UP's Shravasti Has Fewer Primary Health Centres Than The Norm

Shravasti, which is on the Indo-Nepal border, ranks among India's most under-developed districts on several health parameters. As many as 96 of every 1,000 children born died before their first birthday, the highest infant mortality rate of any district in Uttar Pradesh (UP) in 2012-13, the latest comparative district data available. This was higher than the then UP average of 68 deaths per 1,000.

The department of health says there has to be one PHC serving every 30,000 people in the plains. Yet, Shravasti, with a population of nearly 1.1 million, has just 11 PHCs--one for every 100,000 people. Only four of the seven PHCs we visited had an allopathic doctor with a bachelor of medicine and surgery, and at many the positions of pharmacists, lab technicians and other staff were vacant, our reporting showed.

The only PHC that was not overburdened, had decent infrastructure and enough staff for the patient load was the PHC in Katra, we found.

Primary healthcare provides care throughout the lifespan of a person, not just for a set of specific diseases, according to the World Health Organization. "Primary health care ensures people receive comprehensive care - ranging from promotion and prevention to treatment, rehabilitation and palliative care - as close as feasible to people's everyday environment."

Lack of primary healthcare means that diseases that could have been prevented or treated at the primary level, end up overburdening tertiary care centes, turn more severe than they would have been if treated at the right time, or result in death. This story is part of our investigation into India's rural healthcare gaps, and how they are filled.

Unavailability of staff, doctors a major issue

Every PHC should have at least one physician, as per the Ministry of Health and Family Welfare, which says that UP has 2,923 PHCs in all. As of 2020-21, UP had 3,093 physicians appointed, against a requirement of 2,923. Yet, only four of seven PHCs we visited in Shravasti had an allopathic physician, we found.

At least 12 staff members must be present at every PHC, including doctors, nurses, auxiliary nurse midwives (ANMs), pharmacists, lab technicians, etc., the guidelines say. However, at none of the seven PHCs we visited, were all the positions filled.

No road to access Parevpur PHC

There is no road to reach the PHC, a yellow-coloured building in the middle of the fields, in Parevpur, 35 km away from the district headquarters. Patients use a pavement that was built to access it.

The PHC of Parevpur and the road leading to it between the fields. In the picture, Kusma and Jasoda are returning with the medicine.

Kusma Devi (42) and Jasoda Devi (30), had walked 4 km from their village, Dharsava, to reach the PHC. Kusma had low blood pressure and Jasoda had a recurring fever. "Our village is far, so we stopped multiple times on the way to rest," said Jasoda. Poor connectivity restricts the number of people who come to the PHC, PHC staff, patients and villagers told us.

"The road is really bad. We have written to the authorities many times, but nothing has been done yet," said the PHC's medical officer Sharad Awasthi. "It's for this reason that the hospital has not been made a childbirth point. It would be risky for pregnant women to commute on this road."

The sweeper hired is paid only Rs 1,500, Awasthi said. "It happens many times that we end up cleaning the rooms ourselves."

There are eight staff members at the PHC. These include one allopathic doctor, two AYUSH [alternative medicine, including Ayurveda, Yoga, Unani, Siddhi, Homoeopathy] practitioners, one staff nurse, one pharmacist, one lab technician, one ward boy and a sweeper.

The PHC without a building at Sonva

In 2019, the Sonva community health centre (CHC) building came up where the PHC was. But as the CHC is yet to open, the PHC operates out of two rooms in the same building so that patients do not suffer, the staff said.

"We will take the rooms back in our possession when the CHC will start functioning," said Rakesh Bharti, Sonva PHC's medical officer. The PHC does not have its own allopathic doctor, and it is the CHC doctor who also treats patients who come to the PHC.

The PHC had 10 staff members--one AYUSH practitioner, four staff nurses, one lab technician, one ANM, a health assistant, a ward boy and a sweeper.

In flu season, Hariharpur Rani PHC has 100 patients a day

The PHC has nine staff members, including an allopathic doctor, two AYUSH practitioners, a staff nurse, a pharmacist, a lab technician, a health assistant, one ward boy and a sweeper.

