Fact-Finding Report on the State of Public Health Facilities in

Barwani District

25th August 2012 – 31

st August 2012

TABLE OF CONTENTS

I. Introduction

II. Relevant Constitutional Rights, Schemes, Norms

a. NRHM

b. IPHS

III. Issues of Major Concern

a. Shortage of Staff

i. Affect on High Number of ODP Patients

b. Lack of Funds to Hire and Retain Essential Staff

c. Faulty Upgrade of PHCs

d. Lack of Space for Essential Medical Services

e. Non-Registered Pharmacists Dispensing Medicines

f. Lack of Essential Medicines

g. Patients Forced to Purchase Essential Medicines Out of Pocket

h. Poorly-Functioning or Non-Existent Blood Storage Units (BSU)

i. Lack of Reliable Transportation

j. Sterilization Camps

k. Lack of Maternal Death Reporting and 15-49 Maternal Deaths Reporting

l. Lack of Hygiene in All Facilities and a Faulty Waste Management System at Barwani

DH

IV. Recommendations

I. INTRODUCTION

In 2011, the Human Rights Law Network filed a case in the Honourable High Court of Madhya Pradesh

against the Government of Madhya Pradesh in W.P. PIL No. 5097 of 2011, Dunabai v. State of Madhya

Pradesh and Others. The petition alleged that the Respondents had failed to install adequate infrastructure

and facilities in Barwani District’s public healthcare system. The petition also alleged that the

Respondents had failed to post a sufficient number of qualified doctors in Barwani District’s public

healthcare system. These failures, the petition argued, violated the reproductive rights of women and girls

in its failure to implement maternal health strategies and programmes consonant with constitutional,

international, and statutory obligations. The consistent and recorded denial of health care services,

particularly emergency obstetrical care and antenatal care services, highlight a series of systemic failures

that have broken families and raise serious concerns about the provision of health services for the public

at large.

On 11th November 2011, the High Court of Madhya Pradesh issued an order in which it directed the

Respondents to “take immediate steps for providing the minimum basic health facilities to the women in

the area concerned and… place on record…the steps taken by the State in this direction…” After the

Respondents failed to file a report as requested in the order of 11th November, the High Court issued an

order on 27th January 2012 directing the Respondents to “file requisite compliance report/affidavit as

already directed on or before the next date of hearing, failing of which the respondents No. 2 to 4 shall

remain personally present before this Court on the next date of hearing.” In this same order, the case was

listed for 3rd

March 2012.

The Respondents finally filed their compliance report on 26th March 2012. After examining the

Respondent’s report, the High Court wrote, “we find that the steps are not enough and are not in the pace

in which the same are to be taken.”

In light of the Respondent’s failure to implement necessary measures to improve Barwani District’s

public healthcare system, the High Court ordered on 27th July 2012 that “the second respondent

Commissioner, Health Department Government of M.P. and Joint Director health to visit Hospitals,

various Public Health Centres and Community Health Centres at District Barwani within 15 days along

with the Collector Barwani to find out the problems being faced and to find out its solution.” The

Respondents were further ordered to file a “necessary report in that regard…on or before the next date of

hearing,” which was scheduled for 3rd

September 2012.

This report was prepared to provide an updated status on the public healthcare system in Barwani District

and highlight ongoing issues of major concern.

Madhya Pradesh and Barwani District:

As of 2011, the population of Barwani District is 1,385,659 people. According to the Madhya Pradesh

Human Development Report of 2007, Barwani district has the second lowest Human Development Index

amongst all districts of Madhya Pradesh. According to the 2001 Census, which reported Barwani

District’s population as 1,081,039, 67% of the people in Barwani District are Scheduled Tribes (STs).

The District Level Household Survey of 2007-2008 reported that over 65% of pregnant women living in

Barwani District are not receiving essential antenatal, obstetric or postnatal medical assistance. According

to the same report, Accredited Social Health Activists (ASHAs) facilitate or motivate only 1% of women

in Barwani District to use family planning methods, request antenatal care or have institutional delivery.

More recently, The Annual Health Survey 2010-2011 reports that 70.1% of all deliveries in Barwani

District occurred at institutions. Moreover, 65.6% of all deliveries occurred at government institutions.

Correspondingly, 29.7% of all deliveries in Barwani District took place at home and a skilled health

personnel conducted the delivery in only 15.3% of these.

The same report notes that the Crude Death Rate (CDR) in Barwani District is 10.5 women for every

1,000 women compared to Madhya Pradesh’s CDR of 7.5 per 1,000 women. Moreover, the Maternal

Mortality Ratio for the Indore Division is reported as 278 for every 100,000 live births. The distribution

of maternal and non-maternal death by broad age group in Madhya Pradesh is represented as below:

The figures represented above and the facts presented in this report are illustrative of Barwani District’s

broken healthcare system, which fails to meet even the most basic of standards as outlined in the National

Rural Health Mission scheme and the Indian Public Health Standards norms.

