Mohalla Clinics in Delhi and psychological analysis of the idea

INTRODUCTION

 

According to a Report by KPMG and FICCI, India Spends about 4.2% of its GDP on Healthcare, out of which just about 1% is contributed by the Public Sector. In other words about  only about 33% of the total Healthcare Expenditure in India in from the Public Sector, while rest 66% is in the form of Out of Pocket Expenditure of an common Indian. It is shocking to see that while the World Average spending on Healthcare is 6% of a country’s GDP, India is spending abysmal 1.28% of its GDP on Healthcare. According to LANCET report- Healthcare in India is the poorest among the SAARC countries as well, even countries like Afghanistan spend 8.2%, Maldives spend 13.7%, while even a smaller country like Nepal spends 5.8% on Healthcare.

A country like India spending so less on Healthcare is a clear indication of misplaced priorities by the Government, which would eventually lead to wasting our Demographic Dividend and taking it to a level of Demographic Disaster. To take effective advantage of this demographic dividend, it is important to ensure that the people in the country are provided with accessible , affordable, equitable and quality healthcare, to take care of their basic demands and help them focus on enriching their experience of life.

 

Existential issues in healthcare in India

Indian’s healthcare system represents  a spectrum of contrasting landscapes. At one end we have these five star and seven star hospitals which are delivering high tech medical care to rich class mostly of the urban areas. Whereas there are outposts in the “other India” which is trying to desperately trying to live up to their identity of health sub centres. With globalisation, increasing income inequalities, with a section of the population remaining marginalised – these contrasts are expected to rise in the coming times.

There are multi-faceted challenges in delivering healthcare to everyone. The term “everyone” in our

• Awareness – Due to low levels of Educational levels, poor functional literacy, low priority given to healthcare in the education system, cultural bias play important role in people knowing very less about the essentials of healthcare.

          A study in Haryana found that only 11.3% of the adolescent girls studied knew correctly about key reproductive healthcare issues, also another review article in geriatric morbidity found that 20.3 % of the participants were aware of the common causes of prevalent illness and their prevention.

• Access – It is important to make sure that medical facility is available in close proximity of every individual. Physical reach is one of the most important determinant of access . Along with the physical access what is important is that , the quality of the healthcare is also ensured.
• Absence of Human power in healthcare –  For effective healthcare provision in India, what is most important aspect is that we have adequate, efficient and skilful. A study of 2011 estimated that only roughly 20 health workers constitute per 10000 population. Allopathic doctors comprise of 30% of the workforce, nurses and midwives about 30%, pharmacists about 11%, AYUSH practitioners about 9%. Private sector provides majority of the healthcare services in India. It has been difficult so far to harness the private services to provide public healthcare.
• Affordability – The cost of the healthcare is an important aspect of healthcare services at the universal level. India is a country having comparatively low levels of per capita income. The healthcare services being costly has the potential to cause impoverishment to the family.  The issue in India is that the private sector is considered to provide quality healthcare but it is costly and the public sector is affordable but it is perceived to be unreliable, of indifferent quality and not the first choice.

 

The Health Facilities in Delhi

Delhi, the capital city of India which is also a city-state recorded a population of 1.68 crore (16.8 million) in the 2011 census. With a geographical spread of 1483 sq.km, Delhi has population density of 11,297 per sq.km. It is to be noted that 97.5 % of Delhi’s population lives in urban agglomeration and 11% of it lives in slums. As of March 31^st 2014, there were 95 hospitals, 973 nursing homes and 27 special clinics. In addition, 15 government run medical colleges in allopathic system. The Government of Delhi run health facilities examine about 3.35 crore outpatients and treat about 6 lac hospitalised patients every year. The Government of Delhi owns about 1/3^rd to 1/4^th of the total healthcare facilities in Delhi

 

Mohalla Clinics : the Origin of the idea

 

The concept of Mohalla clinics partially originated from the traditional idea and practise of Mohalla Medical units (MMU) or Mobile vans. These MMU’s used to provide health services in underserved areas bringing doctors and other staff along with medicines and supplies. The response was overwhelming to these vans and the communities demanded more of these vans. However later it was realised that the services through MMU was unpredictable and depended on vehicles, doctors, road conditions also the recruitment of staff was a matter of concern . It was suggested to the minister of health that  a more sustainable solution is taken into consideration

The idea of Mohalla clinics came up with expectations that –

• More sustainable solution, where services are based in the community,
• People know where to go for services
• There is component of assurance of availability of providers, medicines and service package
• There is sufficient community linkage and engagement.