"It's the only PHC in the entire block, so we end up catering to a lot of people," said Arun Kumar, the medical officer at the PHC. "To put it in context, this one PHC caters to 40,000-45,000 people. Presently, there is no rush, but in the months when viral and seasonal flu are at their peak, we end up tending to 100 patients in a day. We don't even have any ANM."

Childbirth facility, but lack of equipment for it at Hariduttnagar Girant PHC

Other than being short of space, this PHC is also short of necessary equipment.

"We don't even have an oxygen cylinder," said Vinod Kumar, the medical officer. "During Covid-19, the cylinder from this PHC was taken and sent to a Covid facility. We have not got it back."

In addition, despite being a childbirth facility, where 30 deliveries, on average, happen every month, it does not have a thigh support table and a birthing room warmer, said Alpana Kumari, a nurse at the PHC. "These things are essential."

The bed of the labor room of Hariduttnagar Girant PHC on which the delivery takes place.
This bed keeps on shaking and the fan of this room is not working for many days due to power problem.

Kumari said she spent money from her pocket to get a fan in the labour room repaired, but it still does not work. Further, there is no constant electricity supply to the PHC. "It gets difficult for me and even more difficult for the women who come for deliveries as the temperature has crossed 40 degree Celsius. Because there is no fan, the women insist on going home just a few hours after delivery. They don't feel comfortable here."

There are seven staff members at this PHC--one allopathic doctor, one AYUSH practitioner, one staff nurse, one pharmacist, two ANMs and a sweeper.

Overworked and understaffed Jamunha PHC

This PHC is close to the Nepal border. Since it is the only one deep in the rural hinterland in this area, many patients come to this PHC. There is no allopathic doctor here and two AYUSH practitioners run the PHC, which caters to 40,000-50,000 people.

"We are overworked, and we don't even have enough staff members. Every day, 90-100 patients come to this PHC. In 2018, I treated nearly 35,000 patients," said Suman Babu Tharu, the medical officer. "On some days, I work non-stop from morning to evening."

Compared to the other PHCs, more childbirths happen at this one, with over 70 babies born each month, Tharu said. However, the labour room is relatively small, and sometimes deliveries of babies are done on the floor. Tharu added: "Out of 100 children born, 2-3 cases of stillbirth are reported. In fact, between April 21 and May 20 this year, out of the 36 deliveries that happened at this PHC, two cases of stillbirth were reported."

There are only six staff members at this PHC–two AYUSH practitioners, one pharmacist, two ANMs, and one sweeper.

The PHC at Tilakpur with no doctor

With no doctor at this PHC, a doctor from another PHC visits twice in a week, said a staff member. When we reached this PHC, there were just three staff members--one lab technician, one ANM and a ward boy. There is no pharmacist here.

Tilakpur PHC room with two beds but no fan.

The PHC has one ward, with two beds and no fan. A staff member said as the tap water is contaminated, they spend money out of pocket to buy water.

The PHCs which are more rural and further from the main centres of the district, such as that in Tilakpur, are worse off in terms of staffing as well as equipment, we found. Those that are closer to a highway or the main towns are better off.

"People don't want to get posted at the PHCs in the interiors where there are no facilities. This is why you will not find many employees at the faraway PHCs," said Shravasti chief medical officer A.P. Bhargav. "The fact is that we are somehow managing."

He said that he has heard of new appointments in the near future. "I have heard that there are going to be new appointments in the near future. If that happens then the staff problem would get resolved."

He added that the state health ministry decides the number of PHCs in the district. "If we get a directive to increase the number of PHCs in the future, we will implement that as well."

IndiaSpend contacted Ved Vrat Singh, Director General Medical and Health in Uttar Pradesh, to know if there is a plan to increase the number of PHCs in Shravasti. He said: "There is no such plan. Right now, our priority is to improve the condition of the existing PHCs. The primary issue is that we don't have enough doctors. In the absence of doctors, there is no point opening more PHCs."

He added: "While 19,000 posts of doctors have been sanctioned [including rural and urban PHCs, CHCs and district hospitals], we presently have only 12,000 doctors. In 2021, we had published ads for the recruitment of 3,620 doctors. However, only 450 posts have been filled so far. We now plan to hire doctors who will pass out of the medical colleges that have been opened very recently in the state by the UP government. It will take four-five years for these students to pass out."

(A version of this article first appeared in IndiaSpend Hindi. You can read it here.)

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