FUNCTIONING OF JSB CIVIL HOSPITAL CHIRANG
Conducted By Human Rights Law Network 576 Masjid Road, Jangpura Bhogal New Delhi-110014
Contents 1. Introduction: ...... 3 2. Public Health: a right based approach ...... 4 (a) International legal framework on public health: ...... 4 (b) Constitutional Provisions and Supreme Court Guidelines relation to public health: 7 3. Maternal Health situation in Assam: ...... 10 4. Methodology: ...... 17 5. Indian Public Health Standards Guidelines: an introduction ...... 18 (a) Sub Centre (SC):...... 18 (b)Primary Health Centre (PHC) ...... 19 (c) Community Health Centre (CHC) ...... 19 6. Evaluation of Implementation of IPHS standards for District hospital in Chirang District, Assam:...... 22 a) District Profile: ...... 22 b) Findings: ...... 23 1. Physical Infrastructure: ...... 24 2. Departmental Lay out Clinical Services: ...... 26 3. Intermediate Care Area ...... 29 (Indoor Patient Department): ...... 29 4. Pharmacy (Dispensary) ...... 29 5. Delivery Suite Unit ...... 31 6. Post Partum Unit ...... 32 7. Other Amenties: ...... 32 8. Hospital Transport Services: ...... 33 9. Manpower Requirements: ...... 33 7. Major issues of concerns: ...... 35 8. Conclusion: ...... 37
1. Introduction:
Indian Constitution provides right to health as one of the fundamental rights in corollary to right to life. Thus, denying basic health care means violating right to life. State being the guardian of the citizens’ rights has the duty to protect their legal and fundamental rights. Therefore, it is the basic duty of the state to provide basic health care services to the people in order to protect its citizens from mortality/mobility and lead a healthy life.
Right to health was first articulated in the World Health Organisation (WHO) Constitution in 1946 which states that: "enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being... And then in 1948 ‘health’ was introduced in Universal Declaration of Human Rights as a part of the right to an adequate structure of living (Article 25).”1 WHO has given a very comprehensive definition of the term “health”
“Health is a state of complete physical, mental and social well-being and not merely absence of disease or infirmity. The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion and political belief, economic or social condition.”
Though there is no distinction between men and women for the availability of right to good health and access to medical assistance, women are disproportionately impacted by States' failures to ensure the right to health. One of the leading causes of death for young women in India and the world is maternal mortality. The WHO also defines maternal death as, “the death
1 Right of everyone to the enjoyment of the highest attainable standard of physical and mental health (Right to health): World Medical Association (WMA) of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes.”
Further, WHO reported that over 90% of all maternal deaths are preventable where women receive access to basic antenatal care, skilled delivery assistance, and post-partum services. When governments fail to provide adequate maternal health care, they violate women’s rights to survive pregnancy, to health, to dignity, and to life.
2. Public Health: a right based approach
Public health enters in right based discourse on the basis of few international convention and constitutional provisions.
(a) International legal framework on public health:
There are many international conventions which relate to health rights and India being a party of those conventions India has an obligation to fulfill the provisions of those conventions. The relevant conventions which provides for right to life and good health include the Universal Declaration of Human Rights (UDHR), Declaration of Alma-Ata, International Covenant on Civil and Political Rights (ICCPR), International Covenant on Economic Social and Cultural Rights (ICESCR), Convention on the Elimination of All Forms of Discrimination Against Women (CEDAW).
Article 25 (1) of Universal Declaration of Human Rights (UDHR):
“The Universal Declaration of Human Rights (UDHR), which was adopted by the UN General Assembly on 10 December 1948, was the result of the experience of the Second World War. With the end of that war, and the creation of the United Nations, the international community vowed never again to allow atrocities like those of that conflict happen again. World leaders decided to complement the UN Charter with a road map to guarantee the rights of every individual everywhere.”2 Art. 25(1) of UDHR provide that everyone has the right to a standard living with a right good health it includes the food, house and medical care with necessary social services and the right to security in the event of sickness, disability old age etc.. So India being a party should ensure and protect the right to health without any discrimination. Deceleration of Alma-Ata: International Conference on Primary Health Care was held in Alma Ata, in 1978 express the need for urgent action by all governments, all health and development workers, and the world community to protect and promote the health of all the people of the world. It urges governments, WHO and UNlCEF, and other international organisations, as well as multilateral and bilateral agencies, nongovernmental organisations, funding agencies, all health workers and the whole world community to support national and international commitment to primary health care and to channel increased technical and financial support to it, particularly in the developing countries. The Conference calls on all the aforementioned to collaborate in introducing,
2. Universal Declaration of Human Right(UDHR), 1948 developing and maintaining primary care in accordance with the spirit and content of this Declaration.3 International Covenant on Civil and Political Rights (ICCPR): United Nation (UN) adopted ICCPR in 1966 and came to force in 1976. Under article 11 (3), 19 3(b), 21, 22 (2) every member state has the special responsibilities to protect the public health. Article 12 of International Covenant on Economic Social and Cultural Rights (ICESCR): The ICESCR was adopted by the United Nations General Assembly on 16 December 1966 and entered into force on 3 January 1976. Article 12 of ICESCR: Article 12 establishes ‘the right of everyone to the enjoyment of the highest attainable standard of physical and mental health’. The article lists some of the steps to be taken by States parties such as: the reduction of stillbirths and infant mortality; ensuring the healthy development of children; improving environmental and industrial hygiene; the prevention, treatment and control of diseases; and access to medical care for all.
