ACCESS TO HEALTH CARE IN POST LIBERALISATION INDIA A CASE STUDY OF KANAKLATA CIVIL HOSPITAL SONITPUR

Transcription

1 ACCESS TO HEALTH CARE IN POST LIBERALISATION INDIA A CASE STUDY OF KANAKLATA CIVIL HOSPITAL SONITPUR 1

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3 Contents 1. Introduction: 5 2. Impact of liberalization and privatization on maternal health situation in Assam: Causes of maternal deaths: 11 I. Economic and Social Status: 11 II. Early Marriage and Childbearing 12 III. Institutional Failure: 12 IV. Poor ante natal care and post natal care: 12 V. Other factors: Strategies to prevent and reduce MMR in the country 14 a) Centrally sponsored schemes/policies: 14 b) State sponsored maternal schemes: 16 c) International legal framework on public health: 17 d) Constitutional Provisions and Supreme Court Guidelines in relation to public health: Indian Public Health Standards Guidelines: an Introduction IPHS guidelines for District Hospital: Sonitpur District Profile: Findings: 27 I. Physical Infrastructure: 28 Size of the hospital: 28 II. Hospital Building: 28 III. Departmental Lay out Clinical Services: 31 Outdoor Patient Department (OPD) 31 Clinics 31 Clinical Laboratory: 31 Blood Bank: 32 IV. Intermediate Care Area 32 3

4 Indoor Patient Department: 32 Pharmacy (Dispensary) 33 V. Delivery Suite Unit 34 VI. Post Partum Unit: 35 VII. Other Amenities: 35 VIII. Hospital Transport Services: 36 IX. Manpower Requirements: Major issues of concerns: Conclusion: 40 4

5 1. Introduction: Access to health care is an important component of health sector in India. By health care we mean: Ensuring equitable access for all Indian citizens, residing in any part of the country, regardless of income level, social status, gender, caste or religion, to affordable, accountable, appropriate health services of assured quality (promotive, preventive, curative and rehabilitative) as well as public health services addressing the wider determinants of health delivered to individuals and populations, with the government being the guarantor and enabler, although not necessarily the only provider, of health and related services- Planning Commission of India. After independence efforts were made to invest on education and health apart from the other sector. Various health policies and schemes were adopted to make health services available for the all. Health policies during post independence had two major thrust: Firstly, to build an infrastructure and to provide basic medical care, maternal and child health services; Secondly, to develop specific national health programmes to control communicable diseases, provide family planning services and control severe form of nutritional deficiencies. 1 With the introduction of New Economic Policy (NEP) in 1990, India accepted the private capital inflows in the market. Slowly, India started to privatize health care system in India and accepted the Structural Adjustment Polices (SAP) of International Monetary Funds (IMF) and World Bank for development. 2 The main 1 Qadeer I. Health cares systems in transition lll, India Part l, The Indian Experience: Journal of Public Health Medicine: Vol. 22, No1 2 ibid 5

6 aspect of IMF- World Bank inspired reforms were: cuts in health sectors investments, opening up of medical care to the private sector, introduction of user fees and private investments in public hospitals, and purely technocentric public health interventions, During this period we can see that private companies are playing an important role in health sector. This increases the medical care expenditures for the people. Under such situation there remains a doubt as to whether government succeeded in providing health care services to all. Also, in post liberalization and privatization era in India many policies and schemes had a paradigm shift. Now such policies instead to addressing the common cause now are driven by profit driven motives. For eg: Family Welfare Policy (FWP) which was adopted in 1980 with the objective of combating child, infant and maternal mortality now focused on coercive population control by introducing technocentric and unsafe approaches to reduce the fertility rate and affecting women health. Such technological approach was introduced to combat communicable diseases. But this leads to cost effectiveness of individual patient care rather than maximimzing population coverage. 3 Considering this background into account and attempt has is made to analyse the health care services in Sonitpur district of Assam. To measure the health care services in the district we have conducted a fact finding to Kanaklata Civil Hospital of Tezpur and evaluate the health care services provided by the hospital. Section 1 will look at the maternal health situation in Assam in the post liberalization era. Section 2. We will present a case study of health care services provided Kanaklata Civil Hospital based on Indian Public Health Standard (IPHS) 3 Qadeer I. Health cares systems in transition lll, India Part l, The Indian Experience: Journal of Public Health Medicine: Vol. 22, No1 6

