Rural public health system in Sitapur, Uttar Pradesh - Experiences of a PhD student

The central government has been pumping in a lot of money into the health sector since last two decades. The National Rural Health Mission (NRHM), which has been mainly designed to help state governments to improve the situation of human resources and the infrastructure in government health facilities, has received a new lease of life with an extension of five years. Although many states have shown considerable improvement in the service delivery through enhancement in human resources, their training, and physical infrastructure, there are states like Uttar Pradesh (UP) where we rarely hear any inspiring story of success of transformation in the health system. Conversely, what we get to hear are stories such as the one published in the British Medical Journal and widely covered by the media in our country about the corruption in the implementation of NRHM. In fact, UP turned NRHM into a deadly web of graft and killings. A great chunk of the grant received by Uttar Pradesh was siphoned off by those in the bureaucracy and the government and the little that was left was not used properly. Given the sorry state of affairs, the centre reduced the aid under NRHM for a year. Now, when then NRHM has completed its first phase, it is important to review the progress made by Uttar Pradesh in these seven years. I have been visiting the health facilities of all three levels in the rural areas of district Sitapur since last many months. I am presenting here a snapshot of what the state’s rural health system actually is in the light of the norms laid under the Indian Public Health Standards, even after seven years of generous funding under NRHM.     

Almost 10 kilometres from the district headquarters, is a little bustling town called Ramkot. Like many other towns, it lacks basic civic services. Waterlogging, potholes, open sewage and dust along with vehicular and industrial pollution should not come as a surprise for you. The primary health centre (PHC) here is located about 700 meters away from the main town area. Before the new isolated building was constructed and unveiled in 2001, the PHC had only two rooms with a location in the heart of the town. Now, the number of rooms has increased and it can accommodate many people. The building is spacious and airy. However, the bigger size could only be possible when the location was shifted to outskirts of the town where for almost 200 meters around the PHC, nobody lives. The present location was the result of local politics. The government had no option other than to move the location of the new building to the outskirts of the town. Due to its location, which gives rise to serious security problems, doctors and other health workers do not want to stay on campus at night. The sweeper who also doubles as the watchman cannot do much. I was told that locals have damaged the property in the health centre. One or two families reside inside the boundary wall of the health centre. The health workers try to avoid them because they become furious and may cause physical injuries to them if they are told off. The boundary wall of the health centre remains half-constructed and the main gate is no longer at its place. The wall is broken at many places. The glass in many windows is broken.

Typical Health Sub-Centre - they are often located in the outskirts of the villages - and hence prone to theft, vandalism, misuse and destruction.

