This is my brief pictorial personal account on rural health care in Bihar (5 districts) & UP (one district) done in Oct 2012-the ground situation and challenges.

1. Bihar & UP
Bihar & UP
Some Glimpses the Rural Public
Some Glimpses the Rural Public
Health System
And Some Hard Core Issues
d d
by Shyam Ashtekar
by Shyam Ashtekar
(An unplanned personal visit in Oct 2012)
Tuesday, October 30, 2012 1

2. District Hospital
Bihar‐the typical District Hospital. Shortage of DH in Koshambi (80 km fro m Allahabad) UP‐This
( )
doctors and nurses is writ large on each hospital!
d d i i l h h i l! district hospital has no gynecologist for last 6 months!
Tuesday, October 30, 2012 2

3. Hospital Wards
Typically, Bihar hospital wards are barely livable! Empty wards in Koshambi’s CHC in UP: where are all
Tattered mattresses, rickety cots, torn bedsheets,
y the JSY admissions? (But I am sure other CHCs will have
(
cleanliness are all there to see! wards full of JSY cases)
Tuesday, October 30, 2012 3

4. A delivery room
A delivery room
Pathetic scene of a delivery room in PHC,
with broken del table‐ Bih P i
ith b k d l t bl Bihar‐Purniya In Karari
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 the
work 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!
• ASHAs from ‘good’ families have
already left their work! But Dai is
still there! (why did we start the
ASHA program at all?)
ASHA t ll?)
Tuesday, October 30, 2012 4

5. Efforts to improve the system!
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One of the better DH‐‐ in Purniya dt, Bihar (they have a
color code for bedsheets from Mon to Sunday! And it
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was followed!) In Purnea district city
In Purnea district city
• There is 2 km road from Purnea
station which is full of Pvt
hospitals, clinics, medicine shops,
hospitals 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 is said daily wage in this district
It i id d il i thi di t i t
is around Rs 25/ but there are
also people who can pay.
Tuesday, October 30, 2012 5

6. Medicines in public hospitals
p p
A generic shop with 50% price in Katihar DH Bihar and
below a List of available generics in Bihar Medicine shortage
• However, in Koshambi
district, medicines were in
short supply, in Karari block
mini PHC only paracetamol
was available as the MO
was available as the MO
told me! The CHC
pharmacist also repeated
the same!
th !
Tuesday, October 30, 2012 6

7. OPDs & doctors
OPDs & doctors
UP‐At 12 o’ clock a homeopath came to ‘dispose’ an
OPD in a Bihar PHC OPD..a crowd of 15 patients in the room..this is
p
common
• I did not photograph an
OPD in Bihar, but a doc in
PHC told me he attends 400
patients everyday with 1‐2
AYUSH docs to help! So he
AYUSH docs to help! So he
must also be seeing a
crowd! Plus has 10 JSY
deliveries to attend daily!
d li i t tt d d il !
(this must be verified)
Tuesday, October 30, 2012 7

8. The neat looking PHC in Vaishali district, the queue is
The neat looking PHC in Vaishali district the queue is
for JSY cheques!
Tuesday, October 30, 2012 8

9. In PMCH patna
In 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 they
PMCH where all of Bihar patients have to come if they
cant find help in districts! Bribes and attacks are –they
say‐common in PMCH!
Tuesday, October 30, 2012 9

10. Problems about Govt doctors!
Problems about Govt doctors!
• The regular doctors in Bihar are permitted to do Pvt
practice! So it is official to stay away and work in pvt as
i ! S i i ffi i l d ki
per convenience! I heard an anesthetist comes once a
week for his CHC duty. Also, a Pvt doctor told me every
Govt doctor has to pay the MOH/CS monthly as a
d h h / hl
‘retainership’ no matter what you do! Salaries are paid
irregularly, sometimes not paid even for months
together!
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• The On contract doctors—difficult to get in the first
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place—are also unwilling to work because of poor terms
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of pay etc.
• The conclusion‐both are cribbing and do not work
wholeheartedly!
Tuesday, October 30, 2012 10

11. JSY beneficiaries
JSY beneficiaries
Long queues are common for JSY cheque of 1400/‐ may
gq q y
UP‐JSY payment is beset with frauds,
be this is all that is institutional about delivery! is it increasing quality of care?
is it increasing quality of care?
Tuesday, October 30, 2012 11