7 2. Impact of liberalization and privatization on maternal health situation in Assam: In the post globalization era IMF and World Bank adopted a new Structural Adjustment Program (SAP) in India and other parts of the country. The main objective of SAP is to cut down the budget in food and education, privatization of state owned industry, reducing duties and tariffs so that transnational companies can sell their products at a higher prices and export of the products in the international market at cheaper price. 4 As a result health sector was also affected adversely. During this period there was slash in the health budget and making the health services inaccessible to the poor, privatization of medical care and health policies started focusing on curative care instead of preventative care. Post liberalization there was stagnation of growth in the infrastructure. Limited resources were provided for the maintenance of hospitals and health, improving the referral system, making the medicine available for the people, appointments of doctors. In the absence of medicines, doctors, and basic infrastructure people are forced to avail the services provided by the private companies. 5 By reducing the health expenditure the government accepted the heavy capital inflow from the market. During this period women health was adversely affected because ethnocentric reproductive and child health strategy was adopted. Such approach focused on the population control services, services to promote safe motherhood and child health, establishment of referral system, sexual education and counseling, etc. Thus, through technocentric approach it has narrow its scope to contraception, maternal 4 Senguota A. : Health in the age of Globalisation: Economic and Political Weekly. 5 Qadeer I, Health care systems in transition lll, India, Part l, the India experience: Journal of Public Health Medicine: Vol 22 No.1 7

8 and child health, nutrition, services for RTIs and STDs, AIDS, abortions, and sterility. Further such approach was adopted by World Bank in Family Planning services as a necessary input to improve women health 6 Thus in order to combat high rate of population in India women are being targeted to promote populations control services by the transnational and multinational companies. During this period i.e. post liberalization the union government puts more emphasis on family welfare than on public health. Less attention was focused to prevent maternal deaths and making health services available to pregnant women. There was wide range of criticism and debate from feminist group, health workers, and academicians to include reproductive health as women centric in health policies. As a result Millennium Development Goal (MDG) was adopted in 1994 Cairo conference to reduce maternal mortality in the country along with the objective to end poverty by But here the question did India achieved in attaining the MDG? Every year 130,000 mothers die during childbirth every year. The National Health Policy (NHP) 1983 target for 2000 was to reduce Maternal Mortality Rate to less than200 per 100,000 live births by However, 407 mothers die due to pregnancy related causes, for every 100,000 live births even today. 7 Now, the focus is on reducing maternal mortality rate in the India. India has highest number of maternal mortality rate. The WHO defines maternal death as: 6 Qadeer I: Reproductive Health : A public health perspective: Economic and Political Weekly Vol. 33, No. 41 (Oct , 1998) 7 Globalization and Health: Towards National Health Assembly ll; Booklet- 1 8

9 the death 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 8. Assam has the highest number of maternal deaths as against the country. The maternal mortality rates for the year are shown below: Figure 1: Maternal mortality rate of India Source: Office of Registrar General, SRS ( ) Thus, form the above chart it is clear that Assam recorded highest number of maternal mortality ratio (MMR) with 328 for the year when India s total MMR was 178. However, according to the data of the Registrar General office of India, though the MMR has declined by 16 % from 212 during to 178 during and is likely to reach 140 by 2015 itself, but it is a big challenge to reach Millennium Development Goal (MDG), i.e. 109 per 100,000 live births by end of The following chart shows the declining trend of MMR for the year International Classification of Diseases, 10th Revision, Geneva, World Health Organization,

10 Figure 2 shows the trend of MMR from Though the above figure shows the declining trend in MMR, Assam contributes the highest number of maternal deaths. According to the Sample Registration Survey (SRS) from , the total maternal mortality rate is 167 per 100,000 live births. The World's Mother s report, released in May 2013, by Save the Children, ranked India 142 out of 176 countries. This ranking was developed on the basis of five indicators such as maternal health, children's wellbeing and educational, economic, and political status of women in the country. As per the Annual Health Survey report of , 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 indicate the tragic and desperate maternal health scenario in all of Assam. As per DLHS-3 ( ) data, approximately 40 percent of deliveries in Assam are attended by a trained health worker while the all India data is 52.7 percent. Antennal care (ANC) is one of the important components of improving the maternal health situation. According to the DLHS-3 report, 75 percent women 10

