The qualitative data collection for the study encompassed in-depth interviews and key informant interviews across two districts, Bhagalpur and Jamui. The 21 interviewees included 13 women and 8 men. Ages ranged from 24 to 55, indicating a diverse adult population. The participants had various healthcare and beneficiary roles. Six swasthya mitras—three from each district—were interviewed. A health manager, a nursing officer, a junior researcher in obstetrics and gynecology, a civil surgeon, a deputy director of administration, and six medical officers were included in this group. Narratives from interviews were inductively coded, categorized, and classed into nine data-driven thematic themes. The results section explains each of the nine themes with stakeholder-triangulated narratives. (Fig-1)
Theme 1: Unveiling challenges in government hospitals/public health facilities.
Patients in government hospitals often face a range of problems due to several factors.
Category 1.1: Navigational Confusion
Navigational issues are perceived to be frequent problems in hospitals, affecting patients' ability to locate appropriate service areas.
"They do not get to know the exact location where they have to go. For example, many times when we tell them to go to the second floor, they end up standing outside the Operating Theatre (OT)." (medical officer, DH Jamui).
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"In a government facility, we have to run here and there a lot because we are totally unaware of the structure and functions of the facility and what should be done where. We were completely clueless” (beneficiary, JLNMCH Hospital, Bhagalpur).
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The lack of guidance systems could lead to delays in treatment and heighten patient anxiety, highlighting the need for improved hospital navigation protocols.
Category 1.2: Elderly Patient Concerns
Elderly patients face many problems, specifically concerning getting lost within the hospital setting.
"For instance, when elderly people come in, they get lost. No one comes with them, like those who are 60 years old; they get distressed." (Swasthya Mitra from JLNMCH).
The challenges faced by elderly patients further demonstrated the need for better navigation facilities.
Category 1.3: Admission challenges for critical cases
There are challenges associated with admitting specific types of patients who private hospitals usually do not. This was expressed by the health manager of the hospital.
"Yes, ma'am, private doesn’t admit those kinds of patients. It is an important thing for us; we got her admitted and treated here.(Health Manager, JLNMCH)
Public hospitals often must fill in gaps in healthcare access, taking in patients whom private hospitals refuse to admit. This place added stress to already burdened public healthcare systems.
Category 1.4: The Waiting Game
Patients not only face navigational challenges but also face the problems of long waiting times and the difficulties faced by those who come alone.
“The biggest problem is having to stand in long queues. However, now nobody is helpless. When someone comes alone, they do not get any facility. They do not understand on their own where to go.” (Nursing Officer at JLNMCH Bhagalpur)
Long waiting times added to the systemic pressures on public hospitals, especially impacting those who come unaccompanied.
Category 1.4: The Deterring Chaos
Chaos and hassle in public hospitals have prevented people from seeking medical treatment, revealing systemic challenges.
“The trouble faced in running around is greater than not getting treated. That is why no one wants to go to a government hospital. Otherwise, there is no other issue.” (beneficiary, JLNMCH, Bhagalpur)
Public hospital healthcare is complicated by navigational issues.
Category 1.5: Perceptions and fears of death surrounding government health facilities.
Healthcare use was influenced by public sentiment. Myths, rumors, and poor experiences deterred people from receiving medical treatment. The public perceived that tertiary care patients die and straight away go to their funeral. This made individuals afraid to visit these hospitals. This phobia was inherited.
"Earlier, we used to be scared to go to Mayaganj (Medical College) because everyone would say that once you reach Mayaganj, it is the end; you will not come back. That is why we were very scared about it and did not go there. Everyone at home would start crying and wailing. (Beneficiary, JLNMCH, Bhagalpur)
These rumors and fears created a significant emotional barrier that discouraged people from seeking medical help in tertiary health care facilities.
Category 1.6: Navigating health choices.
Patient perspectives revealed how their decisions and experiences affect healthcare availability. Patients perceived differences in attentiveness between government and private doctors.