 

 

Bounded rationality and decision making

 

Human being though considered to be rational, takes his/her decisions in the context of various conditionalities. The decision making depends on various contextual factors, time available and cognitive limitations. Getting the right healthcare can also be seen in the similar light.

 

What affects  decision making while choosing healthcare service ?

 

Class

People belong to different levels of class in an economy. There is a huge disparity in class based healthcare services that people take. While the well off may choose to go to the big branded hospitals, which have the best possible doctors but charge high. The poor on the other hand  have a hindsight bias of not being able to afford the healthcare that people on a different class levels do afford.

Perceptions of Self Ability & Contextual constraints

 

The perceptions about estimated cost of healthcare in a particular hospital, spending potentials of a person, priorities based on family responsibilities, low per capital income, professional commitments, debt traps are the factors that cause people to keep healthcare at a backseat. Especially, this happens if the cost is on preventive healthcare that curative.

 

Time Available

 

The dilemma that is often faced by people is time vs money. Most of the decisions often compel an individual to sacrifice one of the above. If the rich is short of time and wants to get himself treated, he has to pay more to get quick redressal for his issue. The poor on the other side due to his hindsight bias & perception of self-ability knows that he cannot afford high tech healthcare solutions in good hospitals, he has the option of going to government hospitals and getting himself treated for free or at reduced cost. However, time is an constraint for the poor as well. For the poor taking time off and going to get himself treated is double burden  as he has to pay for his travel, he has to visit multiple times without service guarantee- this directly means that he/she cannot go to work and his losing his wages in the process given the unorganised sector in the country. Also along with losing his wages he has to pay for whatever expenses he/she has to counter. The resource dilemma is overpowered by urgent needs of the day and immediate responsibilities, daily fire fighting and thus healthcare is not put in priority and takes a back seat.

 

Cognitive limitations of Actors

 

The first factor mentioned in the existential issues in healthcare mentioned above was- awareness. The awareness about where to go for which ailment is very low in India. It is seen that due to lack of primary healthcare -people tend to go to bigger hospitals even for very small ailments like common cough and cold, mild fever etc. This causes overcrowding of big hospitals, it indirectly causes a huge gap in a huge gap in demand and supply of effective healthcare facilities. Now, the experience causes regression fallacy in individuals, wherein next time when then encounter an ailment the mental accounting  in their mind makes then not to go to the hospitals and avoid the situation altogether.

 

Taking Satisfying decisions  (Mental construction )

 

The proverb to “Dig a well when one is thirsty” fits aptly while explaining why people go for curative healthcare then preventive healthcare. People avoid visiting a doctor in early stages of ailment due various limitations stated above. When the discomfort increases, they do visit a doctor as they are compelled to when it starts affecting their daily routine. The psychological satisfaction that they have visited a doctor becomes important for an individual over the point of the appropriate time of visiting a doctor. One does not involve in the process of self-reflection and instead keeps consoling ones self that he/she visited a doctor creating mental construction.

 

 

 

CONCEPTUAL DESIGN OF MOHALLA CLINICS

 

 

The idea: To provide free healthcare services through a health facility within a walking distance (around 2-3 km radius or 10-15 min walking), open for at least 4-6 h of every working day, assured availability of identified basic health services, a medicines, and diagnostic tests. Estimated 80%- 90% of health problems are likely to be treated at this level reducing the numbers of patients in need for referral

 

 

Population targeted: Underserved, migrants, Jhuggi Jhopri colony; each clinic aims to serve approximately 10,000-15,000 population

 

Staffing: At least one qualified medical doctor, auxiliary nurse midwife, a pharmacist, and support staff as needed

 

Service provision: An assured package of health services include outpatient consultations, basic first aid services, maternal and child health services including immunization, antenatal and postnatal services, family planning, counselling, and referral to next level of facilities for specialized treatment.