11 received an ANC check up in India, and whereas in Assam, it s near 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) increased from 16.4 percent (DLHS-2) to 18.8 percent (DLHS-3), the statistic is not satisfactory. As recorded in DLHS-3, only 39.4% of women have gone through ANC in their first trimester, only 45% has taken 3 or more ANC and only 32.8% women have taken post ANC within the two weeks of delivery. Unfortunately, Assam continues to remain the State having the highest Maternal Mortality Ratio (MMR). The data released by the Assam National Health Mission shows that 1,155 maternal deaths were reported from April 2014 to March 2015 while the number of deaths between April 2013 and March 2014 was 1,356. According to the data, the state recorded 1,265 maternal deaths in and 1,141 in Causes of maternal deaths: According to a 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. The WHO also reported that in India the main cause of maternal death are post-partum haemorrhage, anaemia, eclampsia, obstructed labour and sepsis. Moreover, other causes are lack of medical assistance, delay occurred at the health care facility or delay in reaching a health care facility. I. Economic and Social Status: 9 Maternal Death Falls in Assam : The Telegraph dated 1st June, 2015: available in the following link: 11

12 The guidelines on Maternal and New Born Health Care reports, Women in poor households have reduced access to nutrition, rest, health education and healthcare which are essential for safe pregnancy. Such women are also likely to be more malnourished and anemic with greater risk of dying as a result of hemorrhage. 10 II. Early Marriage and Childbearing 11 Pregnancy in younger women tends to develop more complications during pregnancy and delivery that sometimes lead to death. Inadequate spacing between two children and frequent childbearing leads to neonatal mortality. III. Institutional Failure: The state violates women s right to health when it fails to ensure available and acceptable health facilities. Through our fact finding we found out that there is lack of ambulance services, lack of specialists and doctors at CHCs and district hospitals, and a lack of medicines at PHCs/CHCs/District hospital. IV. Poor ante natal care and post natal care: Poor antenatal 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 Assam only 7.9% women had received total Operational Guidelines on Maternal and New Born Health, NRHM 11 ibid 12

13 ANC, 45% received 3 pre Antenatal Care (ANC) and 32.8% natal check up. women received post V. Other factors: Lack of awareness about maternal health is another reason for maternal mortality. Most women die due to causes related to pregnancy, childbirth and abortion. It is Source: Register General of India, 2013 unfortunate that a large number of maternal deaths occur due to hemorrhage, obstructed labor and unsafe abortions; while safe and affordable technologies to prevent such deaths exist. Access to skilled assistance and well equipped health institutions during delivery can reduce maternal mortality and improve the entire health scenario. Poor connectivity to the nearest health centre is also a cause of the high MMR in Assam. The road conditions are so pathetic that it becomes painful for a pregnant woman to travel and get medical assistance, so basically most of the women prefer institutional deliveries instead of deliveries at home. In order to improve the maternal health situation in the country few policies and schemes were introduced. Let us look at government intervention in order to prevent maternal morbidity in the country and the state. 13

14 3. Strategies to prevent and reduce MMR in the country The increasing MMR in the country became a serious issue of concerns. Following are few interventions made the Government of India (GoI) and State of Assam. a) Centrally sponsored schemes/policies: National Rural Health Mission (NRHM) was introduced in the year 2005 to provide effect health care facility to the states with weak health infrastructure; Assam is also listed under NRHM. However, NRHM is now covered under the National Health Mission (NHM) to expand the health service facility to the entire nation with the objective, inter alia, to prevent and reduce maternal deaths in the country. Under the umbrella of NHM, GoI introduce Janani Suraksha Yojna (hereinafter referred to as JSY) in 2005 with the objective of reducing maternal and neonatal mortality by promoting institutional delivery among poor pregnant women (Below poverty line Women). It integrates cash assistance with ante natal care during pregnancy period, institutional care during delivery and post partum period. Under this scheme cash assistance of Rs. 1400/- is 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 given to BPL women who give birth at home. Though JSY works as a safe motherhood intervention under the NHM, which focuses on reducing maternal and neo-natal mortality by promoting institutional delivery among the poor pregnant women, till now safe 14