This failure perpetuates the violation of Barwani Districts’ women’s constitutional rights. Women are

routinely denied emergency obstetrical care and access to free health services at Primary Health Centres

(PHC), Community Health Centres (CHC) and the District’s District Hospital. Moreover, the public

health facilities in Barwani District Moreover, these women are denied their legal entitlements to medical

and financial assistance at every stage of their pregnancy, including access to reproductive health services

by an Auxiliary Nurse Midwife (ANM) and an ASHA as mandated under government schemes including

the National Rural Health Mission (NRHM), and the Janani Suraksha Yojana (JSY).

II. RELEVANT CONSTITUTIONAL LAW, SCHEMES, AND NORMS

Constitutional Law

Article 21 of the Constitution of India guarantees the right to life for all Indians and states: “No person

shall be deprived of his life or personal liberty except according to procedure established by law.” The

Supreme Court has also held that Article 21 includes the right to health and appropriate medical care.

Article 14 guarantees the right to freedom from discrimination and Article 15 provides for the right to

equal protection of the law.

In addition to these Constitutional guarantees, India is party to several international conventions that

uphold the right to health, reproductive autonomy, and the right to be free from inhuman and degrading

treatment. The Convention on the Elimination of All Forms of Discrimination Against Women

(CEDAW), the International Covenant on Civil and Political Rights (ICCPR), and the International

Covenant on Economic Social and Cultural Rights (ICESCR) obligate the government of India to

promote, protect, and respect the right to health.

National Rural Health Mission (NRHM)

The National Rural Health Mission (NRHM) was launched to strengthen public health systems in rural

areas. NRHM’s aim is to provide effective health care to India’s rural population with a special focus on

states that have poor public health indicators and/or weak infrastructure.

Through the NRHM, central government funds are provided to state governments to improve the state’s

public healthcare systems. In this way, states bear the responsibility of identifying and assisting their most

broken district public healthcare systems.

Indian Public Health Standards (IPHS)

In 2007 the government of India issued the Indian Public Health Standards (IPHS) for Sub-Centres,

Primary Health Centres (PHCs), Community Health Centres (CHCs), Sub-District and District Hospitals.

The aim of the IPHS is to create uniform standards to improve the quality of health care delivery

throughout India.

Today, these standards are used as the reference point for essential public healthcare infrastructure,

human resources, and for planning upgraded facility level designations. Although the IPHS norms are

often treated as aspirational standards, they are the baseline against which essential manpower, services,

and facilities are tested.

III. ISSUES OF MAJOR CONCERN

In order to investigate the status of Barwani District’s public health facilities, we visited several facilities

of each level of care (primary, secondary, and tertiary) over the course of seven days (25th August – 31

st

August). The following is a list of the facilities we visited:

(a) Pati Community Health Centre (CHC)

(b) Sendhwa Civil Hospital (CH)

(c) Warla CHC

(d) Chachriya Pati Primary Health Centre (PHC)

(e) Balwadi PHC

(f) Dhanora PHC

(g) Niwali CHC

(h) Pansemal CHC

(i) Silawad CHC

(j) Palsood CHC

(k) Rajpur CHC

(l) Barwani District Hospital (DH)

This section is based on our visits to these facilities and discussions with various staff members and users

as well as corroborative information from other documents and studies. The focus of our observations is

to determine the state of these facilities and report whether these facilities offer essential health services

as per both the National Rural Health Mission scheme and India Public Health System norms. The

following is a non-exhaustive list of major issues of concern observed at these facilities. Specific facilities

have been identified under each issue of concern.

a. Shortage of Staff

There is a shortage of staff at every facility we visited. The shortage is prevalent at all levels of staff and

at all levels of facilities. The shortage is most acute in periphery areas where some facilities function

without a doctor depending instead on lower-level staff to manage and run the facility. This severe

shortage in essential staff is in direct violation of both NHRM and IPHS standards. The shortage also

requires frequent referrals of labor complications and emergency services to the nearest CHC or Barwani

DH. The severe shortage of staff and dependency on referrals is impracticable in a district plagued by

poor road infrastructure and even poorer transportation services, unsustainable given the high out-of-

pocket expenses borne by Barwani District’s adivasi and below poverty line population (BPL). The

shortage also costs the lives of many women who die before they can receive necessary medical

treatment. This denial of treatment, whether purposeful or circumstantial, is a violation of the district

population’s right to life as per Article 21 of the Constitution of India.

Dhanora PHC, which serves a population of 30,000 people and performs more than 20 deliveries per

month, has been forced to function without a doctor since 2010. Without a Block Medical Officer (BMO),

a single dresser who has no medical or management training manages the hospital. The rest of the PHC’s

staff is comprised only of a single lab technician and an ANM.

