Maharashtra Health Survey once again proves Health workers toiled, but the under-resourced Health system faltered

The survey was carried out in July this year and covered 122 primary health centres (PHCs), 24 rural hospitals and 14 sub-district hospitals in 17 Maharashtra districts

Key findings- State level survey on Rural health services by Jan Arogya Abhiyan

August27,2021

Focus on the coronavirus pandemic, which saw the postponement of several types of surgeries, and shortage of staff at hospitals were among the factors that affected patients in Maharashtra, as per a survey conducted recently. In a release issued on Saturday, the Jan Arogya Abhiyan, a non-profit public health campaign involving activists, experts and NGOs, which carried out the survey, said cesarean section procedures, trauma care etc took a hit, especially in rural parts of the state.

Jan Arogya Abhiyan has conducted a survey for assessing the situation of health services in rural areas across Maharashtra during the COVID pandemic. This survey covered 122 Primary Health Centres (PHCs), 24 Rural Hospitals (RHs) and 14 Sub District Hospitals (SDHs) from 17 districts across Maharashtra in July 2021. Information was collected by the volunteers of the Jan Arogya Abhiyan network in the respective districts – Akola, Amravati, Ahmednagar, Osmanabad, Aurangabad, Kolhapur, Gadchiroli, Chandrapur, Thane, Nandurbar, Parbhani, Palghar, Pune, Beed, Yavatmal, Solapur and Hingoli.  Key highlights from this survey are as follows:

COVID has seriously impacted essential, routine health services

• Out of 38 RHs and SDHs, 22 (59%) hospitals have not performed Caesarean section operations during COVID period.
• Surgeries not being done in 8 Rural Hospitals (33%), and 4 SDHs (29%) during COVID period.
• Accident cases were not treated in 11 of the sample hospitals in the COVID period.

Continued major shortages of medical humanpower

• There is only one permanent Medical Officer in half (51%) of the PHCs. This means only one regular doctor for over 30,000 population, while the WHO norm is one doctor for 1000 population.
• Only 53% PHCs have permanently employed nurses.
• Posts of essential specialist doctors are vacant in 46% of Rural hospitals and 30% in SDHs – this leads to major gaps in key health services. Extremely important specialists like regular surgeons were available in only 25% of these hospitals, while regular anesthetists were available in only 35% of these facilities.

Although major shortages of staff are partly addressed through contractual engagements, such gaps lead to overload of work for existing staff, while patients suffer due to lack of services.

Inadequate services and facilities

• Sonography machines are not available in 19 (79%) out of 24 RHs. 8 hospitals are not even providing free referral facility for sonography to be provided by an external agency.
• 17 RHs and 4 SDHs (55%) are not having Blood Storage Units for storing and providing blood in the hospitals, which is an essential, life-saving service.
• Children in rural areas did not receive regular check-ups and treatment last year during the pandemic, since doctors from Rashtriya Bal Swasthya Karyakram (RBSK) were shifted for COVID duties.

Surgeries and camps for cataract operations, sterilisation operations etc. have been postponed indefinitely due to the COVID pandemic.

The need for Public Health facilities increased during COVID period, as people from various socio-economic sections required public services for COVID treatment and vaccination. However due to major shortfalls in the public system as described above, rural who have been generally dependent on government hospitals and schemes for free care were forced to resort to private hospitals. This has led to huge number of incidents of massive overcharging for care (both COVID and non-COVID patients) in private sector, the finances of households have collapsed and many rural families have gone into massive debt. Such people often could not receive essential non-COVID services in public health facilities.

Life-saving caesarean deliveries and operations frequently unavailable

Out of 38 RHs and SDHs, 22 (59%) hospitals did not perform Caesarean sections during COVID period. This situation was found to be especially severe in Akola, Amravati, Osmanabad, Thane, Nandurbar, Palghar, Pune, Yavatmal and Hingoli districts.

Total 11 hospitals and health facilities including 2 SDHs were not treating accident cases during COVID period. No surgeries were performed in 8 rural hospitals and 4 sub-district hospitals (32% of sample hospitals) during COVID period. In addition to this, cataract operations, minor surgeries and sterilisation operations have been postponed indefinitely due to shifting of hospitals to COVID care, while they did not have required reserve capacity to continue essential routine services.

Major shortage of essential humanpower in Public health facilities

The survey once again highlighted the major shortage of required humanpower in public health facilities, as compared to population requirements.The survey also highlighted the impact of contractual and vacant posts, leading to existing staff being overworked and stressed as they were assigned COVID duties.

