Health care- Bihar & UP 2012-Dr Shyam Ashtekar

Bihar & UPBihar & UPSome Glimpses the Rural PublicSome Glimpses the Rural Public

Health System d dAnd Some Hard Core Issues

by Shyam Ashtekarby Shyam Ashtekar(An unplanned personal visit in Oct 2012)

Tuesday, October 30, 2012 1

District Hospital

Bihar‐the typical District Hospital. Shortage of d d i i l h h i l!

DH in Koshambi (80 km fro m Allahabad) UP‐This doctors and nurses is writ large on each hospital!

( )district hospital has no gynecologist for last 6 months!


Hospital Wards

Typically, Bihar hospital wards are barely livable! Tattered mattresses, rickety cots, torn bedsheets,

Empty wards in Koshambi’s CHC in UP: where are all the JSY admissions? (But I am sure other CHCs will have y

cleanliness are all there to see!(

wards full of JSY cases)


A delivery roomA delivery room

Pathetic scene of a delivery room in PHC, ith b k d l t bl Bih P i In Karari UPwith broken del table‐ Bihar‐Purniya In Karari UP

• I did not photgraph a labour room here, since a mother was there with her baby!

• May be she had delivered here just an hr before!

• All the equipment was out of work The Pvt Dai conducted thework. The Pvt Dai conducted the birth , in presence of a nurse & ASHA! Birthing is treated as dirty work and the safai –after is called naraksafai!naraksafai!

• ASHAs from ‘good’ families have already left their work! But Dai is still there! (why did we start the ASHA t ll?)ASHA program at all?)


Efforts to improve the system!p y

One of the better DH‐‐ in Purniya dt, Bihar (they have a color code for bedsheets from Mon to Sunday! And it In Purnea district cityywas followed!) In Purnea district city

• There is 2 km road from Purneastation which is full of Pvthospitals clinics medicine shopshospitals, clinics, medicine shops, labs and may be touts!

• The district Hospital marks the end of this Pvt Health bazaar! Patients from surrounding blocks and districts plus from Nepal come here for treatment!It i id d il i thi di t i t• It is said daily wage in this district is around Rs 25/ but there are also people who can pay.


Medicines in public hospitalsp p

A generic shop with 50% price in Katihar DH Bihar and below a List of available generics in Bihar Medicine shortage

• However, in Koshambidistrict, medicines were in short supply, in Karari block mini PHC only paracetamolwas available as the MOwas available as the MO told me! The CHC pharmacist also repeated th !the same!


OPDs & doctorsOPDs & doctors

OPD in a Bihar PHC UP‐At 12 o’ clock a homeopath came to ‘dispose’ an OPD..a crowd of 15 patients in the room..this is

• I did not photograph an OPD in Bihar, but a doc in

pcommon

PHC told me he attends 400 patients everyday with 1‐2 AYUSH docs to help! So heAYUSH docs to help! So he must also be seeing a crowd! Plus has 10 JSY d li i t tt d d il !deliveries to attend daily! (this must be verified)


The neat looking PHC in Vaishali district the queue isThe neat looking PHC in Vaishali district, the queue is for JSY cheques!


In PMCH‐patnaIn PMCH patna

• I saw pathetic conditions in the PMCH (Patna Medical College Hospital), with crowded wards and few doctors, unmanageable conditions! Friction is common in this PMCH where all of Bihar patients have to come if theyPMCH where all of Bihar patients have to come if they cant find help in districts! Bribes and attacks are –they say‐common in PMCH!


Problems about Govt doctors!Problems about Govt doctors!• The regular doctors in Bihar are permitted to do Pvt

i ! S i i ffi i l d k ipractice! So it is official to stay away and work in pvt as per convenience! I heard an anesthetist comes once a week for his CHC duty. Also, a Pvt doctor told me every

d h h / hlGovt doctor has to pay the MOH/CS monthly as a ‘retainership’ no matter what you do! Salaries are paid irregularly, sometimes not paid even for months

htogether!• The On contract doctors—difficult to get in the first

place—are also unwilling to work because of poor terms p g pof pay etc.

• The conclusion‐both are cribbing and do not work wholeheartedly!wholeheartedly!


JSY beneficiariesJSY beneficiaries

Long queues are common for JSY cheque of 1400/‐ may UP‐JSY payment is beset with frauds, is it increasing quality of care?

g q q ybe this is all that is institutional about delivery! is it increasing quality of care?


RSBY scandal in Bihar!RSBY scandal in Bihar!The apparently pro‐people scheme is in for heavy misuse!

Such minimum set ups of illegal doctors also misused the RSBY harvest! 46000 hysterectomies in Bihar alone. And still countingscheme is in for heavy misuse! hysterectomies in Bihar alone. And still counting


The JSY transport!