Convention on the Elimination of All Forms of Discrimination against Women (CEDAW):4 It was adopted in 1979 and came into force in 1981 and it deals with women’s health and particularly reproductive rights Article 10 (h) states that women have the right to "specific educational information to help to ensure the health and well-being of families, including information and advice on family planning.
3. Declaration of Alma Ata, 1976 4. Reproductive Health and CEDAW: Bustelo Carlota: National Women Law Centre Article 12 of the Convention specifically concerns women's health. It obliges States Parties: (1) to "take all appropriate measures to eliminate discrimination against women in the field of health care in order to ensure, on a basis of equality of men and women, access to health care services, including those related to family planning"; (2) to "ensure to women appropriate services in connection with pregnancy, confinement and the post-natal period, granting free services where necessary, as well as adequate nutrition during pregnancy and lactation."
Article 14 deals with rural women's rights. State Parties commit themselves to ensure to such women the right "[t]o have access to adequate health care facilities, including information, counseling and services in family planning.
India as a signatory of these conventions should implement the provisions of those in order to protect and provide its citizen the right to life along with the right to health care and medical treatment. It’s the responsibility of the state to achieve its respective goal by proper implementation of their respective policies.
(b) Constitutional Provisions and Supreme Court Guidelines relation to public health:
The constitution of India has provided various rights to its people, who can avail these rights without any discrimination. Under Article 21 of the constitution of India, it guarantees the right to life and personal liberty which also including a fundamental right to health and medical assistance, right to live with dignity, right to food, right to clean environment, right to adequate drugs, the right to be free from torture and cruel, inhuman, or degrading treatment and right to emergency health care. The Supreme Court held that preservation of human life is of paramount importance. Failure on the part of the govt. hospital to provide timely medical treatment to a person in need of such treatment is the violation of right to life guaranteed under Art. 21.
Article 14 guarantees equality before the law and equal protection by law. The Hon’ble Supreme Court has described gender equality as one of the “most precious Fundamental Rights guaranteed by the Constitution of India.”
Article 15 prohibits discrimination on the grounds of religion, race, caste, sex or place of birth. This also empowers the state to make special provision for the woman and child. While the burdens of pregnancy and childbirth are inequitably borne by women, the ability to reproduce should not increase women’s chances of death, disability, or illness. There is no similar cause of death for young men in India. State should ensure and protect the life of a woman.
Finally, Article 47 provides that the state should raise the nutrition and the standard of living of its people and the improvement of public health which also guarantees access to medical services regardless of status. The Supreme Court of India and various High Courts has issued various orders and judgements to ensure women’s reproductive rights, including the right to survive pregnancy, the state’s duties and responsibilities to run and maintain the health institutions, to provide all medical services which a person is legally entitled to: In Bandhua Mukti Morcha v. Union of India and Ors, [AIR 1984 SC 802], the Supreme Court held that “right to live with human dignity’ also involves right to “protection of health.”
In Paschim Banga Khet Mazdoor Samity v. State of West Bengal, [1996 SCC (4) 37], the Supreme Court held that providing “adequate medical facilities for the people is an essential part” of the government’s obligation to “safeguard the right to life of every person.” It also held that it is the primary duty of a welfare state to ensure that medical facilities are adequate and available to provide treatment and if fails to do so, it’s a violation of right to life of the person.
In Laxmi Mandal v. Deen Dayal Harinagar Hospital &Ors., [W.P. (C) 8853/2008], the Delhi High Court held that an inalienable component of the right to life is “the right to health, which would include the right to access government health facilities and receive a minimum standard of care. In particular this would include the enforcement of the reproductive rights of the mother.”
In Francis Coralie Mullin v. Union Territory of Delhi &Ors., [1981 (1) SCC 608], the Supreme Court held that the right to live with dignity and protection against torture and cruel, inhuman or degrading treatment are implicit in Article 21 of the Indian Constitution.
In Parmanand Katara v. Union of India &Ors.,[1989 SCR (3) 997], the Supreme Court held that Article 21 of the Constitution casts the obligation on the state to preserve life. Every medical practitioner’s duty is to treat emergency cases with expertise and cannot refuse to offer treatment to such cases.