“I sit in my OPD in the government hospital; the patient starts asking when I will sit in my private clinic even if I charge them with fees (it is free in the government hospital) they will come there. I cannot change this mentality.(Medial officer, District Hospital Jamui).
“If we have money, we go to a private health facility” (Beneficiary, District Hospital Jamui)
The patients' decision-making processes within the healthcare spectrum were driven by their paying capacity.
Category 1.7: Communication barriers
In public health facilities, patients find it challenging to comprehend their disease, available treatments, or posttreatment instructions due to language problems or a lack of clear communication between healthcare professionals and patients.
“Most of the patients and their attendees here are not well educated. Therefore, they face problems understanding doctors’ advice.” (Resident, OBGY department)
When patients struggled to understand their diagnosis, treatment options, or posttreatment guidelines, they were less likely to adhere to follow-up protocols. This created a vicious cycle in which inadequate communication exacerbated the lack of follow-up care systems.
Theme 2. Strengthening Public Health Systems with Swasthya Mitra
The establishment of a help desk along with Swasthya mitra in the hospital had transformative impact by serving as a crucial link between hospitals and the communities they serve.
“Now, the burden has become lighter after these people have come”. If any complaint is not coming to us, it means that work is being done. (Health manager, JLNMCH, Bhagalpur)
By unburdening the hospital staff from logistical and administrative tasks, Swasthya Mitra frees up valuable time, thereby expediting the overall treatment initiation process for patients.
Category 2.1: Reduction in the time of treatment initiation: Swasthya Mitra intermediated the acceleration of treatment commencement and provided additional information. They soothed them and expedited the process, minimizing hospital entry to treatment time.
We called up. We said, "Where will we go, we do not even know." Sister (Swasthya Mitra) said, "Come to me, I will be at the gate.". At first, we were very anxious. She calmed us down. She said, "You do not have to worry. Now that you are here, everything will be taken care of." After that, she got us a token, and then she took us to the doctor. (beneficiary, JLNMCH, Bhagalpur)
Swasthya Mitra is expediting the patient journey, particularly for those in labor. By providing immediate guidance for necessary investigations and facilitating rapid transfers to the labor room, Swasthya Mitra not only alleviates stress for patients but also ensures that medical management can commence with minimal delay.
“Many times, when a patient comes into labor, the Swasthya Mitra directly brings them in and guides them through the necessary investigations. She ensures that the patient is swiftly moved to the labor room. This saves time for the medical team and benefits the patient, as their management and care can begin more quickly.’ (Medical Officer, District Hospital, Jamui)
This proactive involvement has led to significant reductions in treatment initiation time.
Category 2.2: Reduction in out-of-pocket expenditure: In a healthcare system where costs can escalate rapidly, a financially viable solution is essential. This was exemplified by a pregnant couple who, facing an emergency, opted for a government hospital over a private facility, significantly reducing their out-of-pocket expenses and illustrating how crucial healthcare services can become more accessible through public healthcare. Additionally, navigating healthcare complexities, particularly during accidental injuries, can be overwhelming, with financial and emotional burdens often impeding decision-making. Here, the role of Swasthya Mitra is pivotal.
“When it was time for delivery, we went to one doctor in private. There, we were told that the baby's umbilical cord was wrapped around its neck, and if surgery was not performed within half an hour, the baby would not be able to be saved. We remembered what our sister had said during a meeting. Therefore, we believe that this approach would be expensive and perhaps not possible. Even if possible, it would be difficult. Therefore, we went to a government hospital instead. (beneficiary, JLNMCH, Bhagalpur)
“Certainly, there has been a significant difference. For instance, when there is an accidental case, it can cause considerable trouble. Going outside [to other medical facilities] would cost approximately 50 - 60,000 rupees. Here (the government hospital), your work is done in just 5000 rupees. Therefore, we explain to them, "Brother, you are poor; you might have to wait a bit, but we will get your work done. We will talk to the doctor on your behalf. However, if you still wish to leave or know [about other options], that is your choice. However, let me assure you that your work will be done here easily” (Swasthya Mitra, JLNMCH, Bhagalpur).