One of the most serious findings is that there is no regular second medical officer in 49% of PHCs. While contractual doctors were filling some of these gaps, in 25% PHCs the post of second medical officer is vacant.We can imagine a single regular medical officer being required to manage the PHC and cover a population of over 30,000 people, while performing outreach COVID activities as well as official record keeping and meetings.This has led to closed OPDs and has affected routine immunisation.

In the sample PHCs, permanent nurses are available in only 52.5% facilities, while 29.2% nurses were contractual 29.2% and 18.3%posts were vacant.

Among PHC drivers (essential to operate ambulances),  surprisingly only 34% were permanentwhile 58% are contractual  and 8% posts vacant.

In Rural hospitals 46% posts of essential specialist doctors are vacant, while 19% are working on contract. The highest number of vacant posts in RHs are Psychiatrists 81%, Surgeons 63%, Anaesthetists 47%, Dentists 47%, Gynaecologists 26% and Paediatricians 23%. This was followed by Medical Officers 2 and 3, Pharmacists, Drivers 25%. 15% of the posts of nurses were found to be vacant.

The district with highest number of vacant posts for specialist doctors: Nandurbar having 68% vacant posts.

In Sub-district hospitals, 30% of specialist doctor posts were vacant and 12% are working on contractual basis. The highest number of vacant posts in SDHs were Psychiatrist 100%, Radiologist 36%, Orthopaedic 36%, and ENT 43%.

The vacancies of specialist doctors have had a direct impact on the special services and surgeries available at the hospital. In addition, doctors in rural hospitals were given COVID duty, which led to long delays for serious non-COVID patients, while in some places, treatment and surgeries for non-COVID patients were discontinued.

Conclusions from the survey

1. The public health system in rural areas was under-resourced to begin with, hence this system came under severe strain during the COVID situation, leading to inability to provide essential care for non-COVID patients. Due to unavailability of care in the public system, patients were often forced to obtain life-saving services in the private sector, especially for caesarean operations and surgeries. This has led to huge expenses and indebtedness for many families.
2. Due to under-staffing of public health facilities and hospitals, the existing doctors and health workers had to perform major overwork in the COVID situation. The tireless work performed by frontline healthcare workers is indeed remarkable, they tried their best to provide essential health services during this crisis. However the under-resourced system faltered under the combination of raised external demand and internal deficiency of staff and facilities.
3. The COVID epidemic should be an eye opener for all of us. The COVID experience has reinforced the fact that especially for rural and adivasi populations, public health services are the mainstay and only reliable source of support. The lesson is that these services must be rapidly upgraded by ensuring regular appointment of adequate staff and expanded facilities, so that the healthcare needs of the entire rural population can be satisfied. Privatisation of public healthcare should never be an option.

Recommendations for immediate action and required policy changes

• The public health system in Maharashtra has 17,000 vacant posts. However under the National Health Mission and the Ayushman Bharat program, thousands of employees have been engaged on a contractual basis since many years. All of these contractual workers must now be regularised, and all vacant posts must be rapidly filled to ensure adequate healthcare staff for the system.
• Keeping in view population requirements in rural areas, Maharashtra requires additional 3444 sub centres, 471 Primary Health centres and 210 Rural hospitals (according to National Health statistics 2019). Similarly in urban areas according to the current population even if one-third of healthcare requirements are fulfilled by the public health system, additional 627 PHCs and at least 58 larger hospitals need to be set up.
• During the Covid situation the shortage of Public hospital beds for serious patients became glaringly obvious. According to WHO norms, 2 hospital beds are required per 1000 population. However Maharashtra currently has only 0.4 government hospital beds for 1000 people. In this situation massively expanding public hospital services by upgrading existing hospitals add setting up additional hospitals in underserved areas is extremely necessary.
• Even though the COVID situation has demonstrated the absolutely essential role of public health services in India, NITI Aayog continues to argue for accelerated privatisation of healthcare. This body is recommending handing over of District hospitals to private players across the country. Maharashtra government is also considering the implementation of the highly problematic ‘Adani model’ of marketisation of public hospitals, which are invaluable social assets. The consequences of such commercialization of public hospitals would be disastrous for both ordinary people add healthcare staff. Given this situation, Maharashtra government must completely reject the recommendations of NITI Aayog for further commercialisation of healthcare, and the Adani model for privatization of public hospitals.

Maharashtra government needs to rapidly double the current public health budget, to support expansion and strengthening of public health services across the state. Combined with this there is need for Maharashtra to adopt a Right to healthcare act which would ensure good quality, free health services for all.