Similarly, although Warla CHC functions under the purview of general doctor Sustia, he had been retired

for years before he was posted to the CHC. Dr. Sustia has not practiced medicine since his retirement and

has not been trained in Basic Emergency Obstetric and Neonatal Care (BMOC) since his reinstatement at

Warla CHC. The remaining staff at the CHC is comprised of one Lady Health Visitor (LHV), one ANM

trained in BMOC, one dresser, one compounder who is on indefinite leave, and one sweeper who works

on contract. Entrusting a CHC that serves a population of 3,500 patients to an unpracticed and untrained

doctor is negligent at best.

At Balwadi CHC, we spoke with homeopathic doctor Sanjai Palijan. The CHC is staffed with eight

ANMs, one Lab Technician, one dresser, one sweeper, and one ward boy. However, all eight of the

CHC’s ANMs are working in Barwani and the CHC functions without a staff equipped to handle

deliveries or labor complications. Moreover, the CHC’s Lab Technician doubles up as the CHC’s

Compounder and Registration Clerk. This shortage of staff undermines the National norms and is a

personal affront to the population Barwani District’s public health system serves.

Silawad PHC was recently upgraded to a CHC, but this new designation is effective on paper only as the

facility is severely ill equipped to function as a CHC. The CHC serves a population of 161,000 people

and is managed under BMO Dr. G.S. Barela. Dr. Barela counts on one Lab Technician, two Lab

assistants, and two general doctors who are rarely at the CHC, as per our interview with Dr. Barela.

Recently, a second general doctor posted to Pati CHC shifted to Silawad CHC because of its lack of

doctors per the population it serves. On a recent visit, the Chief Medical and Health Officer (CMHO)

requested that the general doctor shift back to Pati CHC immediately. The CMHO neither took into

consideration the lack of doctors at Silawad CHC nor proposed posting a second doctor at Silawad CHC

to fill the shortage. This shuffling of doctors without due notice of the population they serve, the staff that

supports them or their lack of infrastructure is myopic and utterly ineffective.

Even Barwani DH, which is often the facility of last resort for many periphery area patients, suffers from

important medical staff shortages. Most negligently, the DH lacks a pathologist in its Blood Storage Unit

(BSU). We spoke with BSU staff at length and found that they are performing lab tests they are neither

authorized nor trained to perform. One of these, a blood cross-matching test requires a pathologist’s

analysis before approval. Lacking a pathologist means that staff conducts and approves tests with

uncertainty and feel liable for preventable mistakes. Most importantly, patients bear the brunt of these

deficient services.

The lack of posted staff at all of the facilities we visited has a major negative effect on the whole of

Barwani District’s public health system. When PHCs or CHCs operate without a doctor or essential staff,

patients are denied emergency and specialty services. These patients are instead forced to travel long

distances to the nearest facility that offers these services. Of all of the facilities we visited, only Barwani

DH offered specialty services and a functional Operating Theatre. Although a few PHCs and CHCs had

an operating theatre, it was only used for very minor surgeries and scheduled sterilization camps.

i. Effect on High Number of OPD Patients

The shortage of staff also has a major negative effect on the length and type of treatment afforded

to OPD patients. Many of the facilities we visited treated hundreds of OPD patients on a daily

basis although there was only doctor posted. Doctors are expected to manage the health facility

and simultaneously provide treatment to each of these patients including diagnosis and

prescribing necessary medications during their 6 hours worth of services. When the team visited

Silawad PHC, Rajpur CHC, and Pansemal CHC it noted that OPD patients received about 2-

minute’s worth of care, which included at most a blood pressure reading, a diagnosis with the use

of a stethoscope, and prescription writing.

The doctors we spoke to at Pati CHC said they treated about 300 OPD patients a day during the

off-season when they are only equipped and have enough time to treat 100 OPD patients per day.

Similarly, Sendhwa CH reported treating between 200 and 250 OPD patients per day.

Using Sendhwa CH as an example of the kind of treatment an OPD patient can expect to receive

on a day with low OPD numbers and two doctors at the health facility, he can expect to receive

3.6 minutes worth of medical attention. This is calculated as:

200 OPD patients per day/2 doctors = 100 OPD patients per doctor

100 OPD patients/6 hours of consulting per doctor per day = 3.6 minutes per OPD patient

This calculation assumes several factors: a) a low OPD average, b) that both doctors are present

at the CH, and c) that both doctors do nothing else but treat OPD patients for 6 hours. These

assumptions are impracticable and underlie the severe lack of adequate OPD care patients are

receiving as well as the general overload of doctors.