These individuals not only steered patients toward cost-effective treatments but also provided emotional support, ensuring that informed decisions were made in stressful situations.
Category 2.3: Swasthya Mitra Synergy enhancing patient care.
Subcategory 2.3.1: Navigation help
The healthcare landscape is rapidly evolving, making hospitals more complex than ever. Coordination between various departments is crucial for efficient service delivery. For a patient or visitor, the first point of contact is often the entrance or the reception desk. Swasthya Mitras came into play, guiding people, offering information, and ensuring that the system works as a well-oiled machine.
"Where is our gynecology department? Where is the OPD running? Where is the labor room? where is the general ward? How will the public know all this? Someone needs to tell them. The government does not have any dedicated staff for any cadre. "(DDA, DH, Jamui).
"No, it was not like this before. Ever since Jeevika’s sister came, people do not have to wait. Earlier, people had to determine where to go. Now, she tells them where to consult depending on their needs and even gets the slip for them." (Nursing Officer, DH, Jamui)
They fill a gap in the system, offering a service that is currently either inadequately provided or altogether missing, particularly in government hospitals.
Swasthya Mitras are not only well versed in hospital navigation but also play a critical role in coordinating with ambulance services. They maintain a registered list of available ambulances and directly assist in the dispatch and receipt of these services.
"We have also tied up ambulance services in this manner with them [Swasthya Mitras], which are registered. Therefore, you will see that if a patient needs an ambulance, even the ambulance register is available with them. "(DDA, DH, Jamui)
"We can assist them. Similarly, if a patient is going from here and they are worried about how to go, we inform them over the phone that a patient is leaving; please make an ambulance available. They make the ambulance available. If the ambulance is going, and they need some papers, we tell them that this is the indoor number, this is the name, so they also inform the ambulance driver about it. There's a very good relationship between these two [parties]." (NO, DH, Jamui)
Subcategory 2.3.2: Overcoming Communication Barriers
Swasthya Mitras have become essential bridges for overcoming communication hurdles between patients and medical professionals.
"After I (swasthya mitra) made the call, the patient asked, 'Where should we go? We have no idea.' I told her to come to me, and we would be waiting at the gate. We took her to the registration counter, then to the doctor. The next day, the doctor called her again." (Swasthya Mitra, JLNMCH Bhagalpur)
Doctors had started communication with the swasthya mitra since they understood the medical terminology. This streamlined patient care and relieved doctors. The patient believed that Swasthya Mitra was linked to the hospital. The doctor and patient attendant communicate via the Swasthya Mitra.
"Doctors explain everything to us first. They only call the attendees to sign." (Swasthya Mitra, JLNMCH Bhagalpur)
The role of Swasthya Mitras extended to coordinating various hospital departments, ensuring smooth processes. Their comprehensive understanding and coordination helped to streamline patient care, effectively utilizing available resources.
“We have health managers of all the departments here. Those people (e.g., Swathya Mitra) coordinate with the doctor and solve them. If blood is required or there is a delay in the operation, the patient meets us and the doctor, and the operation is terminated. whatever the problem is, they coordinate with us and solve them. These Swasthya mitra are like a gateman between the patient and us (health workers). They get the patient to easily reach us and the doctor. These people are doing very well. Early on, the patient faced difficulty due to a lack of information. Now these people get the process done. “(Health manager, JLNMCH, Bhagalpur)
Patients were appreciative of the detailed explanations provided by the Swasthya Mitra. As one respondent put it,
"She explained things that we did not know about, like where the children are, where ultrasound will be done, etc." (beneficiary, JLNMCH, Bhagalpur)
Subcategory 2.3.3: Dealing with critical cases
In addressing critical cases, the role of Swasthya Mitras has proven to be indispensable, particularly in situations where quick and informed decisions are paramount. One notable example involves their capacity to expedite emergency services. Their understanding of hospital protocols and urgency of situations enables them to facilitate faster medical attention. As highlighted by the District Health Authority in Jamui,
“They know which people need to be seen immediately in an emergency... a sideline opens up for them... they get emergency services a bit faster.”
