Assessment of Primary Laboratory Facilities for Rural Health Care Preparedness in Osmanabad District, India

Assessment of primary laboratory facilities for rural health care preparedness in Osmanabad District, India Rahi Jain1 and Bakul Rao2 1Centre for Technology Alternatives for Rural Areas (CTARA), Indian Institute of Technology Bombay (IITB), Mumbai, India-400076, Telephone:+91 9869762701, [email protected] 2Centre for Technology Alternatives for Rural Areas (CTARA), Indian Institute of Technology Bombay (IITB), Powai, Mumbai, India-400076, Telephone:+91 9619182552, [email protected] Corresponding Author: Rahi Jain, Centre for Technology Alternatives for Rural Areas (CTARA), Indian Institute of Technology Bombay (IITB), Powai, Mumbai, India-400076, Telephone: +91 9869762701, [email protected] Acknowledgement We would like to acknowledge the support provided by the Dr. Prashant Narnaware, District Collector, Osmanabad, Maharashtra for granting us permission and providing support during the stay in Osmanabad. We would also like to acknowledge the support of District Health Office, Osmanabad, Maharashtra and all the respondents for their support. Funding: None Conflict of Interest: The authors declare that they have no conflict of interest. 1 Assessment of primary public laboratory facilities for rural health care preparedness in Osmanabad District, India Abstract Government of India has provided Indian Public Health Standards to improve rural health care services and health status, but still rural laboratory is a cause of concern. This study is performed to understand the laboratory facility-level gaps that need to be addressed to improve the public primary health centers (PHCs) present in rural areas. The laboratory assessment is performed for governance, financing, resources and services and results are validated with the PHC laboratory performance. The current assessment shows critical gaps in the facilities regarding governance, services, resources and financing required for the laboratory services at the rural primary health care level. Governance and services need to be strengthened the most followed with sustained availability of resources and financing. Poor health status in rural areas necessitates public health response based on health systems. Therefore, health system preparedness in form of laboratory services are essential in primary health care facilities. Keywords: health care facility; facility preparedness; public laboratories; rural health; India; Bayesian Network 1 Introduction The rural areas in India hold records for 80% of all deaths and nearly 90% of deaths due to communicable diseases, as well as records for maternal, perinatal, and nutritional conditions (Office of Registrar General, 2009). Prevalence of poor health care risk factors (unhealthy diet, reduced physical activity, smoking, hypertension, poor food quality) is increasing and recent studies showed that hypertension and diabetes in 40% (Devi et al., 2013) and 10% (Nazir et al., 2012) of adult Indians respectively. Risk factor control requires multi-disciplinary approach that includes strengthening health system, approaching social determinants of health and health care financing (Gupta et al., 2011). Majority users belongs to economically weaker sections (Pandey et al., 2017; Ranson et al., 2012), which hinders their access to private facilities that are not always affordable. This makes public health care system more responsible 2 for the rural health care. In accordance with the Alma Ata Declaration (World Health Organization, 1978), India focused on providing primary health care facilities to rural areas. India launched National Rural Health Mission (NRHM) in 2005 to provide preventive and basic curative and laboratory health care services in rural areas for the major health issues (MoHFW, 2005). It aims to provide rural health care services and integrate horizontally all vertical disease-based programmes at district level. Primary health care system in rural India has Primary Health Center (PHC) with catchment area of 30000 rural population, which is first point of contact for i) laboratory services, and ii) medical doctor/officer (MO) in rural areas (MoHFW, 2012). NRHM provides Indian Public Health Standards (IPHS) to maintain the PHC quality (MoHFW, 2012). However, over the years PHC have focused on providing the preventive, childbirth and treatment services in rural areas, as a consequence it is possible that certain key aspects of laboratory services are neglected. Medical laboratories strengthen the health care system by providing up to two-third of medical decision making (Forsman, 1996; Khatri and Frieden, 2002). The current study was performed to understand the functioning and preparedness of laboratory facilities in PHCs using Osmanabad District, Maharashtra, India as case study. 