12. RSBY scandal in Bihar!
RSBY scandal in Bihar!
Such minimum set ups of illegal doctors also
The apparently pro‐people misused the RSBY harvest! 46000
hysterectomies in Bihar alone. And still counting
hysterectomies in Bihar alone. And still counting
scheme is in for heavy misuse!
scheme is in for heavy misuse!
Tuesday, October 30, 2012 12

13. The JSY transport!
UP bought the ambulances but they are still stranded in
102 In use in Bihar, this is quite useful in Bihar the scandal, so mothers are mostly brought on
and good roads have made it comfortable
d d d h d i f bl motorbikes by ASHA husbands at a rate of Rs100 one
t bik b ASHA h b d t t f R 100
way!
Tuesday, October 30, 2012 13

14. 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 to
100‐150 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!
Tuesday, October 30, 2012 14

15. ASHAs
Pilot project for using mobile platform for
The ASHA facilitator says health education. UP is expanding such a
everything is on paper!
everything is on paper! scheme now!
h !
Tuesday, October 30, 2012 15

16. ASHA as ‘agent’ ?
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I heard some ASHAs have been used by ANMs to ask the JSY mother to
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cough 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 application.
to 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.
Tuesday, October 30, 2012 16

17. ASHAs
The CTY workers say that 80% of ASHAs are
non0literate with a farji certificate (must be less!), but
Not all ASHAs earn even 1000 a month they are only good for JSY and teekakaran! People will
y yg p
from JSY, many of them cant read !
f JSY f th t d! necer take medicines from them!
Tuesday, October 30, 2012 17

18. ASHAs talk of their woes, too much
work and little pay (what is the stat?)
k dl l ( h h )
ASHAs (in white sari) in a Bihar ASHA in Karai‐Koshambi UP
PHC
Tuesday, October 30, 2012 18

19. ASHA which way to go?
ASHA‐‐ which way to go?
ASHA will educate about child health
IN UP
IN UP in UP; has its own version of IMNCI
in UP has its own version of IMNCI
• Some say most ASHAs are not
even literate!
• In bothUP and Bihar, ASHAs told
In 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)
Tuesday, October 30, 2012 19

20. Anganwadis
Bihar‐Poshahar is a point of UP‐No poshshar for last 3
conflict and corruption
conflict and corruption months (Oct 2012)
months (Oct 2012)
Tuesday, October 30, 2012 20

21. Subcenters
Chrnoic Staff shortage leading closure of
subcenters,
subcenters Many SC in UP are closed
Many SC in UP are closed
This block has27 subcenters but no ANM to staff
Tuesday, October 30, 2012 21

22. Both in UP & Bihar, having 4‐5 children
in families is a common feature!
f l f
A young mother in Bihar
A young mother in Bihar UP
Tuesday, October 30, 2012 22

23. Malaria is endemic, but it is for
informal doctors to treat!
i f l d t t t t!
Ubiquitous water bodies make malaria endemic
Malaria yes, but ASHAs don’t
in Bihar‐ASHA don’t have even chloroquin
i ih d ’ h hl i have even chloroquin!
have even chloroquin!
Tuesday, October 30, 2012 23

24. 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
y p y g Villages in eastern UP are still very poor!
similar situation in Hazipur next to Patna! Electricity is missing 20 hrs a day!
El t i it i i i 20 h d !
Tuesday, October 30, 2012 24

25. Roads
Tuesday, October 30, 2012 25

26. This 2 year boy (Akhilesh is his name) from a Koshambi
village 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 College
help 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!
Tuesday, October 30, 2012 26

27. Where Does ASHA program go from here?
After 7 years of NRHM, it is now clear
te yea s o , t s o c ea
that Pvt informal doctors could not be
eased out and ASHA has been reduced
to a largely non‐medical role of fetching
l l d l l ff h
cases and gathering children for
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
transit support!
t it t!
Tuesday, October 30, 2012 27

28. ‘Informal’ doctors!
Medicine counters are a euphemism for untrained Every village in this district has 1‐2 untrained doctors‐common
doctors in Bihar‐doing valuable public services in Bihar scene in UP. Villagers bank on them and will even protect them
that faces shortage of trained doctors. I counted 10 from action! In the 25 villages of the karyakartas, all but one had a
suchmedical counters in one Bazaar in the Kumarkhand
counters in one Bazaar in the Kumarkhand doctor or two (4 were women). All Zola Chaap docs have
doctor or two (4 were women). All Zola Chaap docs have
block..there are many such bazaars every 5‐7 km mobikes.
distance! All of them were busy when I met them
Tuesday, October 30, 2012 28