In Consumer Education and Research Centre v. Union of India, [1995 SCC (3) 43], the Supreme Court held that Article 21 of the Constitution of India includes a fundamental right to health, and that this right is a “most imperative constitutional goal.”
In Sandesh Bansal vs. Union of India &Ors.,[W.P. (C) 9061/2008] the Indore High Court concluded that timely health care is the essence for pregnant women to protect their fundamental rights to health and life as guaranteed under Article 21 of the Constitution of India. The Court held, "…We observe from the material on record that there is shortage not only of the infrastructure but of the man power also which has adversely affected the effective implementation of the [National Rural Health Mission] which in turn is costing the life of mothers in the course of mothering. It should be remembered that the inability of women to survive pregnancy and child birth violates her fundamental rights as guaranteed under Article 21 of the Constitution of India. And it is primary duty of the government to ensure that every woman survives pregnancy and child birth, for that, the State of Madhya Pradesh is under obligation to secure their life.”
3. Maternal Health situation in Assam: According to Sample Registration Survey (SRS) for the period of 2011-2013 the total on Maternal Mortality Rate is 167 per 100,000 live births. According to the World's Mothers report which was released in May 2013, by Save the Children, India ranked 142 out of 176 countries. This ranking was developed on the basis of five indicators such as maternal health, children's well-being, and educational status, economic and political status of women in the country.
According to the census of 2011 the maternal death rate has fallen to 178 deaths per 100,000 live births. This shows that India manage to achieve the goal to combat maternal deaths but states like Assam, Rajasthan, and Uttar Pradesh/Uttarakhand are still having a high maternal death rate above 300 per 100,000 live births.
Causes of maternal deaths:
According to civil society report on maternal deaths in India, Dead Women Talking, the most common cause of maternal death was post-partum haemorrhage, anaemia, eclampsia, and obstructed labour.
Sources: Register General of India, 2013
Assam has the highest number of maternal deaths in the country. The census of 2011 shows the maternal mortality ratio (MMR) of Assam was 328 which was the highest in the country compared to all India level which is 178, which shows the failure of Govt. to reduce the MMR. As per the Annual Health Survey report of 2010-2011, in upper Assam (Tinsukia, Diburgarh, Sivsagar, Jorhat, Golaghat) the MMR was 430, in North Assam (Marigaon, Nagaon, Sonitpur, Lakhimpur, Dhemaji) the MMR was 367, in Lower Assam ( Kokrajhar, Dhubri, Goalpara, Darrang, Bongaigaon, Barpeta, Kamrup, Nalbari) the MMR was 366 and in the Hills & Barak Valley (Karbi Anglong, North Cachar hills, Chachar, Karimganj, Hailakandi) the MMR was 342. These surveys indicates the pathetic maternal health scenario of entire Assam.
As per DLHS-3 (2007-08) data, approximately 40 percent of deliveries in Assam are attended by trained health worker while the all India data is 52.7 percent. Antennal care (ANC) is one of the important components of improving maternal health situation. According to DLHS-3 report 75 percent women received any ANC check up in India and whereas in Assam it’s near about 74 percent. Though the use of full ANC (at least three visits of ANC check up, at least one TT injection received and 100 IFA tablets/syrup consumed) is increased from 16.4 percent (DLHS-2) to 18.8 percent (DLHS- 3) but the statistic is not satisfactory as recorded in DLHS-3 only 39.4% women has gone through ANC in their first trimester, only 45% has taken 3 or more ANC and only 32.8% women has taken post ANC within the two weeks of delivery. But unfortunately till now Assam, continues to remain the State having the highest Maternal Mortality Ratio (MMR).
To improve the maternal health situation Union of India adopted National Rural Health Mission in 2005 which is now National Health Mission (NHM) with the objective to prevent and reduce maternal deaths in the country. NHM introduce Janani Suraksha Yojna (JSY) in 2005). It is a safe motherhood intervention under the National Rural Health Mission (NHM). It is being implemented with the objective of reducing maternal and neonatal mortality by promoting institutional delivery among poor pregnant women. Under this scheme cash assistance i.e. Rs. 1400/- for Rural Area and Rs. 1000/- for Urban Area has been provided to eligible pregnant women for giving birth in a government health facility, moreover Rs. 500 is for the BPL woman for giving birth in the home. Though JSY works as a safe motherhood intervention under the NRHM which focuses on reducing maternal and neo-natal mortality by promoting institutional delivery among the poor pregnant women but till now safe motherhood remains a major challenge for the overall State. As recorded in the DLHS-3 in Assam only 25.2% women have received cash assistance under the JSY scheme and only 35.3% women has gone through the institutional delivery whereas the percentage of home delivery is 63.6%.