2 Method 2.1 Settings The Osmanabad district has eight blocks (Talukas) with 84% of the entire district’s population (1.7 million) inhabiting in rural areas (Office of Registrar General and Census Commissioner, 2011). It is one of the India’s drought prone districts (Gore et al., 2010), so rural areas do not have access of 24*7 water supply. All villages are electrified (Rural Electrification Corporation Limited (RECL), 2017), but power cuts are common in villages. The district has secondary and primary health care facilities, but do not have any tertiary health care facility like medical colleges, speciality hospitals. The urban areas have secondary health care facilities 3 i.e., one District Hospital, one Maternity and Child Hospital, three Sub-district hospital and seven Community Health Centers (CHCs). The rural areas only have primary health care facilities that consist of 206 SCs and 42 PHCs. The interaction with District Health Office (DHO) bureaucrats and health care facility staff suggests that PHC pharmacists and DHO bureaucrats do the district level budget making for the rural laboratory facilities. The budget making is done based on past field experience and does not involve use of any mathematical model or representation from laboratory experts or staff. 2.1.1 Services DHO focuses only on haemoglobin, HIV, malaria, tuberculosis, pregnancy, urine albumin, urine sugar, blood sugar, and blood group tests services of laboratories in PHCs. All tests, except malaria, and tuberculosis, are kit-based tests that provide results in 1–2 minutes. The remaining two tests are microscopy-based tests and provide results in 10 minutes. Quality assurance is performed only for malaria and tuberculosis tests with 2–3% of the monthly tested samples are sent to district malaria and tuberculosis offices respectively, to crosscheck the results. The district biomedical waste management involves four steps: waste segregation, disinfection, closed dumping, and deep-pit incineration. Alternatively, instead of incineration, waste can be given to a biomedical waste collection agency. The PHCs have cleaning staff to maintain PHC cleanliness including laboratories. The other basic services provided are seating and toilet facilities. The PHCs provide services of collecting patient malaria and tuberculosis sample from home, SC as well as from PHC OPD and inpatient department (IPD) and send the sample to the nearest public health facility for testing. The OPD hours are based on local need to increase laboratory access. The morning timing to start OPD vary from 8:00 am to 9:30 am, while evening OPD is started at 4:00 pm across all PHCs. Additionally, laboratory sample testing starts almost simultaneously upon laboratory sample collection. The test results and report delays depend on test type and the laboratory location. Kit-based tests have lower time delays when compared to the other tests. Further, time delays are less when PHC has laboratory in its premises as compared to PHC 4 not having laboratory in its premises. 2.1.2 Resources The resources are provided by DHO, but PHC can procure resources using RKS funds to meet its emergency or unique local needs. In case of consumables, the procurement process for laboratory consumables is manual and is initiated by the PHC Pharmacist. Pharmacist prepares an indent form, obtains MO approval and takes approved form to DHO inventory store. The store clerk approves the form and provides stock to the pharmacist, who brings it back to the PHC. The laboratory instruments maintenance takes 1–15 days after repairperson/engineer examines the instrument. The repairperson/engineer is accessed through either routine maintenance or non-routine maintenance mechanisms. Routine maintenance involves periodic checks (once per 1–12 months) of the instruments to minimise breakdown. It can be done either by supplier or higher authorities. Non-routine maintenance requires that the PHC or LT take initiative to repair instruments, which is done by either contacting supplier/private repairperson or higher authorities. If the instrument is under an annual maintenance contract, the supplier repairs the instrument, otherwise, the instrument can be taken to any local private repairperson. Higher authorities can respond to the PHC’s needs within 1–180 days, as the repairperson either visits PHC or PHC takes an instrument to a repairperson/higher authority office. The PHC data management is done both manually and electronically using registers and online software (like District Health Information System [DHIS] and Maternity and Child Tracking System [MCTS]) respectively. Manual records are more comprehensive and less accessible for higher authorities than electronic data. Only summary of manual records is sent to higher authorities. Some of the

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