This ability to prioritize urgent cases underscores their critical role in emergency care.
Subcategory 2.3.4: Enhancing Postoperative and Postdischarge Care
Swasthya Mitras plays a crucial role in bridging the gap between hospital care and home recovery in postoperative and postdischarge scenarios. Their proactive engagement ensures continuous and personalized patient care, especially following surgeries such as cesarean sections.
“After she got discharged...we call her after two days...we ask her, 'Sister, how is your cesarean? Are there any issues with the stitches? Is there pain?' If she says there's pain, we tell her to come again the next day and consult us” (Healthcare Worker, Hospital A).
Additionally, they maintain detailed follow-up registers for systematic tracking.
“In the follow-up, we write that this person needs to be called again...we call her to ask if there's any issue” (Healthcare Worker, Hospital B).
Their role in facilitating smooth transitions from hospital to home through diligent follow-ups and effective communication highlights their invaluable contribution to the healthcare system.
Subcategory 2.3.5: Cultivating Compassion
Smiles are often the first sign of warmth and welcome. It is noteworthy that the Swasthya Mitras maintain a pleasant demeanour, greeting everyone with a "smiling face."
"The first thing is that they have a good and smiling face."(medical officer, Jamui)
This not only provides comfort for patients but also promotes a positive work environment for hospital staff and administration. Their good behavior and efficiency have been acknowledged as valuable additions to the hospital’s functioning.
Theme 3: Empowering healthcare access through women’s empowerment
JEEViKA plays an essential role in Bihar women's empowerment. It empowers women economically, socially, and politically, making their lives more rewarding and autonomous. The Swasthya Mitra cadre empowers women in health and nutrition.
Category 3.1: Empowerment through Professional Growth
The journey from dissatisfaction to fulfillment is underscored as Swasthya Mitras recounted their experiences. The shift from the CNRP (community nutrition resource person) to Swasthya Mitra provided a platform for channeling expertise, especially in assisting those in distress.
"In Jeevika, I was working, but there were moments like when a baby died after delivery. In another instance, a woman had low blood levels after childbirth. Despite teaching and advice, we could not provide effective help." (Swathya Mitra, JLNMCH Bhagalpur)
She felt empowered to handle her job responsibilities as a swasthya mitra. She believed that helping patients receive medical treatment strengthened her.
“Living in the village, we interacted with people. Now we converse with prominent doctors. If patients struggle to communicate, we can confidently bridge the gap. When doctors cooperate, we feel empowered and capable.” (Swathya Mitra, JLNMCH Bhagalpur)
Category 3.2: Embracing an “All-rounder” role:
Swasthya Mitras embraced their role as versatile contributors to hospital services. They became "all-rounders" due to their diverse responsibilities.
"We are all-rounders in the hospital because while a nurse or a sister might specialize in one area, we have knowledge about many fields and departments" (Swasthya Mitra, Bhagalpur).
Category 3.3: Familial and Social Recognition
Empowerment extends to family and society. Swasthya Mitras learned medical and communication skills, which family members had acquired. This recognition boosted their family image. Currently, extensive investigations, including kidney function tests (KFTs) and liver function tests (LFTs), are being performed at hospitals. The technical terminology of medical practitioners is now understandable. Many of their family members complemented them, saying they had gained much medical knowledge from their new employment. Swathya Mitra shared these views.
“Since we started working here, we have gained a lot of experience. During training, we were not informed about the details of the investigations that doctors wrote, but as we started working, we learned a lot of things. (Swasthya Mitra, JLNMCH, Bhagalpur)
Category 3.4: Fostering Autonomy in Women's Healthcare Decisions
Bihar women inevitably depend on their husbands for medical appointments due to conventional gender roles. This practice could postpone treatment due to husbands' work. Swasthya Mitra, have transformed the empowerment of female patients and their attendants. They inspired women to seek healthcare. Women felt more secure in hospitals with these dedicated assistants. Once hesitant to seek medical help independently, women now attend hospitals with confidence that Swasthya Mitras is available to help.