This severe shortage in staff is endemic in a broken public health system, belies an acute lack of morale

and support amongst facility staff, and creates a strong sense of distrust in the district’s population. This

shortage also calls into question the implementation of the Janani Suraksha Yojana (JSY) program, which

promotes institutional deliveries through a cash incentive scheme. Is it ethical that a government would

incentivize institutional deliveries in ill-equipped institutions that do not provide essential medical

services? Most importantly, this shortage in staff violates the patients’ right to life and essential health

services.

Table Showing Shortages in Essential Manpower List for PHCs

Essential Man Power List for PHCs Balwadi Chachriya Dhanora

Personnel Type

A

Type

B

Type A Type B Type B

Medical Officer- MBBS 1 1 1 0 0

Medical Officer –AYUSH 1 1 0 0 0

Accountant cum Data Entry

Operator

1 1 0 0 0

Pharmacist 1 1 0 0 0

Pharmacist AYUSH 1 1 0 0 0

Nurse-midwife (Staff-

Nurse)

3 4 0 0 0

Health worker (Female) 1 1 0 0 0

Health Assistant (Male) 1 1 0 0 0

Health Assistant.

(Female)/Lady Health

Visitor

1 1

Health Educator 1 1 0 0 0

Laboratory Technician 1 1 1 1 1

Cold Chain & Vaccine

Logistic Assistant

1 1 0 1 0

Multi-skilled Group D

Worker

2 2 0 0 0

Sanitary worker cum

watchman

1 1 1 0 0

Total 13 14 3 2 1

List Showing Shortages in Essential Manpower List for CHCs

Essential Man Power List

for CHCs

Pati Sendh

wa

War

la

Niw

ali

Panse

mal

Silaw

ad

Palso

od

Rajp

ur

Personnel Essenti

al

Block Medical

Officer/

Medical Super-

intendent

1 1 1 1 1 1 1 1 1

Public Health

Specialist

1 0 0 0 0 0 0 0 0

Public Health

Nurse (PHN) #

1 0 0 0 0 0 0 0 0

Essential Specialty Services

List for CHCs

Pat

i

Sendh

wa

Warl

a

Niwa

li

Panse

mal

Silaw

ad

Palso

od

Rajp

ur

Personnel Essenti

al

General

Surgeon

1 0 0 0 0 0 0 0 0

Physician 1 1 0 0 0 0 0 0 0

Obstetrician &

OBGYN

1 0 0 0 0 0 0 0 0

Pediatrician 1 0 0 0 0 0 0 0 0

Anesthetist 1 0 0 0 0 0 0 0 0

Essential General

Duty Officers List for

CHCs

PAT

I

Sendhw

a

Warl

a

Niwal

i

Pansema

l

Silawa

d

Palsoo

d

Rajpu

r

Personne

l

Essentia

l

Dental

Surgeon

1 0 0 0 0 0 0 0 0

General

Duty

Medical

Officer

2 1 4 0 2 1 (absent

w/o

leave)

3 0 1

Medical

Officer -

AYUSH

1 0 0 0 0 0 0 0 0

Essential Nurses and

Paramedical Staff for

CHCs

Pat

i

Sendh

wa

Warl

a

Niwa

li

Panse

mal

Silaw

ad

Palso

od

Rajp

ur

Personnel Essenti

al

Staff Nurse 10 0 0 0 4 0 0 1 0

Pharmacist 1 0 1 0 0 0 0 0 1

Pharmacist –

AYUSH

1 0 0 0 0 0 1 0 0

Lab.

Technician

2 2 2 0 2 1 0 1 4

Radiographer 1 1 0 0 1 1 0 0 0

Dietician 1 0 0 0 1 0 0 0 0

Ophthalmic

Assistant

1 1 0 0 0 0 0 1 0

Dental

Assistant

1 0 0 0 0 0 0 0 0

Cold Chain &

Vaccine

Logistic

Assistant

1 0 0 0 0 0 0 0 0

OT Technician 1 0 0 0 0 0 0 0 0

Multi

Rehabilitation/

Community

Based

Rehabilitation

1 0 0 0 0 0 0 0

Worker

Counselor 1 0 0 0 0 0 0 0 0

Essential Administrative

Staff List for CHCs

Pat

i

Sendhw

a

Warl

a

Niwal

i

Pansema

l

Silawa

d

Palsoo

d

Rajpu

r

Personnel Essentia

l

Registration

Clerk

2 0 1 0 0 0 0 1 0

Statistical

Assistant/Dat

a Entry

Operator

2 0 0 0 2 0 0 0 1

Account

Assistant

1 0 0 0 0 0 0 1

Administrativ

e Assistant

1 0 0 0 0 0 0 0

Essential Group D Staff

List for CHCs

Pat

i

Sendh

wa

Warl

a

Niwa

li

Panse

mal

Silaw

ad

Palso

od

Rajp

ur

Personnel Essenti

al

Dresser (cert.