15 motherhood remains a major challenge for the State. In Assam, as recorded in the DLHS-3, only 25.2% women are able to receive cash assistance under the JSY scheme and only 35.3% women have gone through the institutional delivery whereas the percentage of home delivery is 63.6%. Janani Shishu Suraksha Karyakarm (JSSK) was launched by the NRHM to improve the health care service by emphasising on entitlements and elimination of out of pocket expenses of pregnant woman and sick neonates. Under this scheme all pregnant women, who come for delivery in public health institutions, and sick infants are entitled to free transport, free drugs, free diagnostic, free blood, free diet up to one year. It is the responsibility of the state government to properly implement the scheme and to perform timely checks for better results. The Government of Assam somehow has failed to improve the maternal health scenario to a great extent. The perusal of various health surveys clearly shows the failure on the part of the Govt. to provide all these services to the entire population. Indira Gandhi Matriva Sahyog Yojna (IGMSY): The Ministry of Women and Child Development (MWCD) formulated a new Scheme for pregnant and lactating mothers. Under this Scheme, a cash incentive of Rs will be provided directly to women of 19 years and above for the first two live births, subject to the woman fulfilling specific conditions relating to maternal child health and nutrition 12. Cash incentive will be provided in three installments; between the second trimesters of pregnancy till the infant completes 6 months of age 13. Women enrolled under IGMSY will be 12 Ministry of Women and Child Development, Year End Review 2011, para. III-2 13 Ibid. 15

16 encouraged to avail JSY package also for institutional delivery and viceversa. However, there is no cash incentive under IGMSY at the time of delivery since cash incentive for this is already provided under JSY. IGMSY is a pilot project and it is implemented only in two district of Assam-Kamrup and Goalpara. To develop the health care sector at the community level, Accredited Social Health Activists (ASHAs) have been engaged. They are the primarily available health workers, working for any health-related demands of deprived sections of the population, especially women and children who find it difficult to access health services in rural areas. The ASHA Programme is expanding across States and has particularly been successful in bringing people back to the Public Health System and has increased the utilization of outpatient services, diagnostic facilities, institutional deliveries and inpatient care. Indian Public Health Standards: Indian Public Health standard was introduced to improve the quality of health care delivery in the country under the National Rural Health Mission. b) State sponsored maternal schemes: Mamoni scheme is sponsored the govt. of Assam, it has been introduced to encourages 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 of Rs. 1000/- in two installments to pregnant women for nutritional support during their pregnancy period. 16

17 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 arise during this period is attended by skilled doctors available at the government hospital. The Assam Public Health Act, 2010 was introduced and implemented by the Govt. of Assam. It expands mother and child health care including reproductive health care aiming for universal coverage. This Act 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 personal and essential drugs; reproductive health service and sexual health care with special emphasis for women and girls. It also provides the other basic facilities which a patient can avail under this Act. It contains the right to access health care services and ensures that there is not any denial of health care directly or indirectly, public or private, including for profit and non-profit service providers, by laying down minimum standards and an appropriate regulatory mechanism. c) International legal framework on public health: Apart from policies and schemes India as a signatory member of UN committee has to implement the following legal provision. There are many international conventions that relate to health rights. India as a party of those conventions has an obligation to fulfill those provisions. The relevant conventions which provide the 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 17

18 Covenant on Economic Social and Cultural Rights (ICESCR), and 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), adopted by the UN General Assembly on December 10, 1948, resulted 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 such atrocities to happen again. World leaders complemented the UN Charter with a road map to guarantee the rights of every individual everywhere. 14 Art. 25(1) of UDHR provides that everyone has the right to a standard living including the right to health, which includes food, housing, and medical care with necessary social services and the right to security in the event of sickness, disability, old age etc. India as a party must ensure and protect the right to health without discrimination. Declaration of Alma-Ata: The International Conference on Primary Health Care was held in Alma Ata in 1978 and highlighted the need for urgent action by all governments, all health & development workers and the world community to protect and promote the health of all the people of the world. It urged governments, the WHO, UNlCEF, other international organisations, multilateral and bilateral agencies, nongovernmental organisations, funding agencies, and all health workers to support a national and international 14 Universal Declaration of Human Right (UDHR),