Apart from JSY, NHM introduced Janani Shishu Suraksha Karyakarm (JSSK). Under this scheme pregnant women are entitled to free transport, free drugs, free diagnostic, free blood, and free diet for delivery in public health institutions . But if one goes through various health related surveys the MMR percentage clearly shows the failure on the part of the Govt. to provide all these services to the entire population. It is the responsibility of the state govt to properly implement the schemes and to do timely checking for the better results. The Govt of Assam somehow is not able to improve the maternal health scenario to a great extent. Schemes like Mamoni have been introduced to encourage pregnant women to undergo at least 3 ante-natal checkups which identify danger signs during pregnancy and offer proper medical care. This scheme provides cash assistance to pregnant women for nutritional support @Rs. 1000/- in two installments.
Mamta scheme is also introduced to reduce the Infant Mortality Rate (IMR) and MMR, by insisting on post delivery hospital stay for 48 hours of the mother and new born. Any complication arising during this period is attended by skilled doctors available at the government hospital.
Moreover in the year 2010 the Govt of Assam also introduced The Assam Public Health Act, which provides mother and child health care including reproductive health care for universal coverage. This Act also provides that every person shall have the right to appropriate health care and health care related functional equipment and other infrastructure, ambulance services, trained medical and professional personnel and essential drugs; reproductive health service and sexual health care with special emphasis for women and girls; and also provides the other basic facilities which a patient can avail under this Act. It also provide access to health care services and ensure that there shall not be any denial of health care directly or indirectly, public or private, including for profit and not for profit service providers, by laying down minimum standards and appropriate regulatory mechanism.
To develop the health care sector in the community level Accredited Social Health Activists (ASHAs) have been engaged. They are the primarily available health workers, basically works for any health related demands of deprived sections of the population, specially women and children, who find it difficult to access health services basically in rural areas. ASHA Programme is expanding across States and has particularly been successful in bringing people back to Public Health System and has increased the utilization of outpatient services, diagnostic facilities, institutional deliveries and inpatient care.
There are many reasons for Assam’s high rate of maternal death like lack of awareness on health care, non implementation of government maternal benefit schemes, poor road connectivity to the nearest health centres, poor antenatal & post natal care, child marriage, poor socio- economic condition etc.
Poor ante natal care and post natal care is one of the big reasons for maternal death. Apart from proving Iron & Folic Acid tablets and TT injections to the pregnant women Ante Natal check up can detect pregnancy complications. If any woman has any kind of complication then it can be treated from the very initial stages. However, DLHS-3 clearly shows that in Asaam only 7.9% women had received total ANC, 45% received 3 pre ANC and 32.8% women received post natal check up.
Lack of awareness about maternal health is another reason for the maternal mortality. Most women die due to causes related to pregnancy, childbirth and abortion. It is unfortunate that a large number of maternal deaths occur due to haemorrhage, obstructed labour and unsafe abortions; while safe and affordable technologies to prevent such deaths to exist. Access to skilled assistance and well equipped health institutions during delivery can reduce maternal mortality and improve entire health scenario.
Poor connectivity to the nearest health centre is also a cause of high MMR in Assam. The road conditions are so pathetic that it becomes painful for a pregnant woman to travel and get a medical assistance, so basically most of the women instead of institutional deliveries prefer deliveries at home.
Even in some places due to non availability of the specialized doctor or due to non availability of required facilities at govt. hospitals women have to travel from one district to another district covering a long distance in order to get a good medical assistance. There is lack of ambulance services, lack of specialist and doctors at district hospital/PHCs/CHCs. Shortage of basic medical facility and short fall of human resource are also contributing factor for the high MMR.
Though the Central Govt. has allocated a huge percentage of money in the health sector, yet it’s not fully invested. Due to which there are problems like non-functioning of the health centres, non availability of equipments, shortage of man power, shortage of medicines and ambulance service facility. The Rural Health Statistics (RHS) Bulletin of March, 2012 M/O Health & Family Welfare shows the shortage of manpower in all the Govt health institute specially in Sub centres, which indicates the required number of health worker are 5841 but only 4604 are in position which shows shortfall of 1234.
At this point of time, there is a special need on the part of the govt to properly implement the health related schemes and to monitor it under a strict vigilance. Moreover the govt should engage more manpower in this sector for the proper functioning of health institutions so that people from every nook and corner of Assam can easily access to the health institution. Timely monitoring and awareness camps amongst the people can also create trust amongst the people so that people can access health institutions without any hesitation. It also help to understand about the basic medical facilities provided by the govt and through which govt can reduce MMR and protect valuable life.
As recorded in the DLHS- 3 to contribute towards the health service the govt of Assam established Medical colleges and hospital throughout the state. Assam has 23 district hospitals, 195 Primary Health Centre, 83 Community Health Centre & 714 Sub Centre.
With the objective of analysing maternal health situation in Assam a team of activist and lawyers visited Chirang district and evaluated the functioning of JSB Civil Hospital (also known as Chirang Civil Hospital), Chirang on the basis of the yardstick of Indian Public Health Standards (IPHS).