"Yes, yes, those sisters (Swasthya Mitras) were a great help. I had gone alone as my husband was not at home that day, and my elderly parents could not accompany me. Therefore, I took my sister-in-law. With a Swasthya Mitra on our side, we felt emboldened. She reassured us that we had made the right decision. Her presence erased our worries." (Beneficiary, JLNMCH, Bhagalpur)
Swasthya Mitras had democratized healthcare for women and changed family healthcare dynamics. This empowerment of female patients and their attendants showed how collaborative healthcare approaches can enable marginalized women to make educated decisions and become self-sufficient.
Theme 4: Shifting preferences from private to government hospitals.
There was a shift toward preferring government healthcare facilities. The patients found government services more convenient and reassuring than private options after the initiation of the help desk by Swasthya Mitra.
"In a government facility, we have to run here and there a lot because we were totally unaware of the structure and functions of the facility and what should be done where. We were completely clueless, but after the Swasthya Mitra cadre was created, she used to explain to us what should be done and where we should go. It was quite easy to manage our health needs in the government facility itself without spending a lot of money from our pocket.” (Beneficiary 3, JLNMCH, Bhagalpur)
The emergence of facilitators such as the Swasthya Mitra played a pivotal role in not only guiding individuals through the intricacies of government healthcare systems but also instilling confidence in their ability to access quality care without enduring financial strain.
Theme 5: Stakeholder satisfaction
Patients and health care staff have praised the emotional support, timely assistance, and clarity of the information provided by the Swasthya Mitras. Their interactions have instilled a new level of trust and comfort, which has been a traditionally lacking element in government healthcare services.
Category 5.1: Patient Satisfaction and Trust
In multiple instances, patients commented on how the Swasthya Mitra was more considerate and helpful than the regular hospital staff. One patient noted,
"No one in such a big hospital talks to us the way they talked. Nurses here do not talk nicely when giving injections; they say things like 'your arm is swollen, extend it properly' (strict tone). (Beneficiary, JLNMCH, Bhagalpur)
Category 5.2: Inclusive Support
A health manager pointed out a case where a local HIV-positive patient, initially denied service at a private facility, was helped by the Swasthya Mitra to be admitted and have her baby delivered safely at the government hospital.
"There was a local patient from a nearby place; she was HIV positive. Her husband was a rickshaw puller. Initially, they visited a private facility, but they were not admitted due to her HIV status. Later, they heard about a Didi (referring to Swasthya Mitra) and contacted her. She helped, and the patient was admitted. The delivery was successful, and the baby was healthy. This effort is truly commendable. (Health Manager, JLNMCH)
By humanizing the experience of navigating often labyrinthine government healthcare systems, the program has significantly improved stakeholder satisfaction across the board. The sweeping approval from various stakeholders demonstrates not only the program’s success but also its potential as a model for similar initiatives aimed at elevating the quality of healthcare in government hospitals.
Theme 6: Swift support and acknowledgment from the government health system
After initiating the services at the facility, the Swasthya Mitra received a supportive and enabling environment. Over time, as everyone became familiar, there was no difficulty for the patients.
"We then introduce ourselves, saying, 'We have a cabin near the ICU here. We are Jeevika Health Friends.' Therefore, they were ignored once or twice. However, as there are four or five counters, by the time we introduced ourselves, others recognized us. Currently, there are no problems. No matter how crowded it is when we go there, they prioritize and attend to our token first. "(Swasthya Mitra, JLNMNCH, Bhagalpur)
For instance, even in situations with long queues, elderly or needy patients associated with Swasthya Mitras receive quicker assistance, as seen in the case of an elderly patient who was immediately admitted upon request.
