A sputtering start to Karnataka's healthcare reforms

The infrastructure and medical services at several primary health centres in the state fall short of the mark, even as district hospitals improve

Staff shortage, lack of infrastructure and dearth of basic facilities — a survey by the Karnataka State Legal Services Authority (KSLSA) found many of the primary health centres, which spearhead the government’s public health outreach, in a bad shape months after the state government initiated the process of ramping up Karnataka’s public health infrastructure.

Since the start of the pandemic, the government has spent nearly Rs 6,000 crore scaling up medical infrastructure.

But how much has the public health infrastructure in the state actually improved during this period?

While officials and experts told DH that the pandemic had led to the improvement of many general hospitals in the region, they agreed that not all of the resources have gone where needed. “The lion’s share of resources ushered in the pandemic have been soaked up by district hospitals. This is partly apt, because districts in Karnataka are large,” said Dr Prashanth N S, Assistant Director (Research), Institute of Public Health, Bengaluru.

In district hospitals, this has meant the addition of new medical equipment, upgrades to intensive care units and improvement of oxygen resources, to prevent a repeat of the tragedy at Chamarajanagar district hospital in May, when 24 people died due to oxygen shortage.

But the concentration of these resources at the district level is also leaving several people out of healthcare coverage.

“There is only one district hospital for 10 lakh people and one taluk hospital for every lakh and half patients, both of which are not enough. And in the meantime, nothing has been done to improve the quality of the more profuse 2,508 primary health centres across the state,” Dr Prashanth said.

“One of our biggest problems is a shortage of human resources,” said Dr Suresh N (name changed), the administrator of a PHC in Bengaluru Urban district.

“We cater to an average of 480 OPD patients a month and we have a regular staff strength of 11 members. I am the only doctor here. There is another Ayush doctor helping with Covid-19 cases but we are concerned that this doctor and many of the auxiliary staff brought in for Covid-19 duties will now be withdrawn,” Dr Suresh said.

As a precursor to the withdrawals, one of two ambulances stationed at the centre for Covid-19 duties have already been taken away from the primary health centre (PHC).

While the PHC has access to some support from non-governmental organisations, it also lacks some basic medical infrastructure.

“Our labs, for one, need to be upgraded. Currently, we can only do Complete Blood Count (CBC) tests, but we would like to do thyroid and liver tests. We also need a warmer for newborns. The one we had broke down about eight months ago and a replacement has not been sent. We require this warmer for underweight babies, otherwise it will be very difficult [to save the life of the child],” Dr Suresh said.

Speaking from rural PHCs, ASHA workers confirmed the staffing shortages while simultaneously highlighting inadequate supplies of medical supplies. “For all of the talk of improvements to be made to PHCs, nothing has really changed,” said one Asha worker from Ballari district.

“At our centre, there is only one doctor here and there is a big queue everyday. Because of the government’s lack of support, there are hardly any stocks of medicine. Patients who come to the PHC find that they have to purchase drugs on their own from local pharmacies. Many angrily tell us that they came to the PHC under the belief that it was free. ‘What is the difference between this PHC and a private clinic?’ they ask.”

“There are 28 non-Covid health programmes that we have to restart — but with the manpower challenge, it is going to be difficult. Moreover, our Covid resources will not be of much help,” the doctor said.

Staff shortages have also beset general hospitals. Speaking to DH, Shivamogga District Health Officer Rajesh Suragihalli said that a dearth of trained staff has imposed major problems for treatment.

“Taluk general hospitals are in need of three additional anesthetists, three physicians to handle any pandemic or medical emergency situations effectively,” he said.

“The dearth of trained staff nurses who can treat critically ill patients in intensive care units will pose a major challenge in the future. When Covid-19 was at its peak, nurses were appointed on contract basis. But they needed training. It became an impediment then. So, the government must continue the services of such staff so that any kind of situation can be managed. The number of beds can be increased in a day but this can't be done with regard to human resources.”

