Source: downtoearth.org.in
The recent outbreak of acute encephalopathy syndrome (AES) in Bihar, which claimed lives of more than 170 children, portrays a crippling rural healthcare system grappling with shortage of health providers and proper infrastructure.
The brain fever in Bihar has not established as encephalitis at the
moment, hence its called encephalopathy — ‘itis’ indicates that the
syndrome is an infection, while the cause is yet to be ascertained
‘pathy’, on the other hand, indicates that the cause is unknown.
Acute encephalitis syndrome, on the other hand, is a broad term and
includes viral infection (encephalitis) and hypoglycaemic encephalopathy
— low sugar levels as a result of malnourishment and lack of proper
diet.
AES is a brain fever that gets manifested in the form of seizures and
needs to be treated speedily — time plays a crucial role in reducing
mortality rates.
“The onset of AES is not from seizure but alteration in brain, which
causes fever and begins much early. A pateint may have four hours from
there till the onset of seizures,” said Shefali Gulati, a specialist in
child neurology at AIIMS-Delhi.
“The beginning of seizures indicates that the brain is swollen. A
child must reach a health facility within five-seven minutes of the
seizure, for the treatment to be effective,” Gulati said.
“The primary healthcare centres (PHCs) must be stocked abundantly
with anti-convulsant drugs, IV fluids and other necessary drugs for
correction of hypoglycaemia (low blood sugar)in AES-affected children,”
she told DTE.
Claims vs reality
In a bid to curtail the disease, the Bihar government had in 2016
prepared a standard operating procedure (SoP). It was subsequently
revised in 2018. The SoP clearly mentions that PHCs have to be prepared
with anti-convulsant and other drugs. It defines role of PHCs, community
health centres (CHCs), district hospitals as well as medical college
hospitals.
While the Bihar government claimed adequate preparation in accordance to the SoP, Down To Earth (DTE) found stark difference between ground reality and the claims made.
In early June, Vijay Kumar from Bahadurpur village of Muzaffarpur
district arrived at the PHC in Kanti block, with his son who was
convulsing. But his son was refused admission in the PHC. Kumar then had
to take him to Sri Krishna Medical College and Hospital (SKMCH) in an
auto, where he later died.
“My child was convulsing badly, his face had deformed and was
unconscious. We had absolutely no idea as to what was happening. But the
compounder in this very PHC refused to admit him saying he would not be
able to do anything. Had the doctors here helped, I would have perhaps
saved my child,” Kumar rued.
Kumar is yet again at the PHC with his ailing wife, who however, has been admitted.
The PHC has a ward dedicated for AES and has two beds. Kumar,
however, claimed that the ward came into existence much later after the
deaths peaked by mid-June.
Muzaffarpur has borne the brunt of the deadly fever with more than
100 deaths and 544 cases. Kanti is one of the four most affected blocks
of the district.
Suraj Das from Jamalabad village of Muzaffarpur’s Meenapur block
narrated a similar story. Das told DTE that there was nobody in the PHC,
when he came with his four-year-old child, early in the day.
It may be mentioned here that the children with AES fall sick between
4 am and 7 am in the morning, and it is the only time of the day when
there is even a chance of getting a healthcare provider in the PHC, as
less than one-fourth PHCs in Bihar run around the day, according to a
Niti Ayog report.
While both Kumar and Das tried going to PHCs, others did not, owing to poor experiences earlier. There were also cases when medicines ran out of stock in the PHCs.
“We don’t have faith on PHCs because they are never functional. We
prefer to take our children to the SKMCH,” Mohammad Sharif Alam of
Madhopur Machhia village, Muzaffarpur who lost his four-year-old son,
told DTE.
Poor infrastructre
More than 70 per cent PHCs, out of 2,012 PHCs in Bihar, function
without a medical officer and a nurse. Hence, they have been deemed
non-eligible for any grading, according to the Union health and family
welfare’s Health Management Information System (HMIS) for 2018-19. The
mandatory criteria for considering a PHC eligible for any grading is at
least a medical officer and a nurse.
In Muzaffarpur alone, 98 out of 103 PHCs were found unfit for grading
while another five, which were found fit for grading, scored zero
(based on availability of laboratory services, ambulance services, OPD
rooms and availability of drugs and other supplies) on a scale of five.
Sitamarhi’s 45 PHCs out of 57 were ineligible and East Champaran’s 83
out of 102 shared the same condition.
In the case of CHCs in Bihar, only 19 per cent got a grade
above four (based on immunisation and family planning methods) in
2017-18, decline of one per cent point from last year.
Bihar is also infamous for not being able to spend a large part of funds provided under the National Rural Health Mission.
The Bihar government took 191 days in 2017-18 to transfer the fund
from state treasury to implementing agency, according to Niti Ayog. This
is the highest across all over India. In Uttar Pradesh, the
corresponding figure was 118.
Lack of human resource
Besides crippling infrastructure, Bihar also faces shortage of health providers.
Unavailability of doctors is the biggest problem grappling the state.
In 2017-18, the state had only 3,679 doctors, against the sanctioned
number of 9,558, according to the Bihar Economic Survey 2018-19.
Worse, instead of adding, the state is also witnessing a decline of doctors: Bihar had 4,106 doctors in 2016-17.
The state has only 2,508 nurses, against the sanctioned posts of
6,423; 19,901 ANMS (Auxillary Nurse Midwives) against the sanctioned
posts of 34,446.
This comes at a time, when the state government is in a bed-increasing spree for its medical college hospitals.
After the AES outbreak this year, chief minister Nitish Kumar announced to increase the bed strength in SKMCH to 1,500 from 610.
The government has also decided to increase up to 5,000 beds from the
existing strength of 2,500 in Patna Medical College and Hospital, the
biggest hospital of the state.
“This is absurd. When all indicators say that they have to put stress
on improving rural health infrastructure, their entire stress is on
increasing tertiary care. Moreover, from where will they get doctors?
The state has not enough doctors to serve current government health
facilities,” Ranjit Kumar, an office bearer of Bihar State Health
Services Association, told DTE.
“This is so because the recruitment of doctors on regular posts in
government sector takes ages in Bihar, but even those working in
government sector do not get promotion in time. Why would doctors want
to stay in in Bihar then,” he added.
The announcement by CM Kumar is also seen as a knee jerk-reaction in
the wake of current outbreak as the deadline seems unrealistic.
“It is impossible to do it in one year time and it would take a
minimum of two years. It takes two years to convert a 6-bedded PHC to
30-bedded CHC, so how would it be possible to convert 610 beds to 1,500
in a year,” a senior health official told DTE, on condition of
anonymity.
