Fact-Finding Report on the State of Public Health Facilities in

Barwani District

25th August 2012 – 31st August 2012

TABLE OF CONTENTS

I. Introduction II. Relevant Constitutional Rights, Schemes, Norms a. NRHM b. IPHS III. Issues of Major Concern a. Shortage of Staff i. Affect on High Number of ODP Patients b. Lack of Funds to Hire and Retain Essential Staff c. Faulty Upgrade of PHCs d. Lack of Space for Essential Medical Services e. Non-Registered Pharmacists Dispensing Medicines f. Lack of Essential Medicines g. Patients Forced to Purchase Essential Medicines Out of Pocket h. Poorly-Functioning or Non-Existent Blood Storage Units (BSU) i. Lack of Reliable Transportation j. Sterilization Camps k. Lack of Maternal Death Reporting and 15-49 Maternal Deaths Reporting l. Lack of Hygiene in All Facilities and a Faulty Waste Management System at DH IV. Recommendations I. INTRODUCTION

In 2011, the Human Rights Law Network filed a case in the Honourable High Court of against the Government of Madhya Pradesh in W.P. PIL No. 5097 of 2011, Dunabai v. State of Madhya Pradesh and Others. The petition alleged that the Respondents had failed to install adequate infrastructure and facilities in ’s public healthcare system. The petition also alleged that the Respondents had failed to post a sufficient number of qualified doctors in Barwani District’s public healthcare system. These failures, the petition argued, violated the reproductive rights of women and girls in its failure to implement maternal health strategies and programmes consonant with constitutional, international, and statutory obligations. The consistent and recorded denial of health care services, particularly emergency obstetrical care and antenatal care services, highlight a series of systemic failures that have broken families and raise serious concerns about the provision of health services for the public at large.

On 11th November 2011, the High Court of Madhya Pradesh issued an order in which it directed the Respondents to “take immediate steps for providing the minimum basic health facilities to the women in the area concerned and… place on record…the steps taken by the State in this direction…” After the Respondents failed to file a report as requested in the order of 11th November, the High Court issued an order on 27th January 2012 directing the Respondents to “file requisite compliance report/affidavit as already directed on or before the next date of hearing, failing of which the respondents No. 2 to 4 shall remain personally present before this Court on the next date of hearing.” In this same order, the case was listed for 3rd March 2012.

The Respondents finally filed their compliance report on 26th March 2012. After examining the Respondent’s report, the High Court wrote, “we find that the steps are not enough and are not in the pace in which the same are to be taken.”

In light of the Respondent’s failure to implement necessary measures to improve Barwani District’s public healthcare system, the High Court ordered on 27th July 2012 that “the second respondent Commissioner, Health Department Government of M.P. and Joint Director health to visit Hospitals, various Public Health Centres and Community Health Centres at District Barwani within 15 days along with the Collector Barwani to find out the problems being faced and to find out its solution.” The Respondents were further ordered to file a “necessary report in that regard…on or before the next date of hearing,” which was scheduled for 3rd September 2012.

This report was prepared to provide an updated status on the public healthcare system in Barwani District and highlight ongoing issues of major concern.

Madhya Pradesh and Barwani District:

As of 2011, the population of Barwani District is 1,385,659 people. According to the Madhya Pradesh Human Development Report of 2007, Barwani district has the second lowest Human Development Index amongst all districts of Madhya Pradesh. According to the 2001 Census, which reported Barwani District’s population as 1,081,039, 67% of the people in Barwani District are Scheduled Tribes (STs).

The District Level Household Survey of 2007-2008 reported that over 65% of pregnant women living in Barwani District are not receiving essential antenatal, obstetric or postnatal medical assistance. According to the same report, Accredited Social Health Activists (ASHAs) facilitate or motivate only 1% of women in Barwani District to use family planning methods, request antenatal care or have institutional delivery.

More recently, The Annual Health Survey 2010-2011 reports that 70.1% of all deliveries in Barwani District occurred at institutions. Moreover, 65.6% of all deliveries occurred at government institutions. Correspondingly, 29.7% of all deliveries in Barwani District took place at home and a skilled health personnel conducted the delivery in only 15.3% of these.

The same report notes that the Crude Death Rate (CDR) in Barwani District is 10.5 women for every 1,000 women compared to Madhya Pradesh’s CDR of 7.5 per 1,000 women. Moreover, the Maternal Mortality Ratio for the Division is reported as 278 for every 100,000 live births. The distribution of maternal and non-maternal death by broad age group in Madhya Pradesh is represented as below:

The figures represented above and the facts presented in this report are illustrative of Barwani District’s broken healthcare system, which fails to meet even the most basic of standards as outlined in the National Rural Health Mission scheme and the Indian Public Health Standards norms.