by Red Cross/

1 0 1 1 2 1 0 0 1

Johns

Ambulance)

Ward Boys/

Nursing

Orderly

5 3 0 0 1 1 0 3 11

Driver* 1* 1 0 0 1 1 0 2 1

TOTAL 46 11 10 2 17 6 5 10 22

b. Lack of Funds to Hire and Retain Essential Staff

Under the government Reproductive and Child Health programme, patients are required to pay user fees

when they receive medical services. These user fees are then used to hire and retain essential staff at all

facility levels. Several of the facilities we visited, however, reported that RCH funds are being used to

purchase medicines that are in short supply.

Sendhwa CH, which serves a population of 350,000, stated that it has had to use its RCH funds to

purchase necessary medicines because the government is not providing them. This means that the CH has

to forego hiring essential lower-level personnel. The misuse of these funds results in a general lack of

staff or in staff hired at below minimum wage on a contractual basis. Again, patients bear the cost of this

administrative misuse in funds as a shortage in staff results in a shortage of essential services.

c. Faulty Upgrade of PHCs

Two of the facilities we visited were recently upgraded from PHCs to CHCs. However, this new

designation is only effective in theory and not in practice. These upgrades have created non-functioning

PHCs, severely ill equipped CHCs, and a lack of access to essential medical services in periphery areas.

Silawad PHC, now, CHC, serves a population of 161,000 people. The facility does not offer any essential

specialty services and functions under the supervision of BMO Dr. G.S. Barela with the support of a

small number of staff. Nevertheless, the CHC handles between 60 to 70 deliveries per month as well as

weekly sterilization camps. The CHC only counts on one staff nurse even though CHCs are meant to have

at least one gynaecologist and 10 Staff Nurses. Silawad CHC also operates without other essential staff

including a general surgeon, physician, paediatrician, anaesthetist, pharmacist, and dresser.

Moreover, although CHCs are supposed to have at least 30 beds in their facility, Silawad CHC has only

six beds. Although Silawad holds a sterilization camp every Tuesday for between 10 and 50 women, it

has no operating theatre. The CHC also functions without an x-ray room, pharmacy, or blood storage unit.

Although the CHC has a functioning lab, the lab only provides haemoglobin, urine, tuberculosis, and

pregnancy tests.

Another PHC was recently upgraded to a CHC without human resource or infrastructural support.

Palsood PHC, now CHC, serves a population of 31,000 people. The CHC lacks a Physician,

Gynaecologist, Pediatrician, Anesthetist, Pharmacist, and Dresser. As such, the CHC does not offer

emergency or in-patient services (IPD). Instead, the CHC provides tertiary-level care for ailments

including hypertension, respiratory complications, and anaemia before referring these to Barwani DH.

Palsood CHC only has six beds although it ought to have at least 30 beds. It lacks an Operating Theatre

and presumably holds its sterilization camps in its labour room. Moreover, the CHC functions without an

x-ray room, pharmacy, or BSU. The CHC lab only provides urine, tuberculosis, malaria, and STD tests.

The designation upgrade of these PHCs not only results in an ill equipped CHC but also undermines the

fact these facilities are also ill equipped PHCs. The upgrades are done in name only as they are not

accompanied by an increase in manpower, expansion in services, or improvement in facilities. If the

purpose of these upgrades is to serve a wider population of patients, they have failed miserably.

The Operation Theatre at the newly upgraded Silawad CHC.

d. Lack of Space for Essential Medical Services

In order to provide essential medical services to its patients, facilities require a facility suited to hold

essential laboratories, operating rooms, offices, labour rooms and so on. Many of the facilities we visited,

however, function without sufficient space for essential services. This results in an overflow of service

spaces and the misuse of severely unhygienic spaces.

We interviewed with doctors who use the same consulting desk to treat OPD in Silawad PHC, Rajpur

CHC, and Pansemal CHC because these facilities lack sufficient space to a) provide each doctor with

their own consulting desk or office or b) afford patients with any semblance of privacy.

When we visited Chachriya Pati PHC, which provides routine urine tests as well as sputum testing for

tuberculosis and blood smear examinations for malaria diagnosis, we found that the PHC’s laboratory had

no designated room. More alarming, the lab technician is forced to use space in a nearby bathroom to

store blood samples and necessary test solutions.

This lack of space underscores the serious deficiency in facilities and lack of district support to provide

facilities with essential infrastructural support.

