The Public Health Ecosystem in Thakurganj, Bihar: A Situational Analysis

Introducing Healthcare Facilities in India:

India has facilities for healthcare both at the public and private level. Public healthcare is established and managed by the government out of its budgetary resources. According to the World Bank the expenditure on healthcare in 2018 was 3.54% of the Indian national GDP, with public health expenditure representing only 1.29% of GDP.

In rural parts of the country, like Bihar where we work, population norms are adopted for establishing public healthcare facilities and the entire rural population is covered under these facilities. The hierarchy is as follows:

The Public Health Centre at Thakurganj, Bihar. Photo Courtesy: Tonmoy Talukdar

• Sub Centre (SC) which is the lowest public health care facility wherein one sub centre is established for every 5,000 persons in the plains and 3,000 persons in hilly/tribal areas. On average there is one SC for every 4–5 villages.
• Primary Health Centre (PHC) wherein one PHC is established per 30,000 persons in the plains and 20,000 persons in hilly/tribal areas. On average there is one PHC for every 14–22 villages.
• Community Health Centre (CHC) wherein one CHC is established for every 1,20,000 persons in the plains and 80,000 persons in the hilly/tribal areas. This means there is one CHC for every 4 to 5 PHCs and on average there is one CHC for every 90–100 villages.

The Situation in Bihar:

As per the 2019 population census of India, Bihar is the second most populated state in the country. The population of Bihar alone is equivalent to the population of the entire country of Japan, and unlike Japan, 40% of the population in Bihar lives below the poverty line. The biggest health hurdles and challenges include infant mortality rate, maternal mortality ratio, fertility rate which only reflect the poor health status of the people.

Resharing data from the State Health Society of Bihar:

The following data has been obtained from the State Health Society of Bihar where the requirement of public health facilities is as per the population census report of 2011. (Please visit: http://statehealthsocietybihar.org/healthinfra.html) for further details.

The gap of available health facilities to the population in Bihar is a disparity and it is this gap that we at Project Potential are innovating and collaborating around. Our mission is to ensure that healthcare facilities become better available, accessible, acceptable and pose quality to what the previous treatment cycle and diagnostic functions entailed. To work towards the enhancement of the public health ecosystem we are working closely with community health workers such as nurses, midwives, ASHAs, rural medical practitioners and so on.

Reintroducing the Tuberculosis Support Project:

A severe illness with much societal stigma and discrimination associated to it, Tuberculosis is still very prevalent and taking lives despite a cure for the same being invented post the second world war. As per the Global TB Report of 2018, 27 lakh people (2.7 million) were infected with TB, out of which approximately 4.4 lakh (440,000) people died from the disease. With the technical expertise of Innovators In Health- a nonprofit working in Samastipur district of Bihar ensuring healthcare for rural poor- we are replicating their tuberculosis support project model across 4 Panchayats of Kishanganj district.

Orientation with ASHA Workers in December 2020 from the Kishanganj Panchayats of Bhatgaon and Besarbati.

• Active Case Finding: Engaging with ASHA’s (Accredited Social Health Activists), we build their capacity to actively identify suspected TB patients at the community level. By providing refresher trainings and additional capacity building, these ASHA’s then monitor and report community members they suspect might have TB. As an incentive, an honorarium is paid to ASHAs for each community member they identify who ultimately tests positive for TB.
• Diagnosis: Suspected TB patients will be provided a container to collect the sputum samples which are then tested for TB. The sputum is transported to the testing center.
• Treatment: We support ASHAs to ensure they have the capabilities to deliver and monitor patient drug consumption along with counselling of patients and their families. We also work with the public health system to ensure ASHAs receive timely payments for TB work so that they remain motivated.

The PHC at Thakurganj:

The Primary Health Centre at Thakurganj is one of the two health care facility units to rural persons in Kishanganj District. The PHC as a “system” is fundamental to our contributions to making India TB free as this is where the sputum testing of patients with TB patients happens. Following sputum testing, it is the PHC which plays a crucial role in patient support and recovery by providing them with required medications, counselling support, and periodic check ups and testing for TB.