This failure perpetuates the violation of Barwani Districts’ women’s constitutional rights. Women are routinely denied emergency obstetrical care and access to free health services at Primary Health Centres (PHC), Community Health Centres (CHC) and the District’s District Hospital. Moreover, the public health facilities in Barwani District Moreover, these women are denied their legal entitlements to medical and financial assistance at every stage of their pregnancy, including access to reproductive health services by an Auxiliary Nurse Midwife (ANM) and an ASHA as mandated under government schemes including the National Rural Health Mission (NRHM), and the Janani Suraksha Yojana (JSY).

II. RELEVANT CONSTITUTIONAL LAW, SCHEMES, AND NORMS

Constitutional Law

Article 21 of the Constitution of guarantees the right to life for all Indians and states: “No person shall be deprived of his life or personal liberty except according to procedure established by law.” The Supreme Court has also held that Article 21 includes the right to health and appropriate medical care. Article 14 guarantees the right to freedom from discrimination and Article 15 provides for the right to equal protection of the law.

In addition to these Constitutional guarantees, India is party to several international conventions that uphold the right to health, reproductive autonomy, and the right to be free from inhuman and degrading treatment. The Convention on the Elimination of All Forms of Discrimination Against Women (CEDAW), the International Covenant on Civil and Political Rights (ICCPR), and the International Covenant on Economic Social and Cultural Rights (ICESCR) obligate the government of India to promote, protect, and respect the right to health.

National Rural Health Mission (NRHM)

The National Rural Health Mission (NRHM) was launched to strengthen public health systems in rural areas. NRHM’s aim is to provide effective health care to India’s rural population with a special focus on states that have poor public health indicators and/or weak infrastructure.

Through the NRHM, central government funds are provided to state governments to improve the state’s public healthcare systems. In this way, states bear the responsibility of identifying and assisting their most broken district public healthcare systems.

Indian Public Health Standards (IPHS)

In 2007 the government of India issued the Indian Public Health Standards (IPHS) for Sub-Centres, Primary Health Centres (PHCs), Community Health Centres (CHCs), Sub-District and District Hospitals. The aim of the IPHS is to create uniform standards to improve the quality of health care delivery throughout India.

Today, these standards are used as the reference point for essential public healthcare infrastructure, human resources, and for planning upgraded facility level designations. Although the IPHS norms are often treated as aspirational standards, they are the baseline against which essential manpower, services, and facilities are tested.

III. ISSUES OF MAJOR CONCERN

In order to investigate the status of Barwani District’s public health facilities, we visited several facilities of each level of care (primary, secondary, and tertiary) over the course of seven days (25th August – 31st August). The following is a list of the facilities we visited:

(a) Pati Community Health Centre (CHC)

(b) Civil Hospital (CH)

(c) Warla CHC

(d) Chachriya Pati Primary Health Centre (PHC)

(e) Balwadi PHC

(f) Dhanora PHC

(g) Niwali CHC

(h) Pansemal CHC

(i) Silawad CHC

(j) Palsood CHC (k) Rajpur CHC

(l) Barwani District Hospital (DH)

This section is based on our visits to these facilities and discussions with various staff members and users as well as corroborative information from other documents and studies. The focus of our observations is to determine the state of these facilities and report whether these facilities offer essential health services as per both the National Rural Health Mission scheme and India Public Health System norms. The following is a non-exhaustive list of major issues of concern observed at these facilities. Specific facilities have been identified under each issue of concern.

a. Shortage of Staff

There is a shortage of staff at every facility we visited. The shortage is prevalent at all levels of staff and at all levels of facilities. The shortage is most acute in periphery areas where some facilities function without a doctor depending instead on lower-level staff to manage and run the facility. This severe shortage in essential staff is in direct violation of both NHRM and IPHS standards. The shortage also requires frequent referrals of labor complications and emergency services to the nearest CHC or Barwani DH. The severe shortage of staff and dependency on referrals is impracticable in a district plagued by poor road infrastructure and even poorer transportation services, unsustainable given the high out-of- pocket expenses borne by Barwani District’s adivasi and below poverty line population (BPL). The shortage also costs the lives of many women who die before they can receive necessary medical treatment. This denial of treatment, whether purposeful or circumstantial, is a violation of the district population’s right to life as per Article 21 of the Constitution of India.

Dhanora PHC, which serves a population of 30,000 people and performs more than 20 deliveries per month, has been forced to function without a doctor since 2010. Without a Block Medical Officer (BMO), a single dresser who has no medical or management training manages the hospital. The rest of the PHC’s staff is comprised only of a single lab technician and an ANM.