These clinics aim to implement national health programs as well

Specialist and referral services and continuum of care: Specialists proposed to be available on weekly basic (pediatrician, gynecologist, and ophthalmologist). A system of referral through a tiered approach to health facilities been proposed (though yet to be made fully functional)

 

Medicines and diagnostics: Sufficient supplies of medicines and diagnostics, free of cost to the people availing these facilities, from an approved list of 108 medicines and provision of >200 diagnostic tests

 

Location: Settings and localities of migrant and poor population lives and demarcated areas called slums and Jhuggi Jhopri colony, where such underserved population lives. First such clinic was established in North‑West Delhi in Jhuggi Jhopri colony and it was situated around 400 m walking

distance from the main road, in the center of Jhuggi Jhopri settlement. The locations are decided with inputs from local community/Resident Welfare Associations (RWA)/survey by planning branch/verification of sites by team of health personnel.

 

Physical infrastructure and accessibility: Proposed to be housed in two to three rooms. The rooms could be either made of prefabricated material (called portacabin) or in private houses with similar amenities. Of the rooms, one to be assigned to a doctor and for medical examination,

sufficient enough to maintain privacy. The other or second room is used for laboratory functions, dispensing medicines, and the waiting seat for next patient to be seen by doctor. If there is a third room available, it could be used as waiting room; else the open space covered through a roof should be as waiting area. The provision of drinking water dispenser and a washroom attached to these facilities. There has to be provision of air‑conditioning and a television with cable connection is part of the design. These clinics to be located in a way to ensure easy accessibility by beneficiaries, with an all‑weather road, accessible by an ambulance, and an open area.

 

Financing: The construction cost of each clinic was estimated nearly 20 lakh Indian rupee (or US $30,000). (However, till December 2016, majority of

clinics were being operated in rented accommodations.) Reportedly, no analysis was done on estimating the operational cost of these clinics.

 

Use of information technology: A token vending machine (similar to what one experience in a bank branch) for patient queuing; computer‑based record maintenance for each of the patient; and use of tablets/software programs for prescription writing/data compilation and technology‑based

tablets are used for conducting a number of laboratory tests.

 

Leadership and governance: Initiative led by the Minister of Health and other Senior Government officials; being implemented through specially enacted agency called Delhi Healthcare Corporation, led by Principal Secretary (health), the top health bureaucrat in the state.

 

Private sector engagement: The private doctors have been recruited to run these clinics at “fee for service” basis at the rate of Rs. 30 per patient as consultation charges. If a helper is positioned, an additional Rs. 10 per patient is paid. The fully ready chamber is made available to these doctors who

are empanelled to manage them in 4-6 h shifts as an outpatient clinic. This is small but major policy step as most of the time, by public sector officials private doctors are seen with complete distrust and with profit motive. That notion could only be dispelled with sustained engagement between two

sectors through top level political leadership.

 

Timing and working days: Minimum clinic time of 4 h which can go up to 6 h. These are expected to be open in morning; however, time of clinic can  be adjusted to patient needs and a few run in evening as well. Open six days a week excluding public holidays.

Other features: A proposed strong and effective referral linkage with attention on continuity of care; financial protection (by free services); reduced cost

of care by higher attention and investment on healthcare, ambulance and transport services

 

Psychological Benefits of the Concept

 

Converting Deliberative Thinking into Intuitive thinking

 

There are two modes of thinking ‘Intuitive’ and ‘Deliberative’ (Kahneman,2003). While deliberative thinking is based on careful assessment and deliberative decision making, intuitive on the other  hand  is based on fast decisions based on automatic processing. It is said that “Humans are Cognitive Misers” , therefore if encountered by an ailment and there are many choices available in the private sector and when one does not know which of the clinics is trust worthy and one is vulnerable of being gullible –  it increases the cognitive load on oneself and it leads to resistance to change and avoiding the situation all together. To avoid the cognitive load one gets subjected to status quo bias, wherein one thinks that it is better to avoid going to the doctor all together as one has to face the following questions of deliberative thinking –

1. Which Doctor to choose ?
2. Should it be a specialist or a general practitioner ?
3. Which branch of medicine should the Doctor belong to ?
4. How does one reach the hospital ? What mode of transport to take ?
5. Should one take leave from his/her workplace and let go the monetary benefits ?
6. Is the ailment more important that other immediate responsibilities at hand ?
7. How much would the Doctor charge ?
8. What is the guarantee of getting good health service even after spending more ?