However, how equipped is the PHC itself in terms of personnel and technical support to patients with TB? Our team did some fact finding by directly interacting with some of the officials there to uncover the following:

Personnel Capacity:

• Staff at the PHC only get training in terms of technical knowledge and role clarity at the start of the job and upon joining. Post that whatever training is received is on an ad-hoc basis when sanctioned by the District Magistrate.
• ASHA Workers hold a monthly end meeting at the PHC as a debriefing on role clarity. A similar meeting is held every Tuesday for Auxiliary Nurse Midwives.

The PHC at Thakurganj during peak hours. Photo Courtesy: Tonmoy Talukdar

Technical Capacity:

• The PHC is equipped to test 5 sputum samples a day stretching to a limit of 7 samples per day.
• The PHC has an x-ray machine for testing and is equipped to check for 8–10 persons in a day.
• On average the PHC uncovers 6 positive TB cases per month with a case spike to 16–20 cases during the months of May to July.
• The PHC has generic medications and these are made available free of cost to the general public.

The Reality of It:

Staffing Issues:

• The main reason for being able to test just 5 sputum samples a day and 8 x-ray’s a day is because there is only one personnel available for each of the respective testing. In other words, the PHC is under-staffed to exceed its capacity for detection in various forms.
• Women staff with small children often do not work in the second half (post lunch) as they have other duties of childcare and household management which call their attention. As a result patients who travel from afar for healthcare post 1 pm in the afternoon need to return home having lost their travel allowance, daily wages and access to healthcare.
• Personnel capacity building happens on an ad hoc basis and manner when sanctioned by the DM. Hence the different structures of community health workers often do not get the opportunity to cross-learn from each other, share their learnings and challenges and refresh their awareness levels with regard to various diseases and infections.
• While it is imperative that all wards in the village have an appointed ASHA worker, some wards do not have ASHA members. As a result, inhabitants in these areas face barriers in their access quality health care.

Equipment Failure:

• With just one lab technician and limited personnel support operating on limited available equipment, mishaps and malfunctions become part and parcel of the daily work load. Often when the x-ray machine gets spoilt it means patients can’t be screened and tested for 3 entire work days and there is no alternative x-ray machine to use. The next best option is to travel to the PHC in Kishanganj which is over 40 kms away and not possible for the majority of patients.

Equipment Shortages and Failure at the Thakurganj PHC. Photo Courtesy: Tonmoy Talukdar

Hygiene and Safety:

• The use of masks and sanitizers along with social distancing measures is not adhered to at the centers despite the COVID 19 pandemic being in full swing.
• The facilities for patients themselves to avail of personal hygiene in the form of functional toilets and waste disposal is either non-existent or extremely unhygienic at the PHC. This signals that the PHC is for the absolute destitute who really have no other option but to avail its facilities whereas people who are still “poor” but not completely destitute might somehow manage to consult a private practitioner.

Lack of Trust:

• Patients don’t get their testing, treatment or government scheme benefits on time. For instance if they travel to the PHC for testing it may not happen that day due to understaffing or equipment failure. Similarly, many government schemes directed at TB patients are not availed on time. This is due to either limited digital literacy (an OTP code needs to be verified on personal mobile number) or failure to report TB on time or a combination of other reasons. All these hiccups in terms of accessing and availing quality healthcare and its facilities only act as deterrents to patients in TB diagnosis, treatment and recovery.

Home screening of TB Community Referrals by our Ground Staff. Photo Courtesy: Tonmoy Talukdar.

Conclusion:

Project Potential’s eArth Swasthya team mobilizes the community, knowledge partners, government stakeholders, and technology required to improve the public healthcare system and health outcomes in rural Bihar. The first step towards catalyzing systemic change is gaining a deeper understanding of the challenges such that we can then identify appropriate measures to remedify the same. We don’t have all the answers or solutions, but with a strong intention and dynamic team, we are working carefully and diligently on resolving health pitfalls in terms of access, availability and quality. One patient and one illness at a time, our end goal is to contribute towards improving the public health ecosystem both as a service provider and a fundamental health right for all.