Similarly, although Warla CHC functions under the purview of general doctor Sustia, he had been retired for years before he was posted to the CHC. Dr. Sustia has not practiced medicine since his retirement and has not been trained in Basic Emergency Obstetric and Neonatal Care (BMOC) since his reinstatement at Warla CHC. The remaining staff at the CHC is comprised of one Lady Health Visitor (LHV), one ANM trained in BMOC, one dresser, one compounder who is on indefinite leave, and one sweeper who works on contract. Entrusting a CHC that serves a population of 3,500 patients to an unpracticed and untrained doctor is negligent at best.

At Balwadi CHC, we spoke with homeopathic doctor Sanjai Palijan. The CHC is staffed with eight ANMs, one Lab Technician, one dresser, one sweeper, and one ward boy. However, all eight of the CHC’s ANMs are working in Barwani and the CHC functions without a staff equipped to handle deliveries or labor complications. Moreover, the CHC’s Lab Technician doubles up as the CHC’s Compounder and Registration Clerk. This shortage of staff undermines the National norms and is a personal affront to the population Barwani District’s public health system serves.

Silawad PHC was recently upgraded to a CHC, but this new designation is effective on paper only as the facility is severely ill equipped to function as a CHC. The CHC serves a population of 161,000 people and is managed under BMO Dr. G.S. Barela. Dr. Barela counts on one Lab Technician, two Lab assistants, and two general doctors who are rarely at the CHC, as per our interview with Dr. Barela. Recently, a second general doctor posted to Pati CHC shifted to Silawad CHC because of its lack of doctors per the population it serves. On a recent visit, the Chief Medical and Health Officer (CMHO) requested that the general doctor shift back to Pati CHC immediately. The CMHO neither took into consideration the lack of doctors at Silawad CHC nor proposed posting a second doctor at Silawad CHC to fill the shortage. This shuffling of doctors without due notice of the population they serve, the staff that supports them or their lack of infrastructure is myopic and utterly ineffective.

Even Barwani DH, which is often the facility of last resort for many periphery area patients, suffers from important medical staff shortages. Most negligently, the DH lacks a pathologist in its Blood Storage Unit (BSU). We spoke with BSU staff at length and found that they are performing lab tests they are neither authorized nor trained to perform. One of these, a blood cross-matching test requires a pathologist’s analysis before approval. Lacking a pathologist means that staff conducts and approves tests with uncertainty and feel liable for preventable mistakes. Most importantly, patients bear the brunt of these deficient services.

The lack of posted staff at all of the facilities we visited has a major negative effect on the whole of Barwani District’s public health system. When PHCs or CHCs operate without a doctor or essential staff, patients are denied emergency and specialty services. These patients are instead forced to travel long distances to the nearest facility that offers these services. Of all of the facilities we visited, only Barwani DH offered specialty services and a functional Operating Theatre. Although a few PHCs and CHCs had an operating theatre, it was only used for very minor surgeries and scheduled sterilization camps.

i. Effect on High Number of OPD Patients

The shortage of staff also has a major negative effect on the length and type of treatment afforded to OPD patients. Many of the facilities we visited treated hundreds of OPD patients on a daily basis although there was only doctor posted. Doctors are expected to manage the health facility and simultaneously provide treatment to each of these patients including diagnosis and prescribing necessary medications during their 6 hours worth of services. When the team visited Silawad PHC, Rajpur CHC, and Pansemal CHC it noted that OPD patients received about 2- minute’s worth of care, which included at most a blood pressure reading, a diagnosis with the use of a stethoscope, and prescription writing.

The doctors we spoke to at Pati CHC said they treated about 300 OPD patients a day during the off-season when they are only equipped and have enough time to treat 100 OPD patients per day. Similarly, Sendhwa CH reported treating between 200 and 250 OPD patients per day.

Using Sendhwa CH as an example of the kind of treatment an OPD patient can expect to receive on a day with low OPD numbers and two doctors at the health facility, he can expect to receive 3.6 minutes worth of medical attention. This is calculated as:

200 OPD patients per day/2 doctors = 100 OPD patients per doctor

100 OPD patients/6 hours of consulting per doctor per day = 3.6 minutes per OPD patient

This calculation assumes several factors: a) a low OPD average, b) that both doctors are present at the CH, and c) that both doctors do nothing else but treat OPD patients for 6 hours. These assumptions are impracticable and underlie the severe lack of adequate OPD care patients are receiving as well as the general overload of doctors.