 

These questions show that it involves a huge amount of mental accounting and deliberative thinking. Now, as policy makers it should be our job to make sure that healthcare services take a form of intuitive thinking and not deliberative thinking so that the status qio bias is avoided and one can take easy decisions, with low cognitive load and use heuristics. But, at the same time it is important that the decision does not prove to be a hasty decision when taken using heuristics and is as good as well thought decision. This is where the concept of Mohalla Clinics is important. As the clinics are supposed to be located in the proximity of 10-15 mins and also that it provides free services with authorised doctor – one does not have to think a lot before going to the clinic.

Creating Foot in the Door

 

Now due to the concept of Mohalla Clinics, which potentially provide affordable, accessible and quality healthcare services and also at the same time reduce your cognitive load, one has more probability to use the services of Mohalla clinics considering the Prospect Theory wherein humans tend to maximise benefits and minimise losses. The close proximity and being free of cost causes the mental accounting to tilt in a way that individual that at least wish to try these medical services.

Now, from that state’s point of view it is a success as it would’ve managed to bring an individual to the hospital. This is the first step of curative healthcare analysis. The Doctor can further analyse the ailment and if something is serious he can advise the patient to visit a Government Hospital and it can thus be lifesaving also in  certain cases.

 

Principle of Authority of Social Influence

 

Authority is one important factor of the 6 factors of Social Influence ( Cialdini, 2001). It is important that understand people tend to believe and be persuaded by “credible, knowledgeable experts”. The Doctors of these Mohalla clinics are experts and senior doctors with decent experience. The merit of the Doctors and their expertise is expected to persuade the patient to follow the advice that the doctor is giving him.

 

Creating Echo chambers

 

The location of the Mohalla clinics is most of the times located in a community. It can be located in  a locality or a jhuggi jhopri. The main obstacle is gaining trust. Now, through the foot in the door and others ways of intervention if once the trust is developed, it will help the people in the locality to get rid of their confirmation biases, previous stereotypes and prejudices. It will then create a Echo chamber of Positivity in the community due to good experiences that people in the community have had. This will lead to developing domino effect in the community.

 

Countering the Stereotypes & Creating a new schema

 

Good experiences by people, or listening to others experiences and knowing the benefits of the service would create a New Schema, i. e – New pieces of information and knowledge and get stored in the mind. It will orient new cognitive frameworks  and help to create long lasting positive effects on our minds.

 

Mere Ownership Effect

 

The Mohalla Clinics of Delhi are created by the Initiative by the Minister of Health and it is  being implemented through an agency which is specially enacted for this cause called Delhi Healthcare Corporation which would be led by Principal Secretary (health and  the top health bureaucrat in the state. This creates a ownership effect as this is a pet project of the Government and the societal goals, satisfaction and positive perception has direct political impact on the people who have designed the model ( This is very important from the political economy perspective ) . This would then create

 

 

CONCLUSION

 

The Government of Delhi has allocated about 12.47 % of its Budget expenditure on healthcare. It has definitely been  most of the high priorities of the Government. The concept of ‘Mohalla Clinics”  was a novel idea. It has the potential to reform primary healthcare in India and solve many issues related to access, affordability, equity and quality of healthcare in India.  The success of the concept of Mohalla Clinics can be seen on two proofs, first that a number of Indian states like Maharashtra, Gujarat, Karnataka and Madhya Pradesh and few municipal corporations like Pune have shown interest in studying and potentially replicating these clinics and it is seen that there is high demand of the services from these clinics. The clinics are delivering assured health services to 70 odd patients every day and they are operating for 6 days a week. Also, one most important factor is that these clinics have brought health on the political spectrum of Indian politics.

The psychological aspect that is associated with the primary healthcare in the country is also focused well by the concept of Mohalla Clinics. The clinics help to counter the hesitancy by most of the people to take the benefits of primary healthcare and alter the status quo. It can potentially lead to heal most of the common ailments at the local level itself and thus reduce the burden on the bigger hospitals. The clinics can revolutionise healthcare in India if it brings in a demand from most states of India, prompts the parties in India to make health a topic in the elections and influence election outcomes. These steps can be in the right direction given the context of Universal Health Coverage schemes in India.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

BIBLIOGRAPHY

 

Lahariya, Chandrakant. (2017). Mohalla Clinics of Delhi, India: Could these become platform to strengthen primary healthcare?. Journal of Family Medicine and Primary Care. 6. 1. 10.4103/jfmpc.jfmpc_29_17.