4. Methodology:
Lawyers and Social Activists from HRLN conducted a fact-finding on 8th August 2015. The fact-finding team interviewed staff of Kajalgaon Civil hospital and pregnant women. This fact finding report is based on both primary and secondary source of information. Interviews were used as the primary method to collect information in the fact finding visit. Apart from the primary data, we also analysed reports and academic literature as secondary sources of information. 5. Indian Public Health Standards Guidelines: an introduction
The health care system in India has expanded considerably over the last few decades. However, the quality of services is not uniform due to various reasons like non availability of manpower, problems of access, acceptability, lack of community involvement, etc. Hence, standards are being introduced in order to improve the quality of public health level. Indian Public Health Standards(IPHS) are a set of standards envisaged to improve the quality of health care delivery in the country under the National Rural Health Mission. In India under IPHS the health care delivery has been provided at three levels namely primary, secondary and tertiary, i.e. in the form of PHCs, CHCs & district level hospitals which also includes sub-centres and sub- district hospitals. IPHS provides for minimum requirements such as healthcare services, staffing, furniture, equipment, infrastructure, medicines, and hygiene which every health institution should maintain.
(a) Sub Centre (SC):
Sub Health Centre is the community’s first point of contact with the government healthcare system. The IPHS provides that Sub centers should have at least one auxiliary nurse midwife (ANM); one Health Worker Male; four beds with mattresses; a fully equipped labor room; a fully equipped Newborn Care Corner; various specified equipment, including sterilization of instruments and equipment; and various supplies and medicines.
The main objectives of IPHS for the sub-centers are as follows: To specify the minimum assured (essential) services that Sub-centre is expected to provide and the desirable services which the states/UT s should aspire to provide through this facility. To maintain an acceptable quality of care for these services. To facilitate monitoring and supervision of these facilities. To make the services provided more accountable and responsive to people’s needs.
(b)Primary Health Centre (PHC)
It is the primary level of health care which acts as the referral unit for six sub centres. Each PHC should have a staff of 13, including a MBBS doctor who acts as the Medical Officer (MO) in charge of managing 1 pharmacist, 1 laboratory technician, 3 ANMs, 2 health assistants, 2 multi-skilled workers, and 1 sanitary worker cum watchman. PHCs should provide 24/7 emergency services including institutional delivery), comprehensive primary healthcare, full coverage of treatment for maternal health and diseases, a large variety of diagnostic laboratory testing services, comprehensive nutrition services, family planning services and have free ambulance service for referrals.
The main objectives of IPHS for PHCs are as follows: To provide comprehensive primary health care to the community through the Primary Health Centres. To achieve and maintain an acceptable standard of quality of care. To make the services more responsive and sensitive to the needs of the community.
(c) Community Health Centre (CHC)
The community Health Centre is the secondary level of health care centre, which are designed to provide referral health care for cases from the primary level and for cases in need of specialist care approaching the centre directly. CHC is a 30 bedded hospital providing specialist care in medicine, obstetrics and gynecology, surgery and pediatrics. Its objective is to provide optimal expert care to the community, to achieve and to maintain an acceptable standard of quality of care and to make the services more responsive and sensitive to the need of the community. CHCs should provide 24/7 emergency services including normal and institutional delivery, essential and emergency obstetric care including surgical interventions like caesarean sections and other medical interventions, safe abortion services, new born car, full coverage of treatment for maternal health and diseases, a large variety of diagnostic laboratory testing services (e.g., pregnancy, blood, urine, stool, RTI/STI, malaria), comprehensive nutrition services, family planning services (including access to a full range of contraceptives), and have transport available for referrals. Staff should be trained in standard treatment protocols for institutional delivery, essential newborn care, and the implementation of all national health programs. The main objective of IPHS standards of CHC are To provide optimal expert care to the community.
To achieve and maintain an acceptable standard of quality of care.
To ensure that services at CHC are commensurate with universal best practices
And are responsive and sensitive to the client needs/expectations.