102 In use in Bihar, this is quite useful in Bihar d d d h d i f bl

UP bought the ambulances but they are still stranded in the scandal, so mothers are mostly brought on

t bik b ASHA h b d t t f R 100and good roads have made it comfortable motorbikes by ASHA husbands at a rate of Rs100 one way!


In Koshambi UP, to get this 1400 Rs cheque after delivery, she has to spend some 500‐700 as follows: Dai 100‐150 mobike transport medicine purchase trip to100 150, mobike transport, medicine purchase, trip to health center with ASHA, small sum to the baboo! The ASHA is unwilling to spend on transport. In Bihar they have the van!


ASHAs

The ASHA facilitator says everything is on paper!

Pilot project for using mobile platform for health education. UP is expanding such a h !everything is on paper! scheme now!


ASHA as ‘agent’ ?g

I heard some ASHAs have been used by ANMs to ask the JSY mother to ycough up some money for issuing cheque or even take turns as a fake case! Photographs are now made compulsory for JSY cheque. I saw photographers working in the hospitals to produce photos for attachment to the applicationto the application.Newspapers have printed this news in UP.One ASHA I met was apprehended by karyakartas for coercing JSY mothers.ASHAs are vulnerable to all such blackmail.


ASHAsASHAs

Not all ASHAs earn even 1000 a month f JSY f th t d !

The CTY workers say that 80% of ASHAs are non0literate with a farji certificate (must be less!), but they are only good for JSY and teekakaran! People will

from JSY, many of them cant read !y y g p

necer take medicines from them!


ASHAs talk of their woes, too much k d l l ( h h )work and little pay (what is the stat?)

ASHAs (in white sari) in a Bihar PHC

ASHA in Karai‐Koshambi UPPHC


ASHA‐‐ which way to go?ASHA which way to go?

IN UPASHA will educate about child health in UP has its own version of IMNCIIN UP in UP; has its own version of IMNCI

• Some say most ASHAs are not even literate!

• In bothUP and Bihar, ASHAs toldIn bothUP and Bihar, ASHAs told me they never got that regular dava peti, but occasionally some medicines!

• But mobile phones can help even• But mobile phones can help even in this situation!

• IMNCI program has been added to their tasks!

• In karari block, the CRY statistics suggests IMR t be about (Koshambi is a backward district near Bundelkhand)


AnganwadisAnganwadisBihar‐Poshahar is a point of conflict and corruption

UP‐No poshshar for last 3 months (Oct 2012)conflict and corruption months (Oct 2012)


SubcentersSubcenters

Chrnoic Staff shortage leading closure of subcenters Many SC in UP are closedsubcenters, This block has27 subcenters but no ANM to staff

Many SC in UP are closed


Both in UP & Bihar, having 4‐5 children f l fin families is a common feature!

A young mother in Bihar UPA young mother in Bihar UP


Malaria is endemic, but it is for i f l d t t t t!informal doctors to treat!

Ubiquitous water bodies make malaria endemic i ih d ’ h hl i

Malaria yes, but ASHAs don’t have even chloroquin!in Bihar‐ASHA don’t have even chloroquin have even chloroquin!


Development Bihar has no electricity for 20 hrs a day, and some districts do only with a sole CFL bulb Pvt generators! A symbolic lantern at 8 pm in Purniya villages! I saw Villages in eastern UP are still very poor!

El t i it i i i 20 h d !y p y gsimilar situation in Hazipur next to Patna! Electricity is missing 20 hrs a day!


Roads


This 2 year boy (Akhilesh is his name) from a Koshambivillage has chronic suppurative ear infection ‘since birth’ as the mother says! But no one has really told her to seek higher care of an ENT surgeon! I gave her a chit to seek help ENT section of the Allahabad medical Collegehelp ENT section of the Allahabad medical College Hospital. The father has lost his hand in a fodder machine and has no employment. The mother has to work and take care! I asked about ASHA’s help! She says she is only for money from pregnant mothers!


Where Does ASHA program go from here?

After 7 years of NRHM, it is now clear te yea s o , t s o c eathat Pvt informal doctors could not be eased out and ASHA has been reduced

l l d l l f f hto a largely non‐medical role of fetching cases and gathering children for

teekakaran!teekakaran!Many ASHAs are not literate and can hope to play any bigger role in the p p y y gg

politics of health care! A dai could have been more effective for JSY and thru

t it t!transit support!Tuesday, October 30, 2012 27

‘Informal’ doctors!Medicine counters are a euphemism for untrained doctors in Bihar‐doing valuable public services in Bihar that faces shortage of trained doctors. I counted 10 suchmedical counters in one Bazaar in the Kumarkhand

Every village in this district has 1‐2 untrained doctors‐common scene in UP. Villagers bank on them and will even protect them from action! In the 25 villages of the karyakartas, all but one had a doctor or two (4 were women). All Zola Chaap docs havesuchmedical counters in one Bazaar in the Kumarkhand

block..there are many such bazaars every 5‐7 km distance! All of them were busy when I met them

doctor or two (4 were women). All Zola Chaap docs have mobikes.