This severe shortage in staff is endemic in a broken public health system, belies an acute lack of morale and support amongst facility staff, and creates a strong sense of distrust in the district’s population. This shortage also calls into question the implementation of the Janani Suraksha Yojana (JSY) program, which promotes institutional deliveries through a cash incentive scheme. Is it ethical that a government would incentivize institutional deliveries in ill-equipped institutions that do not provide essential medical services? Most importantly, this shortage in staff violates the patients’ right to life and essential health services.

Table Showing Shortages in Essential Manpower List for PHCs

Essential Man Power List for PHCs Balwadi Chachriya Dhanora

Personnel Type Type Type A Type B Type B A B

Medical Officer- MBBS 1 1 1 0 0

Medical Officer –AYUSH 1 1 0 0 0

Accountant cum Data Entry 1 1 0 0 0 Operator

Pharmacist 1 1 0 0 0

Pharmacist AYUSH 1 1 0 0 0

Nurse-midwife (Staff- 3 4 0 0 0 Nurse)

Health worker (Female) 1 1 0 0 0

Health Assistant (Male) 1 1 0 0 0

Health Assistant. 1 1 (Female)/Lady Health Visitor

Health Educator 1 1 0 0 0

Laboratory Technician 1 1 1 1 1

Cold Chain & Vaccine 1 1 0 1 0 Logistic Assistant Multi-skilled Group D 2 2 0 0 0 Worker

Sanitary worker cum 1 1 1 0 0 watchman

Total 13 14 3 2 1

List Showing Shortages in Essential Manpower List for CHCs

Essential Man Power List Pati Sendh War Niw Panse Silaw Palso Rajp wa la ali mal ad od ur for CHCs

Personnel Essenti al

Block Medical 1 1 1 1 1 1 1 1 1 Officer/ Medical Super- intendent

Public Health 1 0 0 0 0 0 0 0 0 Specialist

Public Health 1 0 0 0 0 0 0 0 0 Nurse (PHN) #

Essential Specialty Services Pat Sendh Warl Niwa Panse Silaw Palso Rajp List for CHCs i wa a li mal ad od ur

Personnel Essenti al

General 1 0 0 0 0 0 0 0 0 Surgeon

Physician 1 1 0 0 0 0 0 0 0

Obstetrician & 1 0 0 0 0 0 0 0 0 OBGYN

Pediatrician 1 0 0 0 0 0 0 0 0

Anesthetist 1 0 0 0 0 0 0 0 0

Essential General PAT Sendhw Warl Niwal Pansema Silawa Palsoo Rajpu Duty Officers List for I a a i l d d r CHCs

Personne Essentia l l

Dental 1 0 0 0 0 0 0 0 0 Surgeon

General 2 1 4 0 2 1 (absent 3 0 1 Duty w/o Medical leave) Officer

Medical 1 0 0 0 0 0 0 0 0 Officer - AYUSH

Essential Nurses and Pat Sendh Warl Niwa Panse Silaw Palso Rajp Paramedical Staff for i wa a li mal ad od ur CHCs

Personnel Essenti al

Staff Nurse 10 0 0 0 4 0 0 1 0

Pharmacist 1 0 1 0 0 0 0 0 1

Pharmacist – 1 0 0 0 0 0 1 0 0 AYUSH

Lab. 2 2 2 0 2 1 0 1 4 Technician

Radiographer 1 1 0 0 1 1 0 0 0

Dietician 1 0 0 0 1 0 0 0 0

Ophthalmic 1 1 0 0 0 0 0 1 0 Assistant

Dental 1 0 0 0 0 0 0 0 0 Assistant

Cold Chain & 1 0 0 0 0 0 0 0 0 Vaccine Logistic Assistant

OT Technician 1 0 0 0 0 0 0 0 0

Multi 1 0 0 0 0 0 0 0 Rehabilitation/ Community Based Rehabilitation Worker

Counselor 1 0 0 0 0 0 0 0 0

Essential Administrative Pat Sendhw Warl Niwal Pansema Silawa Palsoo Rajpu Staff List for CHCs i a a i l d d r

Personnel Essentia l

Registration 2 0 1 0 0 0 0 1 0 Clerk

Statistical 2 0 0 0 2 0 0 0 1 Assistant/Dat a Entry Operator

Account 1 0 0 0 0 0 0 1 Assistant

Administrativ 1 0 0 0 0 0 0 0 e Assistant

Essential Group D Staff Pat Sendh Warl Niwa Panse Silaw Palso Rajp List for CHCs i wa a li mal ad od ur

Personnel Essenti al

Dresser (cert. 1 0 1 1 2 1 0 0 1 by Red Cross/ Johns Ambulance)

Ward Boys/ 5 3 0 0 1 1 0 3 11 Nursing Orderly

Driver* 1* 1 0 0 1 1 0 2 1

TOTAL 46 11 10 2 17 6 5 10 22

b. Lack of Funds to Hire and Retain Essential Staff

Under the government Reproductive and Child Health programme, patients are required to pay user fees when they receive medical services. These user fees are then used to hire and retain essential staff at all facility levels. Several of the facilities we visited, however, reported that RCH funds are being used to purchase medicines that are in short supply.