29. 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
g
is small! Inside the sky clinic run by WHP!
Inside the sky clinic run by WHP!
Tuesday, October 30, 2012 29

30. Good Schools but teachers not good enough, so bihar is
g g Schooling conditions in UP are pathetic, most
full of pvt coaching classes even in villages in Purniya! teachers on contract and dilapidated bhavans !
h d dil id d bh
Tuesday, October 30, 2012 30

31. Roads
Good Roads everywhere will pave way for more
development! Made a big difference to girls goingto
p g g g g
PMGS roads connect most
high schools villages
villages
Tuesday, October 30, 2012 31

32. Tuesday, October 30, 2012 32

33. Even after CMO deaths in NRHM in UP, political
pressure is telling! How do doctors work in such
situations?
Tuesday, October 30, 2012 33

34. 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 y
RajaBhaiyya as UP’s imp minister.
Tuesday, October 30, 2012 34

35. Summing up (1)
g p( )
Bihar! UP
• Bihar has just woken up after • UP enjoyed a better access
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2‐3 dark decades, and development than
development is slow. Bihar, but faltered on health
Corruption and power deficit
C ti d d fi it
are two major problems! system development
• Health care is hit with poor • NRHM scams have
infrastructure, scant and
i f t t t d tarnished its image further
t i h d it i f th
unhappy staff and abysmal
• 1 PHC for 1lakh pop!
conditions!
• 1 PHC f 1 l kh l
1 PHC for 1 lakh plus pop • JSY has brought the crowds
JSY has brought the crowds
• JSY and free medicines have to public hospitals, but is
brought back poor patients to that all?
health centers!
health centers!
Tuesday, October 30, 2012 35

36. Summing up (2)
g p( )
Bihar! UP
• Big Pvt sector and countless • The RH/CHCs buildings are
The RH/CHCs buildings are
‘informal’ doctors have made better than Bihar, but doctors
it difficult, but people bank on arrive late.
them!
them! • Pvt doctors and informal
doctors and informal
• RSBY is reportedly a scanda! providers have infiltrated deep
into each village.
• ASHAs are merely into JSY &
teekakaran, and nasbandi
, • RSBY is a scandal too.
• No one can solve the • ASHAs are merely into JSY &
complaints! teekakaran, but some kind of
HBNC is being rolled out!
• Doctors unwilling to join, poor
pays and awful working • No one will heed to
No one will heed to
conditions. complaints
• Corruption and governance • Corruption and governance
problems! problems!
Tuesday, October 30, 2012 36

37. 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?
• Governance?
G ?
• 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
Tuesday, October 30, 2012 37

38. MANY PEOPLE ARE TRYING TO
MANY PEOPLE ARE TRYING TO
IMPROVE THESE SYSTEMS, AND THERE
IS SOME CHANGE!
BUT FOR A REAL UHC IT IS INDEED A
BUT FOR A REAL UHC IT IS INDEED A
LONG WAY TO GO FROM HERE!
Tuesday, October 30, 2012 38

39. UNFORTUNATELY MANY OF OUR
STATES ARE IN THE SAME LEAGUE!
ARE WE ON THE RIGHT TRACK?
ARE WE ON THE RIGHT TRACK?
Tuesday, October 30, 2012 39

40. Personal Note
I have been associated with the NRHM and ASHA
program for some years now, and with health
workers for over two decades right from the CHW
k f d d i h f h 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 UP
years 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
g
getting the stats! This is not the whole truth! I
g
respect men and women who are working for
On a boat ride on the Kosi river in Purnea!
change in these conditions!
I toured 4 districts in the Kosi region in Bihar‐katihar,
Madhepura, Purnea, Shupaul And then Vaishali near
Patna! In UP I visited only one district. I took the
travel funds from our trust‐BharatVaidyaka sanatha!
Friends from UP & Bihar helped, mainly Amulya
Nidhi and his network!
Tuesday, October 30, 2012 40

41. Dr Shyam Ashtekar
y
26 October 2012
shyamashtekar@yahoo.com
09422271544
Tuesday, October 30, 2012 41