 

De M, Taraphdar P, Paul S, Halder A. Awareness of breast feeding among mothers attending antenatal OPD of NRS medical college. IOSR J Dent Med Sci. 2016;15:3–8.

Pandey D, Sardana P, Saxena A, Dogra L, Coondoo A, Kamath A, et al. Awareness and attitude towards breastfeeding among two generations of Indian women: A comparative study. PLoS One. 2015;10:

 

Kasthuri, Arvind. “Challenges to Healthcare in India – The Five A’s.” Indian Journal of Community Medicine : Official Publication of Indian Association of Preventive & Social Medicine 43, no. 3 (2018): 141–43. https://doi.org/10.4103/ijcm.IJCM_194_18.

 

PRSIndia. “Delhi Budget Analysis 2019-20,” March 5, 2019. https://www.prsindia.org/parliamenttrack/budgets/delhi-budget-analysis-2019-20.

 

 

Psychological Analysis of Mental Health Crisis in India

 

Authored by Ashima Mahajan

Mental health constitutes an indispensable part of health. It is the level of
psychological well-being or an absence of mental illness. From the positive psychology
perspective, mental health includes individual's ability to live freely without any undue stress or worries and to have a healthy balance between work and home, which consequently will help achieve psychosomatic resilience.
Issues related to mental health might arise due to myriad causes including stress,
tension, loneliness, depression, anxiety, death of a close person, suicidal tendencies, grief, addiction, mood fluctuations as well as learning disabilities. Mental health illnesses can be better managed through various treatments like therapy, counselling sessions and medication and by expert treatment and guidance involving therapists, psychiatrists, psychologists, social workers, nurse practitioners or physicians.
According to the World Health Organization (WHO), mental illness affects closely
50% of the world’s population. Beyond these staggering numbers, it is important to
understand that there lies a lacuna in how mental health is dealt with in our country. There exists a wide institutional gap in our country whereby patients do not receive treatment and care on time mainly because of lack of awareness, the social stigma associated with it, lack of trained professionals, inadequate funding and low funds advocated in the healthcare budget.
Merely framing policies is not the only solution and instead, proper awareness needs to be built along with bringing behavioural change. Further, the problem aggravates with very low spending in health budget by both the union and state government.
Multiple aspects including social, psychological and biological factors determine the
level of mental health of a person at any point in time. A person may experience a poor state of mental health because of stressful work conditions, social exclusion, rapid social change, gender discrimination, unhealthy lifestyle and physical deformities.
In today’s times, people are so conscious and aware of their physical health. They
know what diets to follow, what exercise workout routines to carry out and monitor every aspect of their health using state-of-the-art fitness bands. But this awareness is lacking when
it comes to mental health. It’s a battle in itself to educate people about mental well-being. In our country, the discovery of mental illness is often followed by denial and hesitation to seek help. Despite its enormous social burden, mental health remains a taboo subject that is susceptible to age-old stigmas, prejudices, suffering, discrimination and fears.
To fight mental illness, status quo bias cannot be maintained. Instead, we need to
break psychological inertia and come out of the fear of transparency. It is only when the
victims and their family accept the consequences of the illness can they collectively fight this malady. It can also be noted that mental illness or disorder is not battled alone by the victim.