Sendhwa CH, which serves a population of 350,000, stated that it has had to use its RCH funds to purchase necessary medicines because the government is not providing them. This means that the CH has to forego hiring essential lower-level personnel. The misuse of these funds results in a general lack of staff or in staff hired at below minimum wage on a contractual basis. Again, patients bear the cost of this administrative misuse in funds as a shortage in staff results in a shortage of essential services.

c. Faulty Upgrade of PHCs

Two of the facilities we visited were recently upgraded from PHCs to CHCs. However, this new designation is only effective in theory and not in practice. These upgrades have created non-functioning PHCs, severely ill equipped CHCs, and a lack of access to essential medical services in periphery areas.

Silawad PHC, now, CHC, serves a population of 161,000 people. The facility does not offer any essential specialty services and functions under the supervision of BMO Dr. G.S. Barela with the support of a small number of staff. Nevertheless, the CHC handles between 60 to 70 deliveries per month as well as weekly sterilization camps. The CHC only counts on one staff nurse even though CHCs are meant to have at least one gynaecologist and 10 Staff Nurses. Silawad CHC also operates without other essential staff including a general surgeon, physician, paediatrician, anaesthetist, pharmacist, and dresser.

Moreover, although CHCs are supposed to have at least 30 beds in their facility, Silawad CHC has only six beds. Although Silawad holds a sterilization camp every Tuesday for between 10 and 50 women, it has no operating theatre. The CHC also functions without an x-ray room, pharmacy, or blood storage unit. Although the CHC has a functioning lab, the lab only provides haemoglobin, urine, tuberculosis, and pregnancy tests.

Another PHC was recently upgraded to a CHC without human resource or infrastructural support. Palsood PHC, now CHC, serves a population of 31,000 people. The CHC lacks a Physician, Gynaecologist, Pediatrician, Anesthetist, Pharmacist, and Dresser. As such, the CHC does not offer emergency or in-patient services (IPD). Instead, the CHC provides tertiary-level care for ailments including hypertension, respiratory complications, and anaemia before referring these to Barwani DH.

Palsood CHC only has six beds although it ought to have at least 30 beds. It lacks an Operating Theatre and presumably holds its sterilization camps in its labour room. Moreover, the CHC functions without an x-ray room, pharmacy, or BSU. The CHC lab only provides urine, tuberculosis, malaria, and STD tests.

The designation upgrade of these PHCs not only results in an ill equipped CHC but also undermines the fact these facilities are also ill equipped PHCs. The upgrades are done in name only as they are not accompanied by an increase in manpower, expansion in services, or improvement in facilities. If the purpose of these upgrades is to serve a wider population of patients, they have failed miserably.

The Operation Theatre at the newly upgraded Silawad CHC.

d. Lack of Space for Essential Medical Services

In order to provide essential medical services to its patients, facilities require a facility suited to hold essential laboratories, operating rooms, offices, labour rooms and so on. Many of the facilities we visited, however, function without sufficient space for essential services. This results in an overflow of service spaces and the misuse of severely unhygienic spaces.

We interviewed with doctors who use the same consulting desk to treat OPD in Silawad PHC, Rajpur CHC, and Pansemal CHC because these facilities lack sufficient space to a) provide each doctor with their own consulting desk or office or b) afford patients with any semblance of privacy.

When we visited Chachriya Pati PHC, which provides routine urine tests as well as sputum testing for tuberculosis and blood smear examinations for malaria diagnosis, we found that the PHC’s laboratory had no designated room. More alarming, the lab technician is forced to use space in a nearby bathroom to store blood samples and necessary test solutions.

This lack of space underscores the serious deficiency in facilities and lack of district support to provide facilities with essential infrastructural support.

