(Info) Public Health Facilities in Bundelkhand

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Public Health Facilities in Bundelkhand

By Government of India norms, one primary health centre (PHC) should serve a rural population 30,000 people.  Roughly, that means there should be one PHC per 30 villages.

Census 2001 data showed that in both UP and MP, and all Bundelkhand districts, the coverage was much poorer, with roughly one PHC per 50 villages in both UP Bundelkhand and MP Bundelkhand (see first table in Amenities in Villages and Households).

The poor coverage was also seen when one uses rural population of a district as the criterion. Using Census 2001 population figures (see Current Population), one can see that one PHC served a rural population of more than 50,000 in all districts of the region except Chitrakoot and Chhatarpur. In Banda, one PHC served over 90,000 people - thrice the norm.

At the level of primary sub health centres (PSHCs), the situation was terrible in UP Bundelkhand. While the region should have had over 1000 such centres by norms of the National Rural Health Mission for the region (10 PSHCs per PHC ), it had only around 250; the situation was worst in Lalitpur and Chitrakoot districts where there was only around one PSHC per PHC.

There is a gap even between sanctioned and completed infrastructure. A plan made in 2006 by the Chhatarpur District Collector for the Backward Regions Grant Fund (BRGF) disclosed that while 43 PHCs were sanctioned for the district, there were only 33; buildings for 186 PSHCs were sanctioned but there were only 56 on the ground [ District Collector, p 31].

These gaps were expected to be filled through BRGF, but even after that happens, there would be an increasing gap between demand and supply. Going by population growth trends, Chhatarpur needs to have at least 50 PHCs in 2010, according to Government of India norms (one PHC per rural population unit of 30,000). The gap would be more pronounced at the level of more easily accessible PSHCs: Chhatarpur would require around 450 such centres by 2010 , but would have less than 200 even if the BRGF plan projection is met by that year. (The assumption is that rural population of Chhatarpur, which was around 11.5 lakhs in 2001, would be around 14 lakhs in 2010. The National Rural Health Mission norm for Bundelkhand is that one PSHC should serve a rural population of 3000).

In UP Bundelkhand, the gap between required and available primary health sub centres would be staggering. Looking at the situation in 2001 (see first table in Amenities in Villages and Households ), the progress made since then and population growth trends, it appears that by 2010, PSHCs in the region would be, on an average, catering to 12,000 to 15,000 persons, against the National Rural Health Mission’s norm of 3,000 persons for the region.

Infrastructure is only aspect of health service; the more important aspect is availability of trained staff and adequate stock of medicines. The situation in UP is dismal, and reflected in extremely poor usage of government health facilities. A large `poverty and social monitoring’ survey (PSMS-II) conducted jointly by the state’s Planning Department and the World Bank in 2002-03 found that only 10% of people in rural areas who consulted any medical practitioner went to a government health facility; the rest went to a private sector doctor (35%) or a quack or traditional healer (55%) .  Among poor families in rural areas, the percentage was even lower (7%) [Directorate, p 46]. 

Probably the most important reason for low usage is low staff presence. Quoting a World Bank study, a `note on the health sector in Uttar Pradesh’, prepared by the state’s Planning Department in 2005, reported that 40 to 45% of doctors in PHCs were absent on the day of an unannounced visit [Dept. of Planning, p 14]. As it is, PHCs are few; a poor family living at a distant location would be very foolish to risk expenditure of time and money for a visit to a centre where the chances of the doctor being present are 1: 2.

As regards subhealth centres closer to villages, the vast gap between minimum need and supply has already been mentioned. In UP much of the supply is also incapable of dealing with acute illnesses and accidents ; many sub health centres are manned by ayurvedic or homeopathic doctors with limited and outdated medicine stocks.

The situation seems to be better in MP. A review of health facilities in 2006-07 in 17 states, conducted jointly by representatives of donor agencies and state officials, gave MP the highest rating with 12 points; UP got 6. Among the criteria used was assessment of PHCs and observation of sample health facilities [Dept. of Public Relations].

The rating does not tell us about usage of facilities. PSMS-II data mentioned earlier and field observations indicate that 30-50% of rural people of Bundelkhand who require medical attention consult traditional healers, called vaidyas or vaidoos, and 'ojhas’ who claim to have powerful mantras to drive away evil spirits that bring illness . A survey of 152 villages in Tikamgarh block of Tikamgarh district done in 1993 found that there were 165 well-known vaidyas in the block. The  vaidyas had little or no education, but people had great faith in them; even sick animals were taken for treatment.

