a shortcut for “accredited social health activists” community health workers instituted by the government of Indian and staff of the national Integrated Child Development Services program. They hope that these workers can can provide them with additional information about the other available governmental schemes and services to the group.

A closer examination of common medical conditions, their causes and their costs made it clear that most of them could at least to some extent be prevented with better hygiene. Group members realised that their complaint about a lack of medicine in the government hospitals might also reflect their desire to get medicines and injections when they visit a doctor. ‘I admit I am not very happy with a doctor who does not give me medicines and makes me go back with empty hands. But it is also true that sometimes, medicines are not needed. So it is my mind that perhaps needs changing as much as the hospitals,’ said one smiling.  The group concluded that to change behaviour in the community people need not only increased medical information but also increased faith and trust that prevention can work and medicines are not always needed.

Trust is a particularly rare commodity in communities living with modern slavery, but it helps when people can see concrete examples of success among other people like them. For these villagers, and communities like them, improved access to available government health services will help reduce the need for them to seek out private healthcare and to take out loans. But there is also a need to raise awareness about and gain trust in essential medicines that tend to lack shiny packaging, and in the capacity of people to prevent the diseases which burden a family with the kinds of high-interest loans that risk them getting trapped in modern slavery.

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