Bathroom space used to house Chachirya’s laboratory.

e. Non-Registered Pharmacists Dispensing Medicine

On July 25, 2012, the Pharmacy Council of India issued order Ref. No. 12-8/2005-PCI. That order, which

took immediate effect, prescribed minimum standards of education required to qualify as a pharmacist

and enumerated specific course requirements. Most importantly, in paragraph No. 6, it stated, “[N]o

person other than a registered pharmacist shall compound, prepare, mix, or dispense any medicine on the

prescription of a medical practitioner,” and any person found in violation of this mandate, “shall be

punishable with imprisonment for a term which may extend to six months, or with fine not exceeding one

thousand rupees or with both.” Notwithstanding the issuance of this order, we visited several facilities

where non-registered pharmacists act as compounder, dresser, and dispenser.

At Pati CHC, which serves a population of 140,000 people and treats on average 300 OPD patients daily,

the health centre’s X-ray technician also operates as storekeeper and medicine dispenser. This is in direct

contravention of the above referenced order, which outlaws the dispensing of medicine by a non-

registered pharmacist. Nevertheless, patients require the medicines that have been prescribed to them and

due to a lack of essential staff, e.g., a pharmacist, facilities have no other option but to double up on

personnel. Similarly, at Balwari PHC, the facility’s Dresser also acts as compounder without

authorization or required education requirements. Niwali, a CHC that serves a population of 120,000

people, also functions with two Dressers who perform the functions of a Compounder.

This doubling up of personnel is first and foremost endemic to a severe shortage in staff and training.

Allowing facilities to operate with registered pharmacists is not only grossly negligent but also actionable

under the Pharmacy Council of India’s order.

f. Lack of Medicines

Every facility we visited lack many essential drugs as per the IPHS norms. Most alarming, these facilities

lack basic medicines including insulin, paracetamol, and anti-snake venom and anti-rabies medicines. A

facility that lacks these very basic drugs is, in essence, not a functional facility.

According to the facilities we visited and documentation the CMHO’s office provided us, Barwani

District does not have Insulin injection solubles at any of its Sub-Centre, PHC, or CHC facilities though it

has it available at Barwani DH. This shortage also applies to paracetamol tablets: documentation shows it

is not available in Sub-Centre, PHC, or CHC facilities but is available at Barwani DH. Finally, only one

facility we visited, Niwali CHC, claims to have both anti-snake venom and anti-rabies medicine, while

Silawad CHC claims to have anti-snake venom medicine.

One troubling piece of information we learned from documentation the CMHO’s office provided to us is

that neither Barwani DH nor district public health facilities are stocked with oxygen inhalation cylinders.

This is especially troubling because several of the facilities we visited claim they have oxygen cylinders.

These facilities included Silawad CHC, Rajpur CHC, and Barwani DH. This misinformation stems from

miscommunication between facilities and administration, concealment on the part of public health

facilities or concealment on the part of administration. Regardless, oxygen cylinders are essential to a

functioning facility.

g. Patients Forced to Purchase Essential Medicines Out of Pocket

All of the facilities we visited claim that medicines are provided to patients free of cost. However, when

we visited Sendhwa CH, maternity patients we spoke to claimed they have to pay for essential medicines

out of pocket. Schemes like Janani Shishu Suraksha Karyakram (JSSK) are meant to assist pregnant

women to receive essential prenatal health care services by providing them with essential services and

medicines free of charge. Nevertheless, patients at Sendhwa CH claimed they have to pay for their

medicines in contravention of the JSSK scheme. Most alarming, these patients report paying as much as

Rs. 2,000 in order to receive the essential medicines prescribed to them.

h. Poorly Functioning or Non-Existent Blood Storage Units (BSU)

None of the facilities we visited have a functioning BSU except Barwani DH. This is an alarming fact

especially in light of the district’s high prevalence of anaemia. In fact, anaemia is the leading cause of

maternal deaths and many women present at health facilities with haemoglobin levels as low as two or

three Hb counts. Notwithstanding, facilities continue to operate without a BSU.

Barwani DH is the exception as it has a functioning BSU. Nevertheless, when we spoke to the BSU staff

we learned of an alarming lack and misuse of blood supplies, an essential staff shortage, and a general

lack of space. There was a recently documented case of woman with two or three Hb counts who was

referred to the BSU with a request slip that failed to note the urgent need of the blood transfusion. The

woman was denied a blood supply because the BSU was never alerted to her extremely low Hb count.

The very next day, a doctor referred a patient to the BSU with a request slip that read “Urgent” even

though she had presented with a much higher Hb count. This woman was provided with a blood supply.

We were told that stories like these are the norm. Doctors fail to note the urgency of the blood supply,

personal favours or connections take precedent over medical urgency, and communication between

different medical wards and offices are non-existent.