Bathroom space used to house Chachirya’s laboratory.

e. Non-Registered Pharmacists Dispensing Medicine

On July 25, 2012, the Pharmacy Council of India issued order Ref. No. 12-8/2005-PCI. That order, which took immediate effect, prescribed minimum standards of education required to qualify as a pharmacist and enumerated specific course requirements. Most importantly, in paragraph No. 6, it stated, “[N]o person other than a registered pharmacist shall compound, prepare, mix, or dispense any medicine on the prescription of a medical practitioner,” and any person found in violation of this mandate, “shall be punishable with imprisonment for a term which may extend to six months, or with fine not exceeding one thousand rupees or with both.” Notwithstanding the issuance of this order, we visited several facilities where non-registered pharmacists act as compounder, dresser, and dispenser.

At Pati CHC, which serves a population of 140,000 people and treats on average 300 OPD patients daily, the health centre’s X-ray technician also operates as storekeeper and medicine dispenser. This is in direct contravention of the above referenced order, which outlaws the dispensing of medicine by a non- registered pharmacist. Nevertheless, patients require the medicines that have been prescribed to them and due to a lack of essential staff, e.g., a pharmacist, facilities have no other option but to double up on personnel. Similarly, at Balwari PHC, the facility’s Dresser also acts as compounder without authorization or required education requirements. Niwali, a CHC that serves a population of 120,000 people, also functions with two Dressers who perform the functions of a Compounder.

This doubling up of personnel is first and foremost endemic to a severe shortage in staff and training. Allowing facilities to operate with registered pharmacists is not only grossly negligent but also actionable under the Pharmacy Council of India’s order.

f. Lack of Medicines

Every facility we visited lack many essential drugs as per the IPHS norms. Most alarming, these facilities lack basic medicines including insulin, paracetamol, and anti-snake venom and anti-rabies medicines. A facility that lacks these very basic drugs is, in essence, not a functional facility.

According to the facilities we visited and documentation the CMHO’s office provided us, Barwani District does not have Insulin injection solubles at any of its Sub-Centre, PHC, or CHC facilities though it has it available at Barwani DH. This shortage also applies to paracetamol tablets: documentation shows it is not available in Sub-Centre, PHC, or CHC facilities but is available at Barwani DH. Finally, only one facility we visited, Niwali CHC, claims to have both anti-snake venom and anti-rabies medicine, while Silawad CHC claims to have anti-snake venom medicine.

One troubling piece of information we learned from documentation the CMHO’s office provided to us is that neither Barwani DH nor district public health facilities are stocked with oxygen inhalation cylinders. This is especially troubling because several of the facilities we visited claim they have oxygen cylinders. These facilities included Silawad CHC, Rajpur CHC, and Barwani DH. This misinformation stems from miscommunication between facilities and administration, concealment on the part of public health facilities or concealment on the part of administration. Regardless, oxygen cylinders are essential to a functioning facility.

g. Patients Forced to Purchase Essential Medicines Out of Pocket

All of the facilities we visited claim that medicines are provided to patients free of cost. However, when we visited Sendhwa CH, maternity patients we spoke to claimed they have to pay for essential medicines out of pocket. Schemes like Janani Shishu Suraksha Karyakram (JSSK) are meant to assist pregnant women to receive essential prenatal health care services by providing them with essential services and medicines free of charge. Nevertheless, patients at Sendhwa CH claimed they have to pay for their medicines in contravention of the JSSK scheme. Most alarming, these patients report paying as much as Rs. 2,000 in order to receive the essential medicines prescribed to them.

h. Poorly Functioning or Non-Existent Blood Storage Units (BSU)

None of the facilities we visited have a functioning BSU except Barwani DH. This is an alarming fact especially in light of the district’s high prevalence of anaemia. In fact, anaemia is the leading cause of maternal deaths and many women present at health facilities with haemoglobin levels as low as two or three Hb counts. Notwithstanding, facilities continue to operate without a BSU.

Barwani DH is the exception as it has a functioning BSU. Nevertheless, when we spoke to the BSU staff we learned of an alarming lack and misuse of blood supplies, an essential staff shortage, and a general lack of space. There was a recently documented case of woman with two or three Hb counts who was referred to the BSU with a request slip that failed to note the urgent need of the blood transfusion. The woman was denied a blood supply because the BSU was never alerted to her extremely low Hb count. The very next day, a doctor referred a patient to the BSU with a request slip that read “Urgent” even though she had presented with a much higher Hb count. This woman was provided with a blood supply. We were told that stories like these are the norm. Doctors fail to note the urgency of the blood supply, personal favours or connections take precedent over medical urgency, and communication between different medical wards and offices are non-existent.