DISTRICT HOSPITAL: District hospital is an essential component of the district health system and functions as a secondary level of health care which provides curative, preventive and primitive healthcare services to the people in the district. Every district is expected to have a district hospital linked with the public hospitals/health centres down below the district such as Sub-district/Sub- divisional hospitals, Community Health Centres, Primary Health Centres and Sub-centres. District hospitals should provide 24/7 emergency services including normal and institutional delivery, essential and emergency obstetric care including surgical interventions like caesarean sections and other medical interventions, safe abortion services, new born car, full coverage of treatment for maternal health and diseases, a large variety of diagnostic laboratory testing services (e.g., pregnancy, blood, urine, stool, RTI/STI, malaria, HIV), comprehensive nutrition services, family planning services (including access to a full range of contraceptives), and have ambulance service. As per the number of beds - 100/200/300/400/500 the required no. of man power - doctors are 29 ,34 ,50, 58 and 68; Staff Nurse 45, 90, 135, 180 and 225; Paramedical 31, 42, 66, 81, 100; Lab Tech 6, 9, 12, 15 and 18; Pharmacist 5, 7,9,11 and 13 ; Storekeeper 1, 1, 2, 2 and 2. IPHS provides that a District Hospital is expected to provide have been grouped as Essential (Minimum Assured Services) and Desirable (which we should aspire to achieve). The services include OPD, indoor and Emergency Service. Besides the basic specialty Services, due importance has been given to Newborn Care, Psychiatric services, Physical Medicine and Rehabilitation services, Accident and Trauma Services, Dialysis services, Anti-retroviral therapy and also Patient Safety and Infection control norms. They should be in a position not only to provide all basic speciality services but should aim to develop super-specialty services gradually. District Hospital also needs to be ready for epidemic and disaster management all the times. In addition, it should provide facilities for skill based trainings for different levels of health care workers. Moreover, staff should be trained in standard treatment protocols for institutional delivery, essential newborn care, and the implementation of all national health programs.
The objectives of IPHS standards for DH are as follows: To provide comprehensive secondary health care (specialist and referral services) to the community through the District Hospital.
To achieve and maintain an acceptable standard of quality of care.
To make the services more responsive and sensitive to the needs of the people of the district and the hospitals/centres from where the cases are referred to the district hospitals.
6. Evaluation of Implementation of IPHS standards for District hospital in Chirang District, Assam: a) District Profile:
Chirang district is one of the 27th districts of Assam state in north-east India. It is a new district formed in the Bodoland Territorial Area District (BTAD) under the Govt. of Assam, created vide notification No. GAG (B). 137/ 2002/ Pt/ 117 dtd. 30/10/2003 within Assam under Clause 6 of Article 332 by the 90th Amendment Act, 2003 of the Constitution of India under the provision of the Sixth Schedule. The district Headquarter is in Kajalgaon. As per the 2011 census the population of the district is 4,81,818. Total population of male is 2,44,673 female population 2,37,143 total literacy rate is 55.28%. The health institutions available are –JSB Civil hospital as the district hospital along with 2 Community Health Centre (Bhetagaon CHC and Bengtol CHC ) and 24 Primary Health Centres. b) Findings:
The only civil hospital known as the JSB Civil Hospital (100 bed) in Chirang district located at its headquarters in Kajalgaon, was established in the year 2010. It was initially developed as a super-speciality hospital sanctioned for the Bodoland Territory Area District by the Ministry of Development of Northeastern Region. The administration had earlier aimed to run the hospital as a super-speciality hospital under public-private partnership. Later, because of non-feasibility, the project was converted to that of a civil hospital under National Rural Health Mission. The hospital, with good infrastructure, has been providing poor patients life-support facilities, medical equipment for CT scan, sonography, X-ray, physiotherapy. It has an intensive care unit, sick newborn care unit as well as ophthalmological tools and instrument for ENT treatment.
1. Physical Infrastructure:
Size of the hospital: The size of a district hospital is a function of the hospital bed requirement which in turn is a function of the size of the population it serves. JSB Civil hospital is 100 bedded hospital. 2. Hospital Building: According to the guidelines of IPHS for DH Hospital Management Policy should emphasize on hospital buildings with earthquake proof, flood proof and fire protection features. Infrastructure should be eco-friendly and disabled (physically and visually handicapped) friendly. From our fact finding we found out that the building is not accessible by the disabled people. Although there is provision for lift system but it is not functioning. Hence, pregnant women and disabled people find it difficult to climb the stairs. (i) Appearance and upkeep:
According the guidelines hospital should have high boundary gate with at least two exit gate, proper landscaping and maintenance of trees and gardens, there should be provision for adequate light and there should not be any outdated/unwanted hoardings or posters pasted on the building walls. From our fact finding we found out that posters related to maternal health are pasted in the walls of the buildings.
(ii) Signage: According to the guidelines of the IPHS there should be prominent boards with the name of the hospital and directional signage for few services like blood banks, OPD, etc. During our visit we found that there is proper signage to the services. iii) General Maintenance: Building should be well maintained with no seepage, cracks in the walls, no broken windows and glass panes. There should be no growth of algae and mosses on walls etc. Hospital should have anti-skid and non-slippery floors. From our fact findings we found that the building is well maintained because it is newly constructed. It was constructed in 2010. iv) Condition of roads, pathways and drains: According to the guidelines the hospital should be at such a location which has a motor able road with proper parking spots and there should be no open sewage.