19 commitment to primary health care. It also garnered technical and financial support for health, particularly in the developing countries. The conference called on all the aforementioned to collaborate in introducing, developing, and maintaining primary care in accordance with the spirit and content of this Declaration. 15 International Covenant on Civil and Political Rights (ICCPR): The United Nations (UN) adopted the ICCPR in 1966, coming into force in Under the ICCPR, Article 11 (3), 19 3(b), 21, 22 (2), every member state has special responsibilities to protect the public health. International Covenant on Economic and Social and Cultural Rights (ICESCR): The ICESCR was adopted by the United Nations General Assembly on December, 16, 1966 and entered into force on January 3, Article 12 of ICESCR establishes: the right of everyone to the enjoyment of the highest attainable standard of physical and mental health. This 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): Declaration of Alma Ata, Reproductive Health and CEDAW: Bustelo Carlota: National Women Law Centre 19

20 CEDAW was adopted in 1979 and came into force in It deals with women s health, 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. Article 12 of CEDAW 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" and (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 mandates that State protect such rights for rural women: [t]o have access to adequate health care facilities, including information, counseling and services in family planning. India, as a signatory of these conventions, must implement these provisions to protect and provide its citizen with the right to life along with the right to health care and medical treatment. It is the responsibility of the State to achieve its respective goal by proper implementation of such policies. d) Constitutional Provisions and Supreme Court Guidelines in 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 20

21 the constitution of India, it guarantees the right to life and personal liberty, including the right to health and medical assistance, right to live with dignity, right to food, right to a clean environment, right to adequate drugs, 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 a government hospital to provide timely medical treatment to a person in need of such treatment is a violation of right to life guaranteed under Article 21of the Constitution. Article 14 guarantees equality before the law and equal protection by the law. The 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. It also empowers the state to make special provisions for women and children. 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. States should ensure and protect the life of a woman. Finally, Article 47 provides that the state should ensure the nutrition and the standard of living of its people and improve public health, which guarantees access to medical services, regardless of status. The Supreme Court of India and various High Courts have issued orders and judgments to ensure women s reproductive rights, including the right to survive pregnancy, the state s duties and responsibilities to run and 21

22 maintain the health institutions, and 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 22

23 emergency cases with expertise and never refuse to offer treatment for 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 of 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, " [w]e 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 childbirth 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 childbirth, for that, the State of Madhya Pradesh is under obligation to secure their life. Thus, because of the constitutional provisions and Supreme Court orders health enters into a right based discourse. 4. Indian Public Health Standards Guidelines: an Introduction 23

24 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 and lack of community involvement etc. Hence, standards are being introduced in order to improve the quality of public healthcare. 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 IPHS guidelines for District Hospital: The 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 Subdistrict/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, a new born car, full coverage of treatment for maternal health and diseases, a large variety of 24

25 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 an 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 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 specialty 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. 25

26 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. Sonitpur is one of the High Focus District of Assam in regard to maternal health. One of the major causes of maternal mortality in the district is the poor access to the health services by the people. In the next session we are discussing the health care access in matter of infrastructure according to IPHS guidelines Sonitpur District Profile: Sonitpur district is one of the 27th districts of Assam in north-east India. It is the second largest district in Assam. The population stands at around 1,925,975. It is the third most populous district in Assam. There are around 946 females for every 1000 males in Sonitpur and literacy rate of about 69.96%. The Sonitpur district was formed in 1983 after the split from Darrang. The district Headquarter is in Tezpur. 26