But his family also suffers from this tragedy equally. The sentiments and emotions that go behind the fighting this cause is immense and cannot be ignored.
It is important for everyone to get involved to collectively fight mental illness and
disorder. Workshops and programs in schools, colleges, corporates and communities can help foster a movement for mental health. We must all learn to identify and red-flag signs of mental health concerns in ourselves and in others. A partnership between psychiatrists, social workers, nurses, psychologists, anthropologists, NGOs and local volunteers, that together constitute mental health workforce, contribute vitally in fostering mental health awareness and making mental health services accessible to the masses.
Supporting individuals to talk openly and without inhibitions about their mental
health issues is the crucial first step. Family and friends helping the individuals seek
professional help is the next step. At times, if we see red-flags of mental health issues in
someone close to us, we must think of it as our responsibility to affect an intervention with the help of others. The internet and social media have a huge role to play as well. They have the power to break taboos and alleviate stigma. Online apps and support groups can put those who are suffering in touch with those who can help or are facing similar concerns. Those who have recovered from mental illnesses can share their stories via the social media to inspire
others, across barriers of language, borders and cultures. A mental health campaign on social media is the fastest way to reach out to people. And as our change-makers, our youth have to lead the way in changing mindsets.
To ensure a healthy peace of mind and a stable mindset an environment needs to be
created that respects and protects basic civil, social, political, cultural, psychological and
economic rights. Without guaranteeing and ensuring these rights, it will be difficult to
maintain a high degree of stable mental and emotional health. In this case, awareness needs to be built on various kind of mental health disorders. Additionally, to address the issue from a wholesome perspective, identification, care and protection of mental health is necessary.
The government should frame National mental health policies that focus on both
tackling mental disorders and treating psychological strains that hamper development.
Thereafter, mental health promotion should be mainstreamed into governmental and non- governmental policies and schemes. To provide a comprehensive overview it is essential that in addition to the health sector, other spheres should be included like the education, labour, justice, transport, environment, housing, and welfare sectors.
Mental health problems can be tackled by incorporating them into the primary health
care setup. This involves counselling at primary levels for early detection. There is a shortage of mental healthcare workers in India. A community-based solution inspired by Asha workers model can be adapted to serve the mentally ill population efficiently. In this regard to widening the mental workforce in India, more people should be trained that will not only increase employment opportunities but also help to counter the increasing prevalence of mental disorders.

Nudges could be used to alter people’s choice architecture. This will influence their
behaviour and could prevent major depressive disorders. These nudges can provide a
complimentary and more cost-effective strategy that preventive approaches. Nudges use the concepts of the present bias, bandwagon effect, framing, salience hypothesis and the status quo bias to effectively create an impact. They present strategies to promote healthier behaviours among individuals at high risk of developing depressive disorders.
Mental health is a serious issue that needs to be tackled at the earliest to ensure India’s
demographic dividend is healthy and can contribute effectively to the country’s growth.
Progressive governmental policies based on an evidence-based approach, engaged media, vibrant educational system, responsive industry, utilization of newer technologies and creative crowd-sourcing and engaged NGOs might together collectively work to dispel the blight of mental illness. Therefore, this growing problem can be solved by a collective intervention.

Kashmir children walking on eggshells in Armed conflict

– Authored by Suriya Ansari

Introduction:

With the recent scrapping of Article 370, unrest has been suppressed with communication blackout by imposing curfew and deploying army additional forces which is already one of the most militarized states in the world. Post-independence three generations of Kashmiris have undergone the trauma that has come with AFSPA, geopolitics and instability of political consensus. Development has taken a back seat with constant curfews which has affected shutting down of schools and universities and daily life coming to a standstill. As Dreze says armed conflict affects material and psychological wellbeing of individuals  ‘entitlement failures, health crises, physical violence, forced displacement and related processes’.He argues that “ it also undermines future development prospects by disrupting or destroying the productive infrastructure, public services, settlement patterns, environmental resources, social capital and the institutions of governance” (Dreze, 2000, p.1180).

 

As a policymaker, my focus is on what are the vulnerable risks and resilience necessary for children and youth affected by armed conflict narrative. With a lack of interventions and facilities in dealing or equipping even adults to seek mental health. Children and teens have been exposed to the everydayness of conflict as the everyday norm and imbibing the context as a part of life. The rise of disappearances of teens and children taking up arms to become child soldiers has not been a new instance, with adults resuming normal life post militancy. Trauma due to armed conflict should be viewed as a dynamic process of priming because of adjustment in psychological resilience to prolonged trauma and mental health rather than stereotyping it as a personal trait. For this, the context is necessary even within the Kashmir conflict narrative of how individuals have experienced within their bounded rationality and how actors such as militants, peer groups, armed forces and families influence certain behaviour of children taking arms.

 

Social and Ecological Context:

Modern armed wars often rupture the fabric of life that supports healthy child development. Conflicts suspend families and extended social networks, interrupt usual systems and often feed deep ethnic and political divides.

Source: The social ecological model of risk and protection for children affected by armed conflict

 

As Bronfenbrenner (1979) explains the ecological model of child development. He analyses the relationships of a different environment of how a child interacts with different subsystems. The Microsystem is where the child has the most touchpoint with family and school shaping his/her upbringing. The Mesosystems involves the interaction of extended social network in his/her neighbourhood and family circle. The Exosystem involves societal structure which is often extensions of mesosystems both formal and informal channels through which information is received that builds the narrative for the child. The exosystem may include cultural beliefs, political situations, economic conditions which overlaps how these narratives seep in through these structures to where the child interacts the most. The ability of parents, caregivers and children to shape interactions is dependent on what place and priority do the actors play in the child’s development.