"Yes, we receive assistance very well. Do you have the doctor or those who come to the help desk, they recognize us well, meaning they know we are from this staff right? Now, even the staff know that we are their colleagues, so they expedite our work. "(Swasthya Mitra, JLNMCH Bhagalpur)
Theme 7: Challenges Faced by Swasthya Mitra
Swasthya Mitras played a crucial role in bridging the gap between patients and healthcare services in government facilities. However, their work was not without challenges. They grapple with high patient expectations, resource limitations, administrative pressures, and the need for better infrastructure. The initial phase of work for Swasthya Mitras was arduous. Patients, sometimes with high hopes, sought assistance, assuming that Swasthya Mitras would take care of their concerns. This created expectations that challenged the limited resources and capabilities of these healthcare facilitators.
"In the beginning, we faced many difficulties. For instance, when we started out, any patient who would come were optimistic, thinking 'Didi (sister) will get all my work done. (Swasthya Mitra, JLNMCH, Bhagalpur)
Category 7.1: High Expectations from Beneficiaries
Complexities arose when patients required timely operations, and delays occurred due to resource constraints. Patients and their families experienced frustration when operations did not occur as expected, highlighting the strain on healthcare services.
"Therefore, for instance, when we got the patient admitted to ORTHO (orthopedic department), their surgery should have taken place after 2-3 days. However, surgery did not occur. Everyone became very worried, thinking, 'It is been 4 days, and our surgery hadn't been done. '" (Swasthya Mitra. JLNMCH, Bhagalpur)
Category 7.2: Long Working Hours
Swasthya Mitras described their demanding routines, involving long shifts and continuous availability to attend to patients. As patient footfalls increase throughout the day, maintaining patient records becomes challenging, often leading to incomplete documentation. Patients sometimes misinterpreted or misused the role of Swasthya Mitras, asking them to complete administrative tasks such as issuing certificates.
"We have to do an 8-hour duty. We arrived at 6 AM in the morning. After that, the phone becomes busy, so we must answer it. Currently, token issuing (registration) starts at 8 AM, so patients start coming in at 8 AM, and we get busy assisting them. Then, we must maintain the register, and sometimes there are issues with it, which causes delays. We were unable to complete all the columns for every patient. Therefore, we finish it on the second day."
Category 7.3: Challenges Faced by Swasthya Mitra due to Third-Party Brokers
The third-party brokers or "dalals" pose significant challenges to the efforts of the Swasthya Mitra members, often compromising patient welfare.
Subcategory 7.3.1: Interference by Brokers in Ambulance Services:The advent of ambulance services has provided much-needed support to the community, especially when patients need to be referred from one facility to another. Brokers frequently attempt to divert these ambulances to private practitioners, leading to unnecessary delays and detours. To counter this, drivers alerted Swasthya Mitra members about incoming patients to ensure that they were not misguided by these brokers.
"Ever since we got the charge of ambulance facility management, we get referrals from PHCs (primary health centers), as this is the only district hospital. The referrals that come here, what those people (brokers) do is stop the ambulance right there (outside the hospital gate). They divert the ambulance to private hospitals. Ever since we got the ambulance, the drivers tell us, 'Sister, patients are coming. Please take care of them; otherwise, they will fall into the hands of the agents.' (Swasthya Mitra, District Hospital, Jamui)
Subcategory 7.3.2: Threats and Violence toward Swasthya Mitra Members: Swasthya Mitra members were subjected to verbal abuse and threats of physical violence from brokers. On several occasions, these threats translated into actual acts of violence or confrontation.
“Those agents were saying that ever since Jivika didi took charge, their earnings had virtually stopped. One day, they were verbally abusing even as they walked by. They even tried to get into a physical altercation with us, saying that one day you will get beaten up if you keep doing this. Why does she tell the patient who this will be the treatment, or this will be the test, when it is not available here? We had said, we do not say that. We only arrange for the tests that are available here.” (Swasthya Mitra, District Hospital, Jamui)
Theme 8: Swasthya Mitra stealthy presence in the eyes of a doctor
Swasthya Mitras in hospitals serves various functions aimed at enhancing patient care and experience. However, there is a noticeable gap in understanding among doctors about the role and responsibilities of Swasthya Mitras within a hospital setting.