27 The health institutions available are the Kanaklata Civil hospital as the district hospital along with 4 Community Health Centres and 38 Primary Health Centres Findings: The only civil hospital known is the Kanaklata Civil Hospital (200 beds) in Sonitpur district in Tezpur. Although the hospital has not obtained any environmental clearance certificate from the Pollution Control Board, it is disabled-friendly, as it is a single-story building. There is no waiting space or examination/preparation room available. There is no registration or admission counter. The Kanaklata hospital has disease prevention measures, a functional labor room, newborn care center, operating table, blood storage unit, bio-medical waste management, Figure 1: Overcrowded conditions in Kanaklata Civil Hospital obstetrician and gynecologists, anesthetists, and a lab technician. The total no of population covered by the hospital is as reported in Assam State PIP Sonitpur district profile: At a glance: available at 27 Figure 2: Shortage of beds at Karnaklata Civil Hospital

28 I. 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 18. Kanaklata Civil hospital is a 200 bedded hospital. II. 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 accessible by disabled people since it has only one floor. 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 18 IPHS Guidelines for District Hospitals (101 to 500 bedded), Directorate General of Health Services, Ministry of Health & Family Welfare, Government of India, 2012, p.24 28

29 be provision for adequate light and there should not be any outdated/unwanted hoardings or posters pasted on the building walls. During the visit the team can see posters of JSY, AIDS control, breast feeding, post natal care, antenatal care, and etc. are pasted on the walls. But all the posters were in English. 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. The team found out that the signage to the facilities was available. 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 nonslippery floors. Some people were concerned about the hygiene, sanitation, and environmental Figure 3: Broken almirah, cracks on the walls condition of the hospital. The team found that there was no proper maintenance because there were cracks in the walls, broken window, and etc. Condition of roads, pathways and drains: 29

30 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. Kanaklata Civil Hospital is located in the city with proper roads and transport communications. Kanaklata Civil Hospital is located in the city with proper roads and transport communications. The distance to the nearest community health centre (CHC) in the coverage area is about 28 km. and the farthest CHC is situated within 165 km. The distance from the bus stop to the district hospital is below 5 km. The area of the hospital is approximately 680 sq. The hospital is located near residential area with 216 numbers of indoor beds. 19 Environmental friendly features: The Hospital should be, as far as possible, environment friendly and energy efficient. We found out that the hospital has not obtained an environment clearance certificate from the Pollution Control Board. 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. We found out although there were wheel chair, stretchers but it is not sufficient for large population. 19 Devi Alankrita: Evaluation of Government Hospital in Sonitpur district: International Journal of Healthcare Science: Vol. 1, Issue 1, pp: (50-60), Month: October 2013-March

31 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. The team found that there is proper functioning of administrative block. III. Departmental Lay out Clinical Services: 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 signs visible from distance. In the OPD, there needs to be a reception and waiting space. During our fact finding visit we found that there is no functional waiting space or reception. Clinics The clinics should include general, medical, surgical, ophthalmic, ENT, dental, obstetrics and gynecology, Post Partum Unit, pediatrics, dermatology and venereology, psychiatry, neonatology, orthopedic and social service department. We can see all the above mentioned facilitates available at the hospital. 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 31

32 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. Blood Bank: Every district should have blood bank services based on the guidelines of adhere National Aids Control Organization guidelines and drug and cosmetic act strictly. There is blood bank in the hospital with lab technician. IV. 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 32

33 - Infectious Disease Ward There is no isolation, intensive care unit, examination and preparation room. However there is a labour and delivery room, neo-natal corner, critical care area and examination and preparation room, separation male and female ward. 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 hospital have medical store inside the campus of the hospital. 33

34 V. 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 IPHS guidelines Seating arrangement as per load of patient. Reception and admission Examination and preparation room Labor room/delivery room Neo-natal room Facilities available at Kanaklata Civil Hospital The team also observed that there is no adequate seating arrangement either for patient or for attendant. The team also observed in the maternity ward that patients sitting on the floor. No No One room with 5 beds One neo-natal corner 34