We also learned from staff that the shortage in blood supplies for public health patients comes at the expense of blood supply provided to private health facilities through a private pay-for-services program between public health facilities and Barwani DH. This private agreement results in select public health facility patients being referred to private health facilities and then receiving preference over public health patients when they are referred to the BSU. As ever, this source of corruption costs the lives of patients, in direct violation of both national and international human rights norms, and creates a pervasive lack of confidence in the Barwani District Public Health System.

i. Lack of Reliable Transportation

All of the facilities we visited offer referral services for emergency services and complicated labours. Most referrals originate in periphery PHCs or CHCs and are sent to Barwani DH. Correspondingly, Barwani DH offers referrals to Indore for patients requiring a higher level of health care.

In a public health system that provided free and reliable transportation for these referrals, this situation would not result in numerous avoidable deaths and many more indebted patients. However, this is not the case in Barwani District’s public health system. Most all of the facilities we visited, including Barwani DH, complain of its transportation services and acknowledge that the situation is dire.

Pati CHC, for example, has access to both an ambulance and a Janini Express (JE) but neither of these was functional. The ambulance has been out of order for the last seven months and the JE has been out of order for the last four to five months. Instead, the CHC is forced to rely on a JE stationed in Bukhrata.

The out-of-order JE parked outside Pati CHC.

Both Palsood CHC and Silawad CHC have access to both an ambulance and a JE but their respective ambulances have been out of order for months. These facilities depend on the availability of a JE in moments of urgent medical care.

Barwani DH, which has access to three ambulances, is no better off. Although all three ambulances are functional, one runs on petrol and another is equally expensive costing the patients it transports around Rs. 32,000 for a round-trip to and from Indore.

In a system where periphery and lower-level facilities lack essential staff, diagnostic services, and medicines, referrals are frequent. Thus, patients depend on transportation services to deliver them to the nearest facility equipped to treat them. Unfortunately, more often than not, patients are forced to choose between receiving inadequate medical care or paying substantial sums of money for transportation. This is to say nothing of the distance these patients are forced to travel over very poor road conditions.

j. Sterilization Camps (diverting doctors, no transportation or recovery provisions for women)

All of the facilities we visited reported hosting family planning camps and several of the facilities we visited were hosting sterilization camps. One doctor at Rajpur CHC noted that Barwani District has a sterilization target equal to 1% of its population, which as of the latest census is 13,857 people. He also expressed that district facilities are feeling pressure to meet their targets and are increasing the number of camps they offer. Although women presumably give their consent to participate in these camps in return for cash incentives, the camp’s procedure is essentially a personal and violent attack on these women.

The first sterilization camp we came upon was at Balwadi PHC on a Tuesday early afternoon. We noted the large number of women crowding the PHC’s hallways. Speaking to the ayurvedic doctor on staff, he reported that Dr. Seriwal performed all of the sterilizations at Balwadi PHC and traveled around the whole of Barwani District performing sterilization camps at facilities including Sendhwa CH and Niwali CHC. The ayurvedic doctor explained that Dr. Seriwal performs sterilizations for up to two hours on an average of 50 to 100 women and then travels to other sterilization camps leaving his patients to regain consciousness three to four hours after their operations. That day at Balwadi PHC, the team noted there are not enough beds to host the women while they regain consciousness and nor are there any transportation provisions for the women once they need to travel home.

The room where sterilizations are carried out at Balwadi PHC.

Women waiting to have their sterilization operations at Balwadi PHC.

The team noted the same at Rajpur CHC where it witnessed a group of over 50 women waiting to be sterilized. The doctor had been expected to arrive in the morning hours but was nowhere to be seen when we arrived at 4:00 pm. One of our team members spoke to the women who complain of having trouble receiving their incentive payments and of having to wait so long on the doctor. The doctor arrived at the CHC just after 5:30 pm and was still operating on women when we left the CHC around 7:30 pm. The procedure, as perceived, was harrowing. The women are taken into the operation theatre, put under a strong anaesthesia, operated on for no more than five minutes depending on the number of women present at the camp, then carried out of the room and laid on the hallway floor, covered with a cloth and left there for up to four hours until they regain consciousness. The earliest any of the women at Rajpur CHC would have regained consciousness after her operation would have been 9:00 pm. As at Balwadi PHC, Rajpur CHC has insufficient beds for the number of women at the camp. Also alarming is the total lack of transportation provisions afforded to the women who would be disoriented and in pain after their operations. Finally, if a simple calculation is conducted, one can note that the doctor spends a total of 2.4 minutes operating on each woman. The calculation is as follows:

50 women at the Rajpur CHC camp/1 doctor operating for 120 minutes = 2.4 minutes per woman

Women still waiting to have their sterilization operation under a clock showing the time is 4:40 pm.