There was a general lack of awareness about the purpose of Swasthya Mitras in the hospital environment.
"I have no idea. They might help direct patients to the right place, such as an enquiry desk. (Postgraduate student, OBGY Department, JLNMCH, Bhagalpur)
The doctor's lack of certainty about the role of Swasthya Mitras suggests the need for improved internal communication within the healthcare facility.
"We maximum doctors thought they were on behalf of hospital administration.” (Post graduate student, OBGY department, JLNMCH, Bhagalpur)
Doctors acknowledged the interaction between Swasthya Mitras and patients but also highlighted the absence of any formal introduction or interaction between doctors and Swasthya Mitras.
"Yeah. I admit they accompany patients to OPDs, but still we were clueless, 'who are they?' The interaction between SM and patients seems to be great. However, no interaction/introduction was given by SM to doctors." Postgraduate student, OBGY Department, JLNMCH, Bhagalpur)
The lack of formal introductions between doctors and Swasthya Mitras might impede collaborative patient care.
Theme 9: Impact of Elevating Swasthya Mitra
Category 9.1: Smart Navigation
A template or printed guide showing the services available in the hospital, along with respective room numbers, could aid in better navigation and reduce the time patients and their families spend searching for specific departments or services.
"If we could get a printed template-type guide of where and what services are available in the hospital, then when explaining to someone, we could also give them a piece of paper. If the printed services are all laid out in an organized manner detailing all the arrangements in the hospital, then we can give them directly in written form.” (Deputy Director Administration, Jamui)
Category 9.2: Increased Visibility
Increased visibility of SM personnel (e.g., through recognizable uniforms) and an increase in their training frequency are recommended. Regular meetings and interactions with other hospital staff, including nurses and residents, can increase the role of Swasthya Mitra and enhance its impact on patient care. They should work on the model of community kitchens managed by these self-help groups.
"Today, there is “Didi ki Rasoi (Kitchen operated by members of Self-help group). Yes, it is fully operated by them. Therefore, we understand that the way and the time it has been set up, a place has been created in a hospital where one can sit and eat comfortably. It is not the restaurants or hotels; we have that hotel, but there's certainly an intermediate arrangement, which is ongoing in 38 districts and is right. Swasthya mitras will also have to do this. They will need to be added a bit more, and this will happen. (Civil Surgeon, Jamui District)
There is a need to further incorporate or integrate their services into this system for enhanced efficiency and reach.
Category 9.3: Training and skill development
Refreshers or regular training sessions for these patients are critical. Initial training provided a foundational understanding, but periodic sessions ensure that their skills remain sharp and that they stay updated with the latest best practices.
"Refresher training is needed because in the initial stages, it is like looking at a plot. In the field, if a plow is used, it runs smoothly for the first time. However, unless it is run a couple of times more, it does not get perfectly ready. These individuals are also completely unfamiliar with the medical field. Hence, you will need to provide them with fresher training time to time. "(DDA, Jamui)
Category 9.4: Extended Availability
There were availability issues regarding swasthya mitra. Swasthya Mitras were not available at night, especially in the labor room. Diversion toward private entities became an issue due to the nonavailability of Swasthya Mitras at night, and third parties (referred to as "brokers" here) became more active during these hours, potentially impacting the patient's experience.
“They (brokers) are more active at night. Therefore, if the Swasthya Mitra are present at night as well, then the patient will not suffer.” (Health Manager, JLNMCH, Bhagalpur)
When a patient arrives, Swasthya Mitras often accompanied them to guide them through hospital procedures. This absence, which may last from half an hour to an hour, resulted in their service counter being unattended, as there was only one Swasthya Mitra per shift. Having at least two swasthya mitras per shift can ensure that while one accompanies the patient, the service counter remains.