35 Sterilizing room Sterile store room Scrubbing room Dirty utility Doctors duty room Nursing station Nurses changing room Group C & D room Eclampsia room Female attendant Sweeper No room for patient sterilization/ one room for instrument sterilization No No No Yes - 7 gynaecologists, 6 paediatrics Yes 13 nurses in the maternity ward (per shift only 2/3 nurses for all patients of the maternity ward, for labour room, for delivery room etc) Yes No No 6 (1 or 2 per shift) 6 (1 or 2 per shift) VI. 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. VII. Other Amenities: IPHS guidelines Potable drinking water Functional and clean toilets with running water and flush Facilities available at the district hospital There is provision for drinking water facilities for the people. There is provision for drinking water facilities for the people There are toilets and running water but these are not clean. 35

36 Fans/Coolers Seating arrangement as per load of patient. Fans are available, but the condition of the fans seems to be old. The team also observed that there is no adequate seating arrangement either for patient or for attendant. The team also observed in the maternity wards that patients sit on the floor. VIII. Hospital Transport Services: Hospital shall have well equipped Basic Life support (BLS) and desirably one Advanced Life Support (ALS) ambulance. The team found out that there is only one ambulance and one driver. IX. 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 Specialty 200 beds (as per IPHS guidelines) Available manpower at the hospital Medicine 2 1 Surgery 2 3 Obstetric & 6 3 Gynae Paediatrics 3 0 Anaesthesia 2 3 Opthalmology 1 6 Orthopaedics 1 0 Radiology 1 0 Pathology 2 1 Regular/Contractual 36

37 Ent 1 2 Dental 1 2 Mo Dermatology 1* Psychiatry 1 Microbiology 1* Forensic 1* specialist AYUSH Doctors# Staff Nurse Regular and 38 Contractual 90 Lab technician contractual Total * Desirable *If more than one AYUSH doctors are available, at least one doctor should have a recognised PG qualification in relevant system under AYUSH. District Hospital Man Power Administration Cadre 200 bedded Available HR at Kanaklata Hospital Hospital Administrator 1 Housekeeper/manager 2 Medical Records officer Medical Record Asstt. 2 Accounts/Finance 3 Admn. Officer 1 Office Asstt. Gr I

38 Office Asstt. Gr II 1 1 Ambulance Services (1 driver + 2 Tech.) Total Major issues of concerns: I. From the findings it is clear that 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 the state's failure to provide primary health care to the people. Apart from the fundamental rights we can also witness violation of Article 11 (3), 19 3(b), 21, 22 (2) of ICCPR, by virtue of which every member state has the special responsibility to protect public health, and Article 12 of ICESCR. India is a member to the above mentioned conventions. The findings of this report show that the State of Assam does not abide by its obligations under international law. II. According to the State PIP, , the total number of deliveries recorded is deliveries and 85.8 C-section and 23 maternal deaths are reported. The number of deliveries was high but hospital authority failed to provide adequate beds and moreover there is only one labor room with 5 beds. III. The maternity ward was over crowded. The fact-finding team saw only six to seven nurses for the entire maternity ward. Even the nursing station was overcrowded with attendants. Regarding the facilities as per IPHS 38

39 guidelines, we were informed that the maternity ward has only 35 beds, although it should have 50. Recently, 40 extra beds were donated by some individuals/organisations. The hospital authority has adjusted these 40 beds to the maternity ward for the time being, as there is a severe shortage of beds in the maternity ward. Otherwise, patients have to lie on the floor. In a month, the maternity ward has above 400 in-patients and sometimes they have deliveries in a day. There is a lack of facilities in the delivery unit which fails to comply with IPHS standards. IV. The team also found out that there is only ambulance in the civil. So it becomes very difficult for the patient to avail the ambulance services. Most of the times pregnant women have to hire private vehicle to come to the hospital due to lack of ambulance services in the district. As a result, the out of expenditure increases and this leads to the violations of provisions of JSSK. V. According to State PIP for the year for the Sonitpur there is no budget for operatinational of FRUs/blood bank, 24x7 PHCs, sub centers, referral transport. Total 416 lakh were sanctioned for maternal health covering the maintenance cost of SC, PHC, CHC and DH. VI. In the district there are 275 Sub centre, 58 PHC, 7 CHC, 2 Sub Divisional Community Health Centre (SDCH), 1 DH. There are 221 lakh sanctioned as untied funds and lakh were sanctioned as for annual maintenance. Thus there is budget in the health expenditures. 39