After their operation, women are laid out in the hallway for hours before they regain consciousness.

k. Lack of Maternal Death Reporting and 15-49 Maternal Deaths Reporting (woman died while Commissioner Visited)

Although many of the facilities we visited keep a register of the deaths occurring at their facilities, very few of them have either a Maternal Death Reporting (MDR) or 15-49 Death Reporting procedure in place. Both of these statistics are of course integral to understanding the cause of death for patients but, more importantly, they are illustrative of the deficiencies in medical health facilities and infrastructure in the District. Most of the facilities we visited do not have an institutionalized MDR or 15-49 Death Reporting system in place. Many of the reports we were provided are deficient in their reporting. For example, many of the reports do not note the 3rd delay that caused the patient’s death and instead use vague reasons for the patient’s death. There is also no follow-up on the deceased patient’s family.

Documents provided to us by the Nodal Officer of Community Based MDR and Facility Based MDR shows that between 1st April and 28th August only six MDR were prepared and reported to the office. Of these, two deaths that occurred in May and June are still under audit. The Facility Based MDR reports that only nine women have died between 1st April and 28th August. Most of the deceased were in their first pregnancy and ranged from 17 years of age to 35 years of age. The noted reasons include “severe anaemia with lobar pneumonia” and “eclampsia with acute renal failure.”

l. Lack of Hygiene at All Facilities and Faulty Waste Management System at Barwani DH

All of the facilities we visited are severely unclean and unhygienic. Many of the facilities sit adjacent to dirty standing water and overflowing trash pits. One staff person we spoke to said that medical waste was thrown in a pit very near the facility because the facility had no waste management system.

At Pati CHC we noted that the labour room was unclean even when no delivery was being performed. Its door was locked but the team saw bloodstains on the floor, presumably from a recent delivery that had not been cleaned after. Standing bloodstains are extremely unhygienic. Moreover, the CHC’s labour room should be kept clean at all moments. Standing blood beneath delivery table

The unhygienic labour room at Pati CHC.

The space adjacent to Pati CHC’s new building where we witnessed farm animals graze and defecate.

A wild pig sifting through a trash pit adjacent to Pansemal CHC.

The situation is no better at Barwani DH. Barwani DH has a Waste Management System that collects all obstetric and operating room waste to be incinerated in Indore. Nevertheless, we noticed a staff woman drying, organising, and re-storing used latex gloves that had been used in the women’s hospital ward labour room. Moreover, we noticed trash piles very near the women’s hospital. These piles are littered with medical waste and easily accessible to anyone walking by.

A staff person sorting out used labour room latex gloves for re-use.

A similar process of re-using labour room latex gloves is used at Sendhwa CHC.

The waste management system in place at these facilities is deficient and risks the health of people who might come upon waste pits near the facility.

Used blood supply bag

A dirty box of syringes

A pile of trash just metres outside the women’s hospital at Barwani DH. Note the trashed box of syringes and the blood supply bag strewn amongst the waste.

RECOMMENDATIONS

It is clear that the public health system in Barwani District is broken and in need of effective changes and substantial improvements. The following are recommendations to the State of Madhya Pradesh, Chief Medical and Health Officer of Barwani, Collector of Barwani District and others. These are meant to be undertaken at both the local and state level by all affected stakeholders and in conjunction with programmes proposed by the government itself.

1. Implement a strong and expansive system of communication between all facilities and stakeholders; 2. Ensure that essential doctors are recruited and retained at all facilities; 3. Ensure that essential paramedical, administrative, and Group D personnel are recruited and retained at all facilities; 4. Ensure that all facilities offer all essential medical and diagnostic services as per NRHM scheme and IPHS norms; 5. Keep inventory of medical machines used at all facilities and ensure they are functioning properly; 6. Ensure that a registered pharmacist is posted at all facility levels; 7. Keep an accurate inventory of medicines and ensure that all facilities have essential medicines in stock; 8. Investigate reports of patients forced to purchase medicines out of pocket, provide redress, and ensure no patient is forced to purchase medicines out of pocket in the future 9. Ensure all facilities have a functional BSU with sufficient blood supply and that a pathologist is posted to each BSU; 10. Maintain an up-to-date register of maternal deaths and 15-49 maternal deaths reporting system; 11. Maintain an up-to-date register of referrals; 12. Keep register of ambulances and ensure they are all functioning; 13. Provide infrastructural and human resources support to upgraded facilities; 14. Allow Pansemal CHC to refer complications and emergency services to nearby public health facilities in Maharasthra instead of transporting patients to nearest Madhya Pradesh public health facility; 15. Ensure that sterilization camps guarantee that women have transportation services available to them at no cost; and 16. Ensure that women who participate in sterilization camps receive their promised cash incentive at the time they undergo their tubectomy.