Electricity, water, and sanitation facilities are three most basic amenities and are a must in all the health centres. This health centre, surprisingly, did not have proper provision of any of the above. Electricity supply is very poor in this area. One can see a transformer sitting on the poles but wires are missing. The insides of the rooms at the PHC tell a similar story. Birds nest at places which should have held electrical equipments. None of the rooms have any ceiling fans. The tube lights are missing. The wiring at the main entrance of the main building is incomplete and wires are naked and open. Now, one can now imagine that how difficult it would be for a doctor or any health worker to work in the health facility in summers when the mercury goes as high as 47oC. Similarly, without electricity, it would be very difficult to stay in the health facility in the sultry monsoon season and chilling winters. The health centre has only one hand pump on campus. It is used by both the people illegally residing in the campus and the health workers. There is a water tank sitting high on an iron platform but it has never been used since there is no electricity. One old and unused plastic tank can be seen lying in the veranda of the main building. As far as toilets are concerned, nobody uses them because of lack of supply of water to the toilets.The room where dressing is done is a filthy place equipped with only one bed.
The narrative above is in complete contrast with the guidelines of the Indian Public Health Standards (IPHS). According to IPHS guideline published in 2012, a PHC “should be centrally located in an easily accessible area. The area chosen should have facilities for electricity, all-weather road communication, adequate water supply and telephone. PHC should be away from garbage collection, cattle shed, water logging area, etc. PHC shall have proper boundary wall and gate”. Apart from this, a “PHC should also have proper sign-age and an entrance with barrier free access”. The OPD must have separate wards for men and women. Although there is proper sign-age in the local language, there is no provision for entrance with barrier free access and separate wards for men and women. There must be one generator room and cold chain room. Since, there is no electricity in the campus; the cold chain room does not exist. In the absence of the cold chain in the PHC, the ANM has to go and pick up her vaccines from Barai, Jalalpur mother PHC which is about 25 kilometres from Ramkot. A round trip to the mother PHC would require more than 3 hours as public transport is very poor and causes delays. If she has to reach PHC on time with all the vaccines that she requires for the day, she will have leave her home as early as 6 O’ Clock in the morning. 
IPHS outlines many other facilities such as a computer with internet connection and a decent accommodation to be ‘essential’ at a PHC. The PHC in question unfortunatelyhas none of these two. None of the health workers stay at PHC in the night because the rooms for accommodation are devoid of essential amenities. Although a few rooms are now being constructed for medical officers, it is highly unlikely that they will ever be used as residence in the absence of electricity, water supply and security. Apart from this, as discussed above, the PHC does not have proper lighting, 24 hours electricity, water supply and functioning water storage facility. Despite this, PHC does not have any solar panels installed, although IPHS lists solar energy equipment under ‘desirable’ list. Another feature under desirable list is a lecture hall or a small auditorium for 30 peoplefor training purposes. However, there existed no such arrangement when I visited. 
This is just half of the story. Let us have look at the human resources available at the PHC. According to revised IPHS published in 2012, a PHC should have two medical officers – one MBBS and another from any AyUSH (Ayurvedic, Unani, Siddha, Homeopathy) stream. The PHC in question has only one MBBS medical officer. With only one doctor in position, it becomes very difficult to manage when he/she is on leave or on a tour for field supervision. In that case, the lab technician or the pharmacist writes the prescription which is nothing but playing with the life of the poor patients. Moreover, I witnessed the lab technician, who was writing prescription, advising people to buy medicines from the nearest medical stores in the town. This indicates that either the required medicines are not available with the pharmacist in the PHC or the technician/pharmacist has tie-ups with medical stores in the town market.
Although the number of lab assistants and pharmacists required at the PHC matches the IPHS norm, the PHC lacks required number of Nurses and Accountant cum Data Entry Operator. I have visited many other PHCs as well but I could never find these two cadres in position. Actually, health policies of the state do not envisage having nurses at PHC level. However, according to IPHS, there should be three nurses in position in a PHC. The lady health visitor and health assistant/worker (male), both stay at community health centre (CHC), although IPHS guidelines want them to stay at the PHCs. Two ward boys have been ‘prescribed’ to be in position at the PHC level but this PHC has only one in position. Three others, namely AyUSH pharmacist, health educator and cold chain & vaccine logistic assistant, have been envisaged as ‘desirable’ in IPHS guidelines. However, none of these ‘desirable’ health workers’ posts are sanctioned at the PHC. In such a situation, when the posts are not sanctioned by the government, what one can expect to exist is only a dysfunctional overburdened healthcare delivery system. 
It is not that this is the only story in this district; there are many others in different places. A small village/town called Manwa is about 40 kilometres from the state capital Lucknow and the district headquarters Sitapur. It is located just two kilometres off the national highway and well-connected by a good all-weather road. The PHC at Manwa is officially known as government women’s hospital (Rajkiya Mahila Chikitsalya). As far as the location is concerned, it is located just a few meters off the main road of the village. However, one cannot spot the building in the very first sight as it is painted with a different colour and its architecture is completely different from that of a normal PHC building.
One of the first things that you would notice is that the building is very old. Its inner walls have marks of rainwater leakages from past years. The plaster is broken and coming off the walls. The bricks can be easily seen in many places. There is only one room for two female doctors posted. The ceiling of the room leaks heavily whenever it rains therefore a yellow plastic cover has been placed under the ceiling. There is a rusty, old-looking, green one-and-a-half meter tall almirah for all the medicines and equipment. Imagine, how big would be the stock of medicines contained in it! There is an old wooden table in the centre of the room with two plastic chairs and iron stool around it. The floor of the room is broken and has tiny puddles. The walls of the room are no different from the ones that I have described above. I was told that both female doctors sit in the same room. There is only iron bench available for patients. The bench can accommodate only three adults. I could not find any fan or cooler even in the month of June when the temperatures go as high as 46oC. There is no lighting either.

Typical labour room at a Health Sub-Centre - unused and vandalised

Such dysfunctional hand pumps are commonplace. 

Filthy toilets - Lack of water discourages their use  

There was another room which was closed when I asked them to show me the room. An old rusty bed is lying unused in the room. The room was not even cleaned properly. There is no electricity connection. The power supply in the village itself is erratic. The PHC does not own a generator either. In such a situation, one cannot expect computers, internet and other operation-theatre related equipment to be there in the facility. One should also not expect the existence of an overhead tank, piped supply of water and functional toilets as prescribed in IPHS guidelines. In the absence of electricity supply, the solar cells can be an alternative for regular supply of electricity but the PHC rooftop is barren. The PHC does not have its boundary wall and hence, no main entrance. The building is not at all sufficient to call it a PHC. There are no separate rooms for lab technician, pharmacists, ANM etc. There is no cold chain available here as well. In fact, there is no way a normal or caesarean delivery can take place in the hospital without endangering the life of the mother and the child.

This Health Sub-Centre is located in wilderness. Do you think an ANM can stay alone in this building in the night?