v) Environmental friendly features: The Hospital should be, as far as possible, environment friendly and energy efficient. In an interview with the hospital staff we found out that the hospital has environment clearance certificate. vi) Barrier free access: For easy access to non-ambulant (wheel-chair, stretcher), semi-ambulant, visually disabled and elderly persons infrastructure as per “Guidelines and Space Standards for barrier-free built environment for Disabled and Elderly Persons” of Government of India, is to be provided. vii) Administrative Block Administrative block attached to main hospital along with provision of MS Office and other staff should be provided. Block should have independent access and connectivity to the main hospital building, wherever feasible. There is a set up for administrative block in the hospital but it is not functioning because there are no administrative staffs. viii) Circulation Areas Circulation areas comprise corridors, lifts, ramps, staircase and other common spaces etc. The flooring should be anti-skid and non-slippery. There is lift services in the hospital but it’s not functioning.
2. Departmental Lay out Clinical Services: i) Outdoor Patient Department (OPD)
According to the guidelines the facility shall be planned keeping in mind the maximum peak hour patient load and shall have the scope for future expansion. OPD shall have approach from main road with signage visible from a distance. In OPD section there need to be reception and waiting space. During our fact finding visit we found that though there is OPD section with reception and waiting space but it is not functional.
Photo 1: Reception area of JSB Civil Hospital
ii ) Clinics
The clinics should include general, medical, surgical, ophthalmic, ENT, dental, obstetrics and gynaecology, Post Partum Unit, paediatrics, dermatology and venereology, psychiatry, neonatology, orthopaedic and social service department. There is provision for all the mentioned services but there are no specialists to run the services and so it is closed down. iii) Clinical Laboratory:
According to the IPHS standards the laboratory shall be situated such that it has easy access to IPD as well as OPD patients. The Laboratory shall have adequate space from the point of view of workload as well as maintenance of high level of hygiene to prevent the infection. There should be provision for emergency laboratory services. iv) Blood Bank:
Every district should have blood bank services based on the guidelines of adhere NACO guidelines and drug and cosmetic act strictly. JSB Civil hospital being a super facilities hospital there is provision of blood bank services. During our fact finding to the hospital we found out that the no pregnant women can avail the services of the blood bank and in an interview with the staff nurse the team found out that severe anaemic patient are referred to further institutions. This is because the blood bank is closed down since 2010 and there is no lab technician to run the blood bank.
Photo2 shows the locked blood bank lab of JSB hospital
3. Intermediate Care Area (Indoor Patient Department):
The guidelines state that the
General IPD beds shall be categorized as following Male Medical ward Male surgical ward Female Medical ward Female surgical ward Maternity ward Paediatric ward Nursery Isolation ward
As per need and infrastructure hospital have following wards Emergency ward/trauma ward Burn Ward Orthopaedic ward Post operative ward Ophthalmology Ward Malaria Ward Infectious Disease Ward
In our fact finding visit we can see all the above mentioned wards in the hospital but it is to note that every room is locked out. In the maternity ward we can see few women with their new born baby.
4. Pharmacy (Dispensary)
Pharmacy should have component of medical store facility for indoor patients and separate pharmacy with accessibility for OPD patients. Hospital shall have standard operating procedure for stocking, preventing stock out of essential drugs, receiving, inspecting, handing over, storage and retrieval of drugs, checking quality of drugs, inventory management (ABC & VED), storage of narcotic drugs, checking pilferage, date of expiry, pest and rodent control etc. The team saw an allocated space for pharmacy but like other services the pharmacy is also closed down. Also, the team noticed that there was stock of medicines in sealed packet and they have never been used. No one was present there to take care of the need of the medicines required by the patient. From the personal interviews with the patients who were admitted at the hospital, the team found out that relatives of the patients have to buy medicine outside the hospital.
Photo 3 shows pharmacy area of the hospital
Photo 4 shows the stock of sealed medicines which is kept in the stock room
5. Delivery Suite Unit
The delivery suite unit be located near to operation theatre & located preferably on the ground floor. The delivery Suite Unit should include the facilities of accommodation for various facilities as given below: Reception and admission Examination and Preparation Room Labour Room (clean and a septic room) Delivery Room Neo-natal Room Sterilizing Rooms Sterile Store Room Scrubbing Room Dirty Utility Doctors Duty Room Nursing Station Nurses changing Room Group C & D Room Eclampsia Room The team shows the availability of the delivery services in the hospital and also the labour room was on the ground floor. Interviewing a staff nurse of the hospital the team found out that C-section services are not available because there are no specialists in the hospital. In the hospital only normal deliveries are conducted. In a month approx 50 normal deliveries are conducted in the hospital. One of the staff nurse share that in the month of June there were 42 deliveries and in July 43 babies were born.
6. Post Partum Unit
It is desirable that every District Hospital should have a Post Partum Unit with dedicated staff and infrastructure to provide Post natal services, all Family Planning Services, Safe Abortion services and immunization in an integrated manner. The focus will be to promote Post Partum Sterilization and will be provided if the case load of the deliveries is more than 75 per month. There is functional partum unit.