SKY clinics of WHP in Bihar!SKY clinics of WHP in Bihar!WHP is trying to improve the ‘informal’ doctors with teleclinic network, however the numbers and coverage Inside the sky clinic run by WHP!gis small! Inside the sky clinic run by WHP!


Good Schools but teachers not good enough, so bihar is Schooling conditions in UP are pathetic, most h d dil id d bh !

g gfull of pvt coaching classes even in villages in Purniya! teachers on contract and dilapidated bhavans !


Roads

Good Roads everywhere will pave way for more development! Made a big difference to girls goingto

PMGS roads connect most villagesp g g g g

high schools villages



Even after CMO deaths in NRHM in UP, political pressure is telling! How do doctors work in such situations?


I was told that this Koshambi district has about 2000 gun licenses. I saw two karyakartas carry their guns. A kartoos costs about 300‐500 apiece. There are many unlicensed guns too. The people are used to terror. Who will govern and how? The very next district has the famous g yRajaBhaiyya as UP’s imp minister.


Summing up (1)g p ( )Bihar! UP

d b• Bihar has just woken up after 2‐3 dark decades, development is slow. C ti d d fi it

• UP enjoyed a better access and development than Bihar, but faltered on health

Corruption and power deficit are two major problems!

• Health care is hit with poor i f t t t d

system development

• NRHM scams have t i h d it i f thinfrastructure, scant and

unhappy staff and abysmal conditions!

• 1 PHC f 1 l kh l

tarnished its image further

• 1 PHC for 1lakh pop!

• JSY has brought the crowds• 1 PHC for 1 lakh plus pop• JSY and free medicines have

brought back poor patients to health centers!

JSY has brought the crowds to public hospitals, but is that all?

health centers!


Summing up (2)g p ( )Bihar! UP

• The RH/CHCs buildings are• Big Pvt sector and countless ‘informal’ doctors have made it difficult, but people bank on them!

• The RH/CHCs buildings are better than Bihar, but doctors arrive late.

• Pvt doctors and informalthem! • RSBY is reportedly a scanda!• ASHAs are merely into JSY &

teekakaran, and nasbandi

Pvt doctors and informal providers have infiltrated deep into each village.

• RSBY is a scandal too.,• No one can solve the

complaints!• Doctors unwilling to join, poor

• ASHAs are merely into JSY & teekakaran, but some kind of HBNC is being rolled out!

• No one will heed topays and awful working conditions.

• Corruption and governance problems!

• No one will heed to complaints

• Corruption and governance problems!problems! problems!


The Questions are..The Questions are..Where do we begin health reforms?

• Training more doctors and nurses?

• Banning Informal doctors? Or thru their inclusion?

• CBHM? RSBY?

• Child survival?

G ?• Governance?

• Free medicines?

• Increasing fund supply?Increasing fund supply?

• what is the period of framework?

• Is NRHM helping—is it the right prescription?p g g p p


MANY PEOPLE ARE TRYING TOMANY PEOPLE ARE TRYING TO IMPROVE THESE SYSTEMS, AND THERE

IS SOME CHANGE! BUT FOR A REAL UHC IT IS INDEED ABUT FOR A REAL UHC IT IS INDEED A LONG WAY TO GO FROM HERE!


UNFORTUNATELY MANY OF OUR STATES ARE IN THE SAME LEAGUE! ARE WE ON THE RIGHT TRACK?ARE WE ON THE RIGHT TRACK?


Personal NoteI have been associated with the NRHM and ASHA program for some years now, and with health

k f d d i h f h CHWworkers for over two decades right from the CHW scheme! For two years I also participated in the Common Review Mission! This 2012 tour was more of out curiosity to know the ground realities after 7 years of NRHM in Bihar and UP I have toured UPyears of NRHM in Bihar and UP. I have toured UP earlier. In 2008. This is not a systematic fact finding mission, there was no sampling, no enquiries with officers or getting the stats! This is not the whole truth! I g grespect men and women who are working for change in these conditions!I toured 4 districts in the Kosi region in Bihar‐katihar, Madhepura, Purnea, Shupaul And then Vaishali near

On a boat ride on the Kosi river in Purnea!

Patna! In UP I visited only one district. I took the travel funds from our trust‐BharatVaidyaka sanatha! Friends from UP & Bihar helped, mainly AmulyaNidhi and his network!


Dr Shyam Ashtekary26 October 2012

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Health & Medicine

Health care- Bihar & UP 2012-Dr Shyam Ashtekar