 

Bounded rationality framed by Individuals:

Children try to frame narratives through their peers and older teens within the neighbourhood and school. Individuals growing piece this information from ongoing stone-pelting, adult conversations with armed men patrolling neighbourhood. While soldiers have been provided positive framing that they protect citizens. Children going to school comes across conflicting narrative during a street protest and pellet showers. While mostly caregivers keep a close gauge on avoiding children chanting slogans on Azadi to avoid children going into the menace. The other side of the truth is also that children adjust the discomfort as an everyday norm while going to school. Children tend to show a buffer in absorbing the shocks of trauma due to sense of empathy,shared experience that makes an individual less vulnerable as opposed to a group,a community connection of growth and trust in each other, a sense of anchoring connection with spirituality which comes with religion.

 

Religion plays the first stepping stones through familial ties through which a child learns to associate with cultural identity. They help children to make sense and trauma they survive. Supportive adults, neighbourhood networks and mentors within the community help in building resilience against trauma.

 

Influence of Microsystem on children :

 

Children who could make sense of conflict setup through their fathers and mothers felt a sense of attachment to understand and communicate frightful situations. The process of interpretation and reassurance by caregivers plays an important role to create a sense of blanket comfort to survive such conflicts. It is interesting to see that adults who have been a part of militancy rise have made efforts that their children study away from the valley and receive education in Jammu and outside J&K. When they become teens and come back to valley most do notice aggressive behaviours and bouts of depression to piece the narratives to make sense from the outside valley and within the valley.Children of families associated with displaced siblings and adults faces issues with internalising emotional and behavioural problems.

 

Exposure to community violence where stone-pelting was highly prevalent showed major impact on children.Children showing high degree of intrusive thinking shows symptoms of Post Traumatic Stress Disorder (PTSD) were likely to show anxiety ,depression and emotional withdrawal often falling to patterns of substance abuse if they come across teenagers coming across such behavioural patterns.

 

Parent’s Mental health :

The loss of revenue from tourism due to the two-decade-long armed conflict also added in the impoverishment of people in the valley. Thus resulting in the overall backwardness of the valley and particularly of those families who are the victims of the two-decade-long conflict in Kashmir.The impoverished families have a direct impact on their children in a number of ways such as compelling young kids to work, at the expense of their schooling, under-nourishment and malnourished. Dar and Khaki (2012) noted, “The macro figures at the state level reflect this dismal picture of high child labour in the state. The state has seen an increase of 149% from 2003 to 2011 in child labour.While as the comparative figures for the whole of India show that there were 1,07,53,985 child labourers in 1971 and this increased to 1,26,66,377 in 2001, an increase of just 17.7 % (RGI, 1971 and 2001 in NCPCR, N.D)”^[1].

 

A range of activities including construction work, tea stalls, mechanic shops,transport industry and carpet industry has employed children as cheap labour (Dar and Khaki, 2012). Bhat and Rather (2009) also found poverty was one of the reasons for engagements of children in handicrafts in Kashmir. Most of them were out of schools, and almost two-third of children (69%) were girls. The reports have also shown a high exploitation of such children. Gani and Shah (1998) found that most of the children engaged in the carpet industry belonged to the poor and vulnerable families.

 

Parents and family network act as two roles either they act as a protective shield or complicate child’s management when they themselves handle it poorly. Children’s mental health has often been associated with maternal mental health. PTSD of a child is strongly linked with the mother’s symptoms of showing signs of PTSD or prolonged depression. The Association of Parents of Disappeared Persons (APDP) estimates more than 8,000 have disappeared since 1989 (APDP, 2009; IPTK and APDP, 2015). Their widows and orphan children are referred to as ‘half widows’ and ‘half-orphans’.

 

Child care institutions and Schools:

Educational institutions played important role in managing the child’s need and importance of school helps in “mitigating the needs of child trauma” fostering learning and increasing the scope of the framing to help in better choice architecture.Opportunities to return back to schools helps to instill hope and channelise ways to detect symptoms of behaviours on the early onset.Literacy rates has been slower as enrollments have been severly affected with constant shutdowns during curfew. School infrastructures have been severly damaged ,reducing availability of human resources,disruption in transportation and demotivated teachers have disempowered schools to function effectively.