7. Other Amenities: IPHS guidelines Facilities available at the district hospital Potable drinking water There is provision for drinking water facilities for the people. One of the patients informed the team that they have to buy water. Functional and clean toilets with running There are no clean toilets and running water and flush water.
Fans/Coolers Fans are available, but the condition of the fans seems to be old. Seating arrangement as per load of The team also observed that there is no patient. adequate seating arrangement either for patient or for attendant. The team also observed in the maternity wards that patients sit on the floor.
Photo 5 shows the unclean toilets
8. Hospital Transport Services:
Hospital shall have well equipped Basic Life support (BLS) and desirably one Advanced Life Support (ALS) ambulance. At present, though there are four ambulances available in the Civil Hospital, only one ambulance is covering the entire district due to the non appointment of drivers.
9. Manpower Requirements:
Following is the minimum essential manpower required for a functional District Hospital of different bed strengths as indicated. Efforts shall be made by the States/UTs to provide all desirable services including super- specialty services as listed, as and when the required manpower is available in the concerned District/State. District Hospital Manpower-Medical Specialty 100 beds Medicine 2 Surgery 2 Obstetric & Gynae 2 Paediatrics 2 Anaesthesia 2 Opthalmology 1 Orthopaedics 1 Radiology 1 Pathology 1 ent 1 Dental 1 Mo 11 Dermatology 1* Psychiatry 1 Microbiology 1* Forensic specialist 1* AYUSH Doctors# 1 Total 29+ 3 * Desirable *If more than one AYUSH doctors are available, at least one doctor should have a recognised PG qualification in relevant system under AYUSH.
One of the staff nurse shared the information that the shortage of manpower is one of the main problem which they are facing. There are only 11 doctors (4 appointed under NRHM), 1 gynaecologist and 13 stuff nurses.
District Hospital Man Power – Administration
Cadre 100 bedded
Hospital Administrator 1 Housekeeper/manager 1
Medical Records officer 1
Medical Record Asstt. 1
Accounts/Finance 2
Admn. Officer 1
Office Asstt. Gr I 1
Office Asstt. Gr II 1
Ambulance Services (1 driver + 1 2 Tech.) Total
No administrative officer, medical record officer, etc are appointed till date.
7. Major issues of concerns:
According to the state PIP total no of population covers by JSB hospital covers is 503153 lakh. Thus, the civil hospital failed to provide basic health facilities to such a huge population of the district. This clearly shows the violation of right to health and state failure to provide primary health care to the people. Apart from the fundamental rights we can also witness violation of Article 25 (1) UDHR, article 11 (3), 19 3(b), 21, 22 (2) of ICCPR every member state has the special responsibilities to protect the public health and Article 12 of ICESCR. India is a member to the above mentioned convention and thus the state failed to adhere by the obligations mentioned in the conventions to maintain a healthy and developed life. JSB Civil hospital is a 100-bedded hospital and it was reported in State PIP that for the year 2013-2014, the rate of bed occupancy is 1%. Bed occupancy rate is a calculation used to show the actual utilization of an inpatient health facility for a given time period. It is expressed as a percent and other terms which are often used synonymously include "percent occupancy," "percentage of occupancy," or "occupancy ratio." In the Bureau of Health Statistics, occupancy rates are routinely calculated for hospitals and nursing homes and aggregated at the facility, county and state level. The calculation of occupancy rates is not limited to the facility as a whole. Occupancy rates are often calculated to determine the utilization of a specific inpatient unit such as obstetric, psychiatric, medical/surgical, etc. By interviewing patient and pregnant women admitted at the hospital the team reported that due to non availability of basic health services like medicines, doctors, transport people prefer to go to private hospitals instead of civil hospital. From the fact finding, the team found out that due to the lack of services like blood banks, lab facilities, lack of manpower no caesarean deliveries are done. Most of the times they referred the complicated cases to Bongaigaon civil hospital. This means that a pregnant woman in her labor pain has to travel 55 kms. Moreover, due to absence of referral transport service they have to hire a private vehicle to reach to Bongaigaon. Thus, out of pocket expenditures increases and this leads to the violations of provisions of JSSK under which every pregnant woman is entitled to free treatment, free transport services. Further, it is mentioned above that most of the relatives of the pregnant women informed the team that they have to buy medicines, bloods, etc. This also increases the out of pocket expenditure and leading to the violations of JSSK.
8. Conclusion:
Thus, from the above analysis it is clear that people are deprived from the basic health services. This leads to the violations for their fundamental rights, non implementation of Supreme Court orders on maternal health and provisions of international conventions on health. Thus the state failure to protect and prevent the maternal health situation gives us the distance dream in achieving Minimum Development Goal to improve the maternal health situation in the country.