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Healthcare’s primary problem

Children with acute encephalitis syndrome undergo treatment at the Sri Krishna Medical College and Hospital in Muzaffarpur, Bihar. As of June 21,104 of the 424 children admitted since January 1 had died due to AES.

Children with acute encephalitis syndrome undergo treatment at the Sri Krishna Medical College and Hospital in Muzaffarpur, Bihar. As of June 21,104 of the 424 children admitted since January 1 had died due to AES.   | Photo Credit: Ranjeet Kumar

It is imperative to promote community-based care rather than relying only on hospital services

The deaths of 154 children in Bihar due to acute encephalitis syndrome (AES) has laid bare the precarious capacity of the State’s healthcare apparatus to handle outbreaks. AES has been linked to two factors: litchi consumption by starving children and a long, ongoing heat wave. As promises of bolstering the health infrastructure are being made, it is important to analyse what could have formed the ideal line of action.

AES is largely preventable both before and just after the onset of the disease, and treatable with high chances of success on availability of medical intervention within 2-4 hours of symptoms. Therefore, the first signs of an outbreak must prompt strong prevention measures. These include, apart from a robust health education drive and replenishing primary health centres (PHCs) with essential supplies, extensive deployment of peripheral health workers (ASHA workers) and ambulance services to facilitate rapid identification and management of suspected cases. Vacant doctor positions in PHCs must be urgently filled through deputation. Furthermore, short-term scaling-up of the Poshan Abhiyaan and the supplementary nutrition programme — which makes available hot, cooked meals for pre-school children at Anganwadis along with take home ration for mothers and distribution of glucose/ORS packets in risk households — are imperative. Nearly every one of these elements lies undermined in Bihar.

Crumbling healthcare in Bihar

In Bihar, one PHC caters to about 1 lakh people rather than the norm of 1 PHC per 30,000 people. Furthermore, it is critical for such a PHC, catering to more than three times the standard population size, to have at least two doctors. However, three-fourths of the nearly 1,900 PHCs in Bihar have just one doctor each. Muzaffarpur has 103 PHCs (about 70 short of the ideal number) with 98 of them falling short of basic requirements outlined by the Health Management Information System. Bihar, one of the most populous States, had a doctor-population ratio of 1:17,685 in 2018, 60% higher than the national average, and with only 2% of the total MBBS seats in the country. There is also a one-fifth shortage of ASHA personnel, and nearly one-third of the sub-health centres have no health workers at all. While the State reels under the highest load of malnutrition in India, a study found that around 71% and 38% of funds meant for hot, cooked meals and take home ration, respectively, under the supplementary nutrition programme, were pilfered. Meals were served for just more than half the number of prescribed days, and only about half the number of beneficiaries on average actually got them.

This is not all. Even those PHCs with adequate supplies remain underutilised. Perennial subscription to selective healthcare services by PHCs, like family planning and immunisation, have cultivated the perception that PHCs are inept as centres of general healthcare. This leads patients either directly to apex government hospitals situated far away or to unqualified private providers. This results in a patient losing precious time in transit and landing up in a hospital in a critical and often irreversible stage of illness.

Merely strengthening the tertiary care sector will be inefficient and ineffective. Most attention was focused on the poor state of the Sri Krishna Medical College and Hospital in Muzaffarpur, with 600 beds, already functioning beyond its full capacity. Hospitals in Muzzafarpur have a bed occupancy of over 300%, three times the full occupancy. In such a case, even a significant addition of hospital beds and ICUs won’t solve the problem. ICUs can only deal with the most advanced cases. A narrow focus on the hospital sector will wastefully increase costs, ignore the majority of cases, increase the number of cases that are in advanced stages, while continuing to overstretch public hospitals.

Revamp primary health infrastructure

The solution lies in building more functional PHCs and sub-health centers; scaling-up the cadres of ASHA workers; strict monitoring of nutrition programmes; and addressing the maldistribution of doctors and medical colleges. The resultant robust primary care system can then be geared towards being more responsive to future outbreaks. We should also bolster our technical capacity to better investigate the causes of such outbreaks and operationalise a concrete long-term strategy.

Policy documents, while emphasising on financial and managerial aspects of public health, fail to address the aberrant developmental paradigm of our health services. Decades of hospital-centric growth of health services have eroded faith in community-based healthcare. In these circumstances, even easily manageable illnesses increase demand for hospital services rather than PHCs. There is need to work on inculcating confidence in community-based care.

Soham D. Bhaduri is a Mumbai-based doctor and Editor, The Indian Practitioner

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Printable version | May 23, 2020 8:53:57 PM | https://www.thehindu.com/opinion/op-ed/healthcares-primary-problem/article28263232.ece

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