PHC Shahpur makes use of its resources in this way
As far human resources are concerned, there are two medical officers available at the centre which means the IPHS norms about the number of doctors are being fully complied with. However, lab technician, nurses, accountant-cum-data entry-operator and ward boys are not in position. Not even a single ANM has been positioned here to help the medical officers/doctors. In this situation, one cannot expect to get proper care and services. There is a sweeper at the PHC who lives in the nearby quarters constructed for the support health worker and ANM positioned at HSC. LHV and health worker/assistant (male) stay at the community health centre while as per IPHS guidelines they actually should be the part of the PHC staff. As far as health educator is concerned, he is only found at CHC that is at the block level. The government in Uttar Pradesh has not been able to deploy health educators at all the PHCs.
Let us have a look at what happens in the health sub centres (HSC) which are the first contact point between common masses and the public health care system. The sub centre (SC) I visited is located (exactly fifteen kilometres towards the west from the district headquarters on the national highway 24) just 100 meters off the highway. At the very first sight, what I could see was a thick wall of shrubs and bushes along the walls of the sub centre. The building of the sub centre has been constructed a few years ago. However, the layers of the plaster on the boundary wall have started coming off the wall and bricks can be easily seen. The main gate of the building remains open 24X7. Let us have a glimpse of amenities provided at the SC for health workers. Since there is no electricity connection, we cannot expect the standard electric items. No electricity automatically translates into no running water. There is a hand pump but it takes ages to get water from it. The toilet is not used because of the absence of running water in it. The premises are not kept clean as there is no support worker at the HSC. Although, the ANM does hire a person to clean it occasionally, she complains that villagers make it dirty in various ways including open defecation by small children. The HSC has been looted twice.

Unused resources

In the absence of any amenities and security, the ANM does not stay at the health centre and comes to the health centre twice a week from the nearest town. As per IPHS, HSC should have an ANM residence with all the facilities and she should stay at SC. IPHS guidelines also state that apart from ANM, there should be an additional ANM and a male health worker (MHW) at the HSC. However, none of the HSCs in the district have any additional ANM or MHW. The lack of these two health worker and the support worker overburdens ANM. She does most of the things alone or with the accredited social health worker (ASHA) working in her area. 
Such a grim situation prevails even though the above mentioned HSC and PHCs are have better access (compared to the others in the district) to the headquarters and the capital city and well-connected with the national and state highways. Now, one can imagine what could be the situation in the interiors especially those located on the eastern border of the district. This part of the district faces devastating floods every year posing tremendous challenges to the health department. In the interiors, where road connectivity is poor, no health worker wants to stay for long.They get ‘attached’ (that is they are posted at location ‘A’ but work at location ‘B’. How does it happen is a serious question) to the health centres nearest to their village or home town. The consequence of such practices is a serious distributional inequality of human resources among the health facilities. Apart from this, severe shortages (unfilled positions) also plague the health system. For example, the government records at the chief medical officer’s office at the headquarters show that the community health centres (CHCs) located in the two eastern towns of the district have no specialist doctors in position although the posts are sanctioned. Similarly, PHCs and HSCs in these areas also do not have enough human and infrastructural resources to cater to poor population effectively. These interiors are also the areas where senior officials do not venture regularly to monitor the functioning of the health centres. This could also be the reason why health centres are in bad shape both in terms of human resources and physical infrastructure. Although local media regularly reports the events of unavailability/absenteeism of health workers, equipment and other related news from different blocks of the district, you cannot trace the will to change the situation in the statements made by the medical officers and other responsible people. When asked, the officials at every level have set answers for every question.

These beds are being used by resident doctors.

It was 11:00 AM and PHC was still closed.

These shocking stories indicate the kind of improvement primary health centres in the state of Uttar Pradesh have made during first phase of NRHM i.e. during 2005-2012. The state has miserably failed to improve its health centres both in terms of infrastructure and human resources. Forget about the Bureau of Indian Standards (BIS) guidelines about staffing of the health facilities, the state has not been able to fulfil even the ‘essential’ criteria of IPHS which are less resource intensive than BIS. Shortages and inequalities in the distribution of human resources, poor infrastructure (lack of essential amenities, availability, use and misuse of drugs and equipment) and multilayer corruption, the health system in the district has become completely dysfunctional and almost useless for the poor whom they boast to cater to. In the light of the recent NRHM corruption scandal, it can be said that only the infusion of cash alone will not deliver results in Uttar Pradesh. The state needs to revamp monitoring at all levels. The new lease of life given to NRHM till 2017 could be a golden opportunity for Uttar Pradesh to improve the state of health infrastructure and human resources. However, to turn this opportunity into a reality, the state government and the bureaucracy in the state need to be serious and determined.
Aditya Singh
 Original article can be accessed from Governance now website