Part III

)' l:: t"i ? t: ltJ l,J i4i i"i:a {-} Tt l L ?tJ8 tl {- : t i }.t-i l li l: ft i i Lt: l>

From the above discussion, one thing becomes vefy cleat - that the poof funning of the public health services, particulady in Dumka district, is a reality that has spread its roots into the depths of peoples' minds. The unreliability of the public health services is increasingly pushing the people towards private practitioners. The study team visited all the BPHCs and PHCs of the study blocks (13 in Birbhum and 12in Dumka) and some sub centresunder those PHCs (18 in Birbhum and !3 in Dumka). The visits (that included interviews with severai local residents) suggest a fair degree of difference in the functioning of the health delivery system of the two study districts. While in Dumka district almost all the additionai PHCs and sub centtes were non-functional and the functionality of the PHCs (at the block headquarters) was very poor, in Birbhum things were considerabiy different. While in Dumka district some of the sub centfes and even PHCs only exist on paper (some sub centreswere fbund to be used as public lavatories by local people!) in Birbhum all the PHCs and sub centres have physical and operational existence' Hor.vel'er, we found inter-biock variations in terms of infrastructure, staff pat-

t"o.r u.rd the delivery of health cafe at the PHCs and sub centfes of Birbhum district. While some of the sub centres rn a particuiar block were found to have been occupied by vagabonds or destitutes and the iocal residents reportedly had no idea about the running of the sub centres, in one block the sub centres acted as one of the main pillars of the heaith system (interestingly in that particular block, the BPHC did not have the reputation of good service delivety). Table 8.5 Functional Status of the public
Bitbhutn

health delivery system.

Durnka

Exrsting and functioning regularly Exisung and functionLngpartiallY

Existing but defunct No physical existence Tota.l visite<l

.'B?HC 3 {100)

PHC

Sub-cefrtte

PHC

APHC

Sub*ccntre

7 n0)
-l tJtti

10.(56):

3 (100) 7,;QB) 2 {22) 3(100)

2 (15)

6 (33\ I (6)
1'{6}

5 f3B)
3 \ZJ)

3 (23)

3 1100;

10(100)

18 {100)

e (100) 13(100)

Figares in l,ar,nlhxcs intliruk penentaS,

Table 8,6 Service availability in the public health system

Statr:s. BI'HC locateclat nloct headquarter ,{vailabie Medical officer's availabi.liry Not available
Availability of medicines
2*

Services

Bitbhum PHC opemied uuder thr

I)amka

, Sutr,
cbgtre.

PHC
located at Block h* dqo"t,.t,

, B3lre
2

:.:.;.::: ::]
NA

,: i::,:l:

Additional operated under dre PHC .

Sub centre

* Howevet, at least in one caseu'e have found a doctor practicing at his private clinic during *'orking hours. Also ln some cases absenteeism among some of the doctors was found to a large extent. ** Irtegularity in attendanceby the doctors was repottedly a common phenomenon. In fact, in one of the PHCs v.e could not find any visirs. doctor ir.rspitc of Fourconsecutive *** D^t^ for two PHCs in Birbhum was not available. Seven sub centtes of Birbhum and nine sub centres of Dumka wete found closed on the days of visit, although visits were planned according to the opentional calendar of the sub centres (In Bitbhum sub centres rvere supposed to oPen on Ntondai', Wednesdal' and Friday between 8 AM - 12 PNI. In Dumka sub centres *-ere supposed to open every weekday benteen 8 ANI - 12 PNI except Tuesday.) '# In tact, very litde medicine rvas reportedlr provided to the patients. Also in some cases,as some of the respondent-. alleged both PI{C and APHC staff charged moner' for the medicines given to then

3**
I

NA NA

NA.

A11 presctibed medicine s

Partial No medicine

tl

8#
I

Diagnostics facilities

Blood
Pathological

NA N.A NA.
8

NA, NA NA 9
o

3
1

X-ray
No test Bed fac.ilides
n vallaflle

NA NA NA
NA

NA

NA
NA NA

Not avarlable

Child birth'
tacllltles

Avaiiable Not available

3 3

z 6 lLl+*x

NA 18*** 3

NA
t 3i.+*

Total rrumber of cenres visitcr

As mentioned above, the APHCs in Dumka district were found to be almost defunct. Aithough the situation was comparatively bettet in Birbhum, all the BPHCs and PHCs suffet from infrastructute, staff, fund and othet problems. Above all, the problem of motivation among the health personnel seems to have made the problem worse. {,l ; . ( r-,l.. 'l t'L The poor functioning of the public health delivery system, particulady in Dumka district, has left beneficiaries, especially the poor, at the mercy of the private health care (non)system. In Birbhum the situation is comparatively bettet, yet it still demands a lot of attention. Such dependence on private practilioners not only has economic implications but also much deepet social implications. Private practitioners, who have almost zero accountability to the public, are divided into two broad the classes qualified and unqualified. In most of the cases, poor have no option but to depend upon unqualified quacks and onlv the comparatively weaithy can afford the services of qualified medical practitioners. Even when the poor avail of the services of qualified doctors (often by selling andf or mortgaging their assets, sometimes becoming completely pauperised in the ptocess) they ate not assured of the care drat a rich patient gets. In this manner, the absence ot inadequaq. of the public health services- which are supposed to safeguardthe interests of the poor - and the gradual withdrawal of the state from the health sector (either completely'or in the form of introducing user charges),coupled to the dependenceupon private services, intensifies class and social barriers with adverse impacts on health, economy, Jiteracy and other socialfactors.l6 Finally, there is a rich heritage of public health care in India. History not only provides examples of the flourishing of scientific medical practices in India mote than two thousand years ago, but also suggests a public health delivery system since ancient times. The remnants of a public hospital of the Magadhan period at I{umrhar, Patna, the capital city of present day Bihar, still amazes r.isitors. Public health delivery systems were also available during the later period of Mughal and Sultanate rule in India. After gaining freedom from rwo hundred years of colonial rule, India now has a functional democracy. The gains of such a democracy can ver.Y easily be undone in the absence of an effective public health delivety system.