 

What has resulted is absenteeism , lack of retention of students reduction in school days and difficulties in commuting that has resulted most of the parents to send children outside valley for education. The question still does not solve in the inability to improve the quality of School in the valley. MSF in their survey found that school related problem scored highly among children with 15.5% being unable to attend school and 16.3 % having problems in studying (MSF, 2016).

 

Macrosystem : The cultural,historical and political context of war

 

Recently 146 Juveniles were recently detained between August 5 and Septemeber 23 for “ in conflict with law”. The youngest of them was nine year old. They were release either on same or after a brief period just before Eid. A total of 46 juveniles were detained in observation homes in Srinagar and Jannu since August 5^[2].

 

The Amnesty International reports states ‘ A Lawless Law: Detention under the Public Safety Act’ 35 highlighted ,  “In practice, the J&K state authorities appear to treat boys above the age of 16 as adults and detain them without trial under the PSA and ordinary criminal law, holding them in regular prisons along with adult prisoners. Amnesty International is aware of a number of cases of children detained during demonstrations in which stones were thrown” (Amnesty International, 2011).

 

Macrosystem dynamics of political context helps to draw relations from the historical context and religious Jihad connotation leading to disparate voices and support creating current instability.The Separatist movement and beliefs perpetuated due to lack of common consensus disrupting the state machinery which led development to climb in the lowest priority.Political ideologies, cultural context ,religious tensions between the Kashmiri Muslims and Kashmiri Pandits during the exodus have historically percipitated which has underlined the political agenda and manifestos influencing the alienation of Kashmir community in shorud of silence.

 

What affects now is how will the new generation rise from the shattered and fractured governance? The uprising within valley is just a matter of a ticking bomb that will shape the lives of children and youth in the midst of hopelessness and at the edge of being cornered by Centre with disgrace as the whole country rejoiced with the scrapping of Article 370.

 

I will conclude with the final poem of Makhdoom Mohiuddin

 

Qaid -Incarceration

 

Incarceration but not the period of incarceration

Oppression but not a complaint against the oppression, nor its redressal

Night, its stillness and loneliness

Far away from the ramparts of assembly

From the depth of the city’s heart

Comes the echo of the tolling bell

The mind starts

The flame of breathing quivers

The candle of the night of my imagination is awakened

And each moment of life is recollected

Crowds of men on highways and in streets

And their brisk steps

Wrinkles of confusion on their foreheads

Regret of the past

And anxiety of the future

In their looks

Hundreds and thousands of people

Hundreds and thousands of steps

Beating hearts of hundreds and thousands of people

Sad with the oppression of the ruler

Exhausted with the persecution of politics

Who knows

At what crossroads

Do they become an explosion suddenly

Hope of youth

Depressed and compelled for decades

Tied to the chains

Goes to sleep

Clinking of the chains

While changing the sides

Speaks of the hustle of life

In my dreams

I regret that my precious life was wasted in prison

And not in the prison of the freedom of my motherland.

 

 

 

 

 

Bibliography

 

“The IRC’s Emergency Education Programme For Chechen Children And Adolescents | Forced Migration Review”. 2019. Fmreview.Org. https://www.fmreview.org/displaced-children-and-adolescents/betancourt-winthrop-smith-dunn.

 

“144 Juveniles Were Detained In J&K After Abrogation Of Article 370: Report”. 2019. Telegraphindia.Com. https://www.telegraphindia.com/india/144-juveniles-were-detained-in-j-k-after-abrogation-of-article-370-report/cid/1709434.

 

Shah, Khalid. 2019. “Children As Combatants And The Failure Of State And Society: The Case Of The Kashmir Conflict | ORF”. ORF. https://www.orfonline.org/research/children-as-combatants-and-the-failure-of-state-and-society-the-case-of-the-kashmir-conflict-47514/#_ednref13.

 

 

 

 

 

 

^[1] (2019) Impact of Armed conflict on children in Kashmir (Shodganga) pg 15

^[2] (“144 Juveniles Were Detained In J&K After Abrogation Of Article 370: Report” 2019)