We also learned from staff that the shortage in blood supplies for public health patients comes at the

expense of blood supply provided to private health facilities through a private pay-for-services program

between public health facilities and Barwani DH. This private agreement results in select public health

facility patients being referred to private health facilities and then receiving preference over public health

patients when they are referred to the BSU. As ever, this source of corruption costs the lives of patients, in

direct violation of both national and international human rights norms, and creates a pervasive lack of

confidence in the Barwani District Public Health System.

i. Lack of Reliable Transportation

All of the facilities we visited offer referral services for emergency services and complicated labours.

Most referrals originate in periphery PHCs or CHCs and are sent to Barwani DH. Correspondingly,

Barwani DH offers referrals to Indore for patients requiring a higher level of health care.

In a public health system that provided free and reliable transportation for these referrals, this situation

would not result in numerous avoidable deaths and many more indebted patients. However, this is not the

case in Barwani District’s public health system. Most all of the facilities we visited, including Barwani

DH, complain of its transportation services and acknowledge that the situation is dire.

Pati CHC, for example, has access to both an ambulance and a Janini Express (JE) but neither of these

was functional. The ambulance has been out of order for the last seven months and the JE has been out of

order for the last four to five months. Instead, the CHC is forced to rely on a JE stationed in Bukhrata.

The out-of-order JE parked outside Pati CHC.

Both Palsood CHC and Silawad CHC have access to both an ambulance and a JE but their respective

ambulances have been out of order for months. These facilities depend on the availability of a JE in

moments of urgent medical care.

Barwani DH, which has access to three ambulances, is no better off. Although all three ambulances are

functional, one runs on petrol and another is equally expensive costing the patients it transports around

Rs. 32,000 for a round-trip to and from Indore.

In a system where periphery and lower-level facilities lack essential staff, diagnostic services, and

medicines, referrals are frequent. Thus, patients depend on transportation services to deliver them to the

nearest facility equipped to treat them. Unfortunately, more often than not, patients are forced to choose

between receiving inadequate medical care or paying substantial sums of money for transportation. This

is to say nothing of the distance these patients are forced to travel over very poor road conditions.

j. Sterilization Camps (diverting doctors, no transportation or recovery provisions for

women)

All of the facilities we visited reported hosting family planning camps and several of the facilities we

visited were hosting sterilization camps. One doctor at Rajpur CHC noted that Barwani District has a

sterilization target equal to 1% of its population, which as of the latest census is 13,857 people. He also

expressed that district facilities are feeling pressure to meet their targets and are increasing the number of

camps they offer. Although women presumably give their consent to participate in these camps in return

for cash incentives, the camp’s procedure is essentially a personal and violent attack on these women.

The first sterilization camp we came upon was at Balwadi PHC on a Tuesday early afternoon. We noted

the large number of women crowding the PHC’s hallways. Speaking to the ayurvedic doctor on staff, he

reported that Dr. Seriwal performed all of the sterilizations at Balwadi PHC and traveled around the

whole of Barwani District performing sterilization camps at facilities including Sendhwa CH and Niwali

CHC. The ayurvedic doctor explained that Dr. Seriwal performs sterilizations for up to two hours on an

average of 50 to 100 women and then travels to other sterilization camps leaving his patients to regain

consciousness three to four hours after their operations. That day at Balwadi PHC, the team noted there

are not enough beds to host the women while they regain consciousness and nor are there any

transportation provisions for the women once they need to travel home.

The room where sterilizations are carried out at Balwadi PHC.

Women waiting to have their sterilization operations at Balwadi PHC.

The team noted the same at Rajpur CHC where it witnessed a group of over 50 women waiting to be

sterilized. The doctor had been expected to arrive in the morning hours but was nowhere to be seen when

we arrived at 4:00 pm. One of our team members spoke to the women who complain of having trouble

receiving their incentive payments and of having to wait so long on the doctor. The doctor arrived at the

CHC just after 5:30 pm and was still operating on women when we left the CHC around 7:30 pm. The

procedure, as perceived, was harrowing. The women are taken into the operation theatre, put under a

strong anaesthesia, operated on for no more than five minutes depending on the number of women present

at the camp, then carried out of the room and laid on the hallway floor, covered with a cloth and left there

for up to four hours until they regain consciousness. The earliest any of the women at Rajpur CHC would

have regained consciousness after her operation would have been 9:00 pm. As at Balwadi PHC, Rajpur

CHC has insufficient beds for the number of women at the camp. Also alarming is the total lack of

transportation provisions afforded to the women who would be disoriented and in pain after their

operations. Finally, if a simple calculation is conducted, one can note that the doctor spends a total of 2.4

minutes operating on each woman. The calculation is as follows:

50 women at the Rajpur CHC camp/1 doctor operating for 120 minutes = 2.4 minutes per woman

Women still waiting to have their

sterilization operation under a clock

showing the time is 4:40 pm.

