Lets Keep the Hope in the Public Health System and Invest in it too

I am new to the field of health. I was so unaware of so many things that last year when I started visiting the health clinics run by Rural Medical Practitioners (RMPs) or quacks in Uttar Pradesh, I was shocked to see them. Since then I have traveled to many government and non-governmental health facilities (not the fancy private ones) and the my shockers are behaving better. However this note is not about how bad the public health facilities are, this is about a pleasant surprise that I encountered during my recent visit to one of the High Priority Districts of Rajasthan. This is about the human spirit that I celebrate whenever I encounter. This is about making the best given all the constraints in the system. 

We all know the statistics. Our health sector is suffering from chronic problem around human resource. We dont have enough doctors in the public sector (the lure of private sector is too much), not enough nurses, ANMs (Auxiliary Nursing Matron) and now in Rajasthan they also face a problem with recruitment of ASHAs as they raised the minimum qualification to 10th pass for them. This is the same state where in the state capital's biggest hospital, cow urine is being used as a disinfectant (http://timesofindia.indiatimes.com/city/jaipur/Rajasthan-hospital-to-try-out-cow-urine-disinfectant/articleshow/48993649.cms).

Coming to my visit. I visited 3 Blocks of a HPD in Rajasthan this week and was pleasantly surprised to see how things are working in spite of all the constraints. It is that one ANM, that one doctor, that one PMO who is making a difference in spite of many constraints of infrastructure, a non-functioning and corrupt CMHO. For those uninitiated, CMHO is the highest in the public health system in a district in India. We started our journey from a Subsidiary Health Center, where the ANM had a room and an annexe smaller than a bathroom but she is immensely popular due to her skills of delivery and gets more than 150 delivery cases per year! She has been recognized for her services as one of the NGOs working in the district highlighted this to the District Collector. Her small Health Centre behind which she also lives has been recognized as a Delivery Point and when we visited her, she had supplies of all the essential medicines. Her Delivery Point was exceptionally clean and connected through solar batteries for 24 hour electricity. She did not have a washroom though. Neither running water. She fills a large pot with a tap and uses it to clean herself and the patient. This can be nothing short of a nightmare to not to ave water in a Delivery room but she is managing and not one death in the last five years. She calls up 104 (Janani Express Ambulance) to send high risk mothers to the nearest referral unit. What is most challenging? She said, "To attend to a child and the mother together once the baby is delivered. I bring the baby quickly to the main examination bed and cover it, while the mother is still there on the delivery bed, delivering her placenta. If the baby needs my attention in cleaning meconium, performing suction, the mother is left unattended for some time. I wish I had an assistant". We talked to the officials later and understood they were indeed thinking of giving her some assistance but in taking care of the immunization work that she does in the villages, so that she can stay at the facility 24 by 7. 

We  met Dr Gupta in one of the 30 bedded community health center (CHC) and he was more than happy to receive us past his OPD hours. He said he had about two hours then before he starts seeing more patients. He sees 250 to 300 patients per day. The facility is near marble mines and hence sees a lot of accident patients too. When we met him, he was the only doctor in his facility with 8 nurses, He had another doctor working with him, who was transferred all of a sudden. No body wanted to discuss why. "Political reasons. You know all that madam...." was all I was told. In a district that has a Total Fertility Rate (TFR) of 3.7, Dr. Gupta attends to a lot of deliveries. His facility also had Newborn Care Corner. He was more than happy to show us around and explained how he needed hands-on training on use of certain machines even when they reached his facility. he described how he saved life by acting on time when a woman with no alarming history started bleeding profusely  on the delivery table. The building was not one of the best and Dr. Gupta did not have any support of any other doctor and was residing next to the mortuary but when we sat down with him to talk about the greatest challenges, he chose to talk about how identification of high risk pregnancies can be done better. He said, "It has to get better. We have to show how to do it." Very soon we realized that he has already talked to the local business people regarding how can they hold camps to reach out to all the mothers in ANC (Ante-natal Care) period. His idea is that they would reach out through the SHCs and make the ANMs sit with them to understand better recording of history. He said, "They ask, how many kids you have? And the mother says three. What gets missed is how many miscarriages she had, if any. Did any of her child die? and thus we miss the high risk pregnancy." He informed us this would have been done already had his colleague not been transferred. He had talked to the local business men about how they could contribute by bringing patients in cars and spreading information about the camps. When one of our team members said, he should give this idea in writing to be shared with MD, National Rural Health Mission (NRHM), the doctor was reluctant. He said, "One should only talk when one has done something. What is the point telling now? If this saves the lives of women, we will talk about it." I did not have much to say, anyway. 

We visited the district hospital the next day. This is a 150 bedded hospital which very often have to admit between 170-180 patients. It sees 1000 to 1100 Out patients per day with 50 new cases that require admission. It runs a hospital as well as a dharmashala for patient attendants. The PMO or the Chief Functionary of the hospital, is over 60 years and had to be given 2 years extension in absence of qualified doctors in the state. And the enthusiasm that he has will put many 30 year old to shame. We saw fully functional laboratory that gives reports on the same day starting at 2 pm. It has token system. Your number gets displayed outside the lab for you to collect your reports. We saw no one with outside foot-wears there. Every table had hand-sanitizer. The machines are calibrated every morning and they churn out between 150 to 200 blood, stool, urine reports per day between 8 am to 2 pm. We proudly clicked a group photo in front of the lab. In the indoor wards, they have color coded the bed-sheets so that they are changed every day. We were there on a Wednesday and saw green bed-sheets every where. Did I mention I saw pink bed-sheets in all the facilities I visited the previous day? Tuesday is the pink day.

In most of the hospitals across India (and in railway stations) you can follow your nose to the washrooms due to the stink. The PMO was so confident of the bathrooms being cleaned every two hours that he first took us to the bathrooms to check, when he got out of his room. He showed us the hypo-chloride solution mops that are used. "No brooms here", he mentioned. No cow urine too, I noticed. The staff shortage got a passing mention when we prodded. It is life here. The PMO takes help of local NGOs and gets workers placed in the hospital to run it better. We met a doctor who was in charge of the canteen. Pretty unusual, isn't it? No wonder the PMO said when the inspection teams that visit from other districts, like to eat in the hospital canteen rather than anywhere outside. Another thing that really struck me here was the public participation in the betterment of the hospital. All the curtains are made with easily washable material that has been donated by local families. Before the yearly inspection of the hospital the PMO was stuck with a list of things not in place. With the help of the District Collector and the Rogi Kalyan Samiti (committee that monitors the functions of the district hopital), the PMO could get public support to fill these gaps. I wish more and more hospitals get such public support. 

We then visited the Special New born Care Unit (SNCU) that had 12 beds, 2 pediatrician on call, 6 stationed specialized nurses. The unit had three oxygen concentrator, one ventilator, four photo-therapy machines. Visiting SNCUs is always a very emotional experience as you see tiny babies struggling without their mothers. SNCU staff was well informed, showed around, told me about all the functions of the machines in absence of the doctor too. I must had looked particularly distressed so they quickly added, "All of them will be released within a week, trust us madam. We had 12 babies till yesterday. 6 got released." Do they check them after they are gone back home. They do. Do all the low birth weight babies survive after going back home? Especially the really tiny ones? Not all. The district is particularly poor and there is a reason why they are such low birth weight to begin with. Some lucky ones turn up at the malnutrition treatment center (MTC) and get another lease of life however, others get lost in the huge statistics called CMR.