It was a problem that the Commissioner for Health, Dr Thrilok Chandra, said that the state is trying to fix.

“We are empowering PHCs with oxygen concentrators, so the first point of care can be the PHCs itself,” he said.

Work underway

“Some 750 PHCs are being given Rs 20 lakh each under the CM-AMRUT scheme, where basic electrical and civil infrastructure are to be upgraded. By the end of the year, it will be completed. Apart from that, manpower-wise, most of the vacancies have been filled up by general duty medical officers and also the rural candidates who have come in.”

When it came to human resources, he added that 850 general duty medical officers are permanent.

“Apart from that we have taken compulsory rural service MBBS graduates as well. We have around 100 vacancies, but we have released the second list as well, so that will be filled up shortly,” he said.

The dearth of resources at PHCs has certain ramifications, according to Teena Xavier, a member of Maternal and Child Health Campaigns (Karnataka).

“For example, during Covid-19, nobody spoke about malnutrition and maternal deaths but these are serious and ongoing problems. Ordinary people could not get the medical assistance they needed, either because the programmes were not running or because healthcare staff were prioritising Covid-19 cases. In Bengaluru Urban’s Jigani PHC, for example, the staff were completely overburdened with Covid-19 cases,” Xavier said.

ASHA workers, however, confirmed that non-covid services had badly been affected. One worker in Ballari district explained that the district, which is the scene of major vaccine hesitancy, had created a Catch-22 situation.

Medical workers were finding it difficult to carry out vaccinations, the completion of which would allow them to focus on their other roles — including following up on pregnant women and maternity cases.

Coincidentally, KSLSA officials who also surveyed the Jigani PHC found that the “staff were working hard.”

The centre had a staff of 20 who were seeing an average of 1,800 patients a month, while also having treated 3,672 Covid-19 patients since the pandemic began.

The stretching of resources has led to at least four maternal deaths in the Jigani area, Xavier said. “This is significant because in NFHS-5, The Ministry of Health and Family Welfare said maternal deaths had largely been eliminated. That is clearly no longer true,” she added.

Covidisation of healthcare

It is not just expectant mothers whose lives are endangered by what one expert described as the “Covidisation” of healthcare, but also those suffering from a host of rare diseases unconnected to Covid-19.

For Gagandeep Singh Chandok, President of Thalassemia and Sickle Cell Society of Bangalore, the pandemic has meant an 18-month long tussle with the government to get help for the Thalassemia sufferers in the state.

The community has been largely deprived of state subsidised medicine and blood supplies since March 2020.

Because of the high cost of Thalassemia medication, the Government of India distributes drugs free of cost to the community through the National Health Mission (NHM).

However, the lives of 17,000-odd people afflicted with the condition in Karnataka was thrown into turmoil last year, after it became clear that the government’s plan to sanction a tender to procure new stocks of drugs had collapsed.

Chandok said members of the community have been scrambling to procure drugs independently, but most would have to spend anywhere between Rs 14,750 to up to Rs 30,000 per month. “Most people cannot afford it,” he said.

As dire as Bengaluru’s Thalassemia community is, at least they have a voice through their society leadership, Dr Prashant pointed out, saying that others have not been so fortunate.

“For example, incidences of sickle cell anemia are large among adivasis and OBCs. Who is there to speak for them? Already, many of these groups do not trust government healthcare services and for many communities, it is difficult to access healthcare,” he said.

He warned that the full impact of the government’s inability to scale up health resources to tackle both Covid-19 and non-Covid-19 issues will not be manifest until decades later.

“Malnutrition has risen as feeding and anganwadi programmes are not running properly, maternal and pediatric health care has suffered as Asha workers and ANMs are busy with covid-19 vaccination duties. The neglect of basic health services will have a generational impact that will be felt 20 to 30 years from now,” he added.

(With inputs from Nrupthunga S K in Davangere)

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