After their operation, women are laid out in the hallway for hours before they regain consciousness.

k. Lack of Maternal Death Reporting and 15-49 Maternal Deaths Reporting (woman

died while Commissioner Visited)

Although many of the facilities we visited keep a register of the deaths occurring at their facilities, very

few of them have either a Maternal Death Reporting (MDR) or 15-49 Death Reporting procedure in

place. Both of these statistics are of course integral to understanding the cause of death for patients but,

more importantly, they are illustrative of the deficiencies in medical health facilities and infrastructure in

the District. Most of the facilities we visited do not have an institutionalized MDR or 15-49 Death

Reporting system in place. Many of the reports we were provided are deficient in their reporting. For

example, many of the reports do not note the 3rd

delay that caused the patient’s death and instead use

vague reasons for the patient’s death. There is also no follow-up on the deceased patient’s family.

Documents provided to us by the Nodal Officer of Community Based MDR and Facility Based MDR

shows that between 1st April and 28

th August only six MDR were prepared and reported to the office. Of

these, two deaths that occurred in May and June are still under audit. The Facility Based MDR reports

that only nine women have died between 1st April and 28

th August. Most of the deceased were in their

first pregnancy and ranged from 17 years of age to 35 years of age. The noted reasons include “severe

anaemia with lobar pneumonia” and “eclampsia with acute renal failure.”

l. Lack of Hygiene at All Facilities and Faulty Waste Management System at Barwani

DH

All of the facilities we visited are severely unclean and unhygienic. Many of the facilities sit adjacent to

dirty standing water and overflowing trash pits. One staff person we spoke to said that medical waste was

thrown in a pit very near the facility because the facility had no waste management system.

At Pati CHC we noted that the labour room was unclean even when no delivery was being performed. Its

door was locked but the team saw bloodstains on the floor, presumably from a recent delivery that had not

been cleaned after. Standing bloodstains are extremely unhygienic. Moreover, the CHC’s labour room

should be kept clean at all moments.

The unhygienic labour room at Pati CHC.

The space adjacent to Pati CHC’s new building where we witnessed farm animals graze and defecate.

Standing blood beneath

delivery table

A wild pig sifting through a trash pit adjacent to Pansemal CHC.

The situation is no better at Barwani DH. Barwani DH has a Waste Management System that collects all

obstetric and operating room waste to be incinerated in Indore. Nevertheless, we noticed a staff woman

drying, organising, and re-storing used latex gloves that had been used in the women’s hospital ward

labour room. Moreover, we noticed trash piles very near the women’s hospital. These piles are littered

with medical waste and easily accessible to anyone walking by.

A staff person sorting out used labour room latex gloves for re-use.

A similar process of re-using labour room latex gloves is used at Sendhwa CHC.

The waste management system in place at these facilities is deficient and risks the health of people who

might come upon waste pits near the facility.

A pile of trash just metres outside the women’s hospital at Barwani DH. Note the trashed box of syringes

and the blood supply bag strewn amongst the waste.

Used blood supply bag

A dirty box

of syringes

RECOMMENDATIONS

It is clear that the public health system in Barwani District is broken and in need of effective changes and

substantial improvements. The following are recommendations to the State of Madhya Pradesh, Chief

Medical and Health Officer of Barwani, Collector of Barwani District and others. These are meant to be

undertaken at both the local and state level by all affected stakeholders and in conjunction with

programmes proposed by the government itself.

1. Implement a strong and expansive system of communication between all facilities and

stakeholders;

2. Ensure that essential doctors are recruited and retained at all facilities;

3. Ensure that essential paramedical, administrative, and Group D personnel are recruited and

retained at all facilities;

4. Ensure that all facilities offer all essential medical and diagnostic services as per NRHM scheme

and IPHS norms;

5. Keep inventory of medical machines used at all facilities and ensure they are functioning

properly;

6. Ensure that a registered pharmacist is posted at all facility levels;

7. Keep an accurate inventory of medicines and ensure that all facilities have essential medicines in

stock;

8. Investigate reports of patients forced to purchase medicines out of pocket, provide redress, and

ensure no patient is forced to purchase medicines out of pocket in the future

9. Ensure all facilities have a functional BSU with sufficient blood supply and that a pathologist is

posted to each BSU;

10. Maintain an up-to-date register of maternal deaths and 15-49 maternal deaths reporting system;

11. Maintain an up-to-date register of referrals;

12. Keep register of ambulances and ensure they are all functioning;

13. Provide infrastructural and human resources support to upgraded facilities;

14. Allow Pansemal CHC to refer complications and emergency services to nearby public health

facilities in Maharasthra instead of transporting patients to nearest Madhya Pradesh public health

facility;

15. Ensure that sterilization camps guarantee that women have transportation services available to

them at no cost; and

16. Ensure that women who participate in sterilization camps receive their promised cash incentive at

the time they undergo their tubectomy.