The survey also found there were 157 practising ojhas in the block, who give mantras not only for illnesses, but also for realising desires like having a male child or winning a court case; ojhas were even consulted for recovering stolen property. Some ojhas, like one in a village called Chhipon, claimed to get their powers on one particular day and a huge crowd gathered on that day - in the crowd were many educated people too [Samarthan, p 41].

A few tantra-mantra practitioners have diversified and moved with the times, in a manner of speaking. In Badhokar Khurd block of Banda, the son of a famous mantra dispenser has a 'hospital’ exclusively for treatment of mental illnesses, especially schizophrenia. Patients are observed in the 'hospital’ for many days or weeks and appropriate mantras are given. The 'hospital’ stay may have to be repeated or modified over the years. In 2007, all-inclusive cost of treatment ran into several thousand rupees per week. Demand was high and booking had to be done months in advance.

Such methods of  cure, which may be called under the category of faith healing, probably do work for a lot of people, and many vaidyas probably have good knowledge of medicinal plants, but it is difficult to distinguish between `genuine’ healers and rogues. Besides, the most common illness in rural India, diarrohea, can only be tackled by adopting good hygiene practices and simple home treatment methods; recourse to healers - or medicines - will do no good.

In both UP and MP Bundelkhand, all systems of medicine fail miserably at the stage of life when healthcare is most crucial: when a woman is expecting and in the first year of an infant. This is reflected in mortality rates (see tables in Health Indicators).

One basic problem is very low percentage of births in hospitals (`institutional deliveries’) or at home with assistance of skilled professionals. While 2005-06 National Family Health Survey data indicated that 72% of births in rural MP and 76% in rural UP take place at home with assistance of relatives or traditional midwives, PSMS-II data indicated that among poor households in rural areas of UP Bundelkhand, the percentage of institutional deliveries was almost nil [Directorate, Table 22].

Another related problem is low presence of anganwadis, which are supposed to provide `integrated’ care and supplementary nutrition to young children and expectant mothers. PSMS-II mentioned earlier reported that over 60% of rural households in UP either stated that there was no anganwadi in their village, or they did not know of its existence. Only 10% of rural children in the age group 0-6 years went to an anganwadi [Directorate, p 47].

The Chhatarpur BRGF plan disclosed that there were only 285 anganwadis in the district, against a sanctioned requirement of 891 [District Collector, p 31]. The gap was proposed to be filled through BRGF funds. The plan proposed that the anganwadi buildings would be 'multipurpose’ centres: the buildings would function as panchayat bhavan; community centres, with play equipment for children, and as `resource’ centres.

Public health sector performance is also very poor with respect to prevention and control of contagious and infectious diseases. The Chhatarpur BRGF plan noted that the district was `highly prone’ to filariasis, elephantiasis and malaria. Malaria is also common in Panna, as mentioned in the discussion on the Ken Betwa link plan.

The problem has to be obviously tackled at the more basic level of sanitation and sewage disposal; the problem is extremely serious in many urban settlements inhabited largely by poor families. Quite often, slums are near dirty nalas or ponds choked with filth, making the inhabitants highly vulnerable to malaria and diarrhoeal disease.

Urban poor face other severe health-related limitations. While anganwadis are far and few in rural areas of UP, they are almost non-existent in urban areas. According to an analysis of National Family Health Survey (1998-99) data, across UP less than 30% of children of age 12-23 months among the urban poor had received complete immunisation.

The analysis also showed that around 30% of children of the urban poor reported diarrhea in the two weeks preceding the survey and around 20% of children suffered from acute respiratory condition, primarily pneumonia, due to pollution and highly congested living conditions [Urban Health Resource Centre, pp 39-43].

Congested living conditions also aggravate TB among adults, and its high prevalence in urban slum areas of Bundelkhand has not received any special attention (see Poor Widows). 

Another problem that has emerged due to high seasonal and annual migration is HIV-AIDS. High prevalence of HIV/AIDS cases has been detected in Lalitpur, Banda, Chitrakoot by the National Aids Control Organisation (NACO) and the Uttar Pradesh State Aids Control Society (Indian Express, May 18, 2008). Till December 2008, there was not a single anti retroviral treatment (ART) facility in the region.

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Courtesy : bundelkhandinfo.org