Maharashtra: Primary Health Centres left out of Covid care net
At a primary health centre (PHC) in Amravati district’s Morshi taluka, patients who come in with Covid-19 like symptoms such as high fever, breathlessness or depleting oxygen saturation are immediately referred to the district hospital, 30 km away. The PHC located in Vichori village is among the 59 such centres in the district. Yet, despite being the nearest medical centres for the community, they have merely acted as referral centres in the pandemic.
Dr Satish Pawar, additional mission director, Directorate of Health Services, Maharashtra said that PHCs so far have been kept away from treating Covid-19. “The primary centres implement crucial programmes like maternal and childcare,” said Pawar. “We did not want Covid-19 to affect any of the other health programmes. It is a conscious decision to refer all Covid-19 patients to designated Covid Care Centres, rural hospitals or district hospitals,” he said. “Rare exceptions may be made in cases where access to designated Covid care centres is difficult. But such need has not occurred so far,” he added.
However, data over the past month indicates that most of the cases in Maharashtra have emerged from rural parts of the state.
Take the case of Amravati, which recorded 8,204 active Covid-19 cases on May 24. Nearly 80% were from rural areas. The district in Vidarbha region was the first to record the spike of the second wave. From less than 100 cases daily till January-end, it reported its highest single-day spike of 1,067 cases in the third week of February. At the time, the numbers rose rapidly in urbanised pockets of Achalpur and Warud, prompting authorities to impose a lockdown on February 23, and which ended on March 8. Simultaneously, they focused on testing and tracing. This so-called “Amravati pattern”, officials said, helped bring down the numbers.
On May 12, Amravati district recorded 1,089 cases, with 1,097 active cases. The rural share of daily cases on that day was 76.12%, while in active cases, it was 57%. The gap between the rural and urban areas has only been increasing since then, even though the overall cases have been falling. On May 25, Amravati district recorded 605 cases, but 560 of those were in the rural areas, with only 45 in the city. That’s a rural share of 92.56%. On May 25, Amravati district had 1,376 active cases, with the rural part contributing 820 or nearly 60% of those.
Other badly affected districts are showing a similar pattern. Until the second week of May, Ahmednagar, Jalgaon, Solapur, Sangli and Kolhapur recorded disproportionately high rates of rural cases. On May 13, rural parts of Ahmednagar reported 2,370 new cases as opposed to just 255 in the urban parts. In Jalgaon, 575 new cases were recorded in rural areas whereas 71 new cases came from urban Jalgaon. Solapur rural saw 1,569 new cases while the urban pockets in the district clocked 125 cases (that’s a difference of 1,155%). Kolhapur and Sangli recorded 1,144 and 1,229 cases in rural areas and 125 and 234 new cases in the urban areas, respectively, on the same day.
As the cases spike across rural Maharashtra, officials now realize that PHCs can play a crucial role in curbing the spread of the coronavirus disease by ensuring that villagers wouldn’t have to travel far for treatment. But, to achieve this, the state must first overcome some roadblocks.
In a video conference with doctors from his constituency of Varanasi last week, Prime Minister Narendra Modi emphasised the need to bring medical services closer to the Covid-19 patients, and said “jahan bimaar, wahin upchaar” [treat the sick where they are located] should be the goal.
Even the Union health ministry’s recently released guidelines on Covid-19 Containment and Management in Peri-Urban, Rural and Tribal areas, recognizes the need for stronger primary level health care infrastructure to intensify the state’s response to the pandemic.
Maharashtra’s network of 1,829 PHCs in the rural areas are ill-equipped and under-staffed. According to the Rural Health Statistics (2019-2020), a report brought out by the Government of India’s National Health Mission, there were 1,962 vacant posts of female health care workers in PHCs across the state in 2020. Of the 3,587 sanctioned posts of doctors, 739 are vacant; 669 of the 3,834 sanctioned posts of nurses are vacant. Maharashtra requires 1,112 specialists like obstetricians, gynecologists, physicians and pediatricians in its PHCs and Community Health Centres (CHCs) but only has 558 sanctioned posts of which 159 are vacant, leading to an overall shortfall of 713 specialists in rural pockets. The state has 32 vacant posts of radiographers, 247 vacant posts of pharmacists and 544 vacant posts of lab technicians in the PHCs and CHCs.
LACK OF INFRASTRUCTURE
A PHC typically has two doctors and support staff like supervisors, a pharmacist, and a lab technician. One PHC is commonly connected to five sub-centres which have a female and male healthcare worker each.
“We mainly offer primary first aid, antenatal and prenatal care, run OPDs every day and implement immunization drives,” said Yogesh Gawai, a healthcare worker attached to the PHC in Vichori village in Amravati. This PHC, for example, has a four-bed ward, a delivery room and a minor operation theatre for family planning procedures. But the PHC does not have an ICU set up or a specialist doctor. The medical officers in most PHCs are Bachelor of Ayurvedic Medicine and Surgery (BAMS) doctors.
“The only medical equipment used at PHC is a stethoscope. Anything beyond that is referred ahead,” said a health worker who did not wish to be named. In the tough rural terrain with bad road connectivity, reaching advanced medical centres in district hospitals becomes challenging for patients, leading to delays in seeking medical treatment.
Last August, the Vichori PHC was equipped with an oxygen cylinder and last week they received two oxygen concentrators gifted by guardian minister Yashomati Thakur. The PHC staff is yet to be trained in using the concentrators. “PHCs were never envisaged to tackle diseases like Covid-19,” said Dr Dilip Ranmale, district health officer of Amravati. “But we are now trying to expand their use without affecting the non-Covid work,” he said, adding that the PHC staff has played a crucial role in contact tracing and rolling out vaccination in the pandemic.
“Nearly 85% of the Covid-19 cases are mild or asymptomatic, and such patients could easily be managed at well equipped, well-staffed primary centres,” said health activist Dr Abhijit More. “If patients are diagnosed and treated at the earliest, the further complications of requiring oxygen or ventilators can be controlled largely. But PHC’s in Maharashtra have not been upgraded to keep up with such challenges.”
UPSCALING INFRA NEEDS
Washim district’s Ashegaon village appointed two MBBS doctors last week. Till now, the centre was led by BAMS doctors who were appointed on a contractual basis. The centre has a pharmacist, a staff nurse, two supervisors and three multipurpose workers. “But we have a shortfall of at least five staff members including two Auxiliary Nursing Midwifery (ANM) staff,” said a health worker. The PHC caters to a population of 28,000 across 21 villages. The staff has been trained in recording pulse oximeter readings after Covid-19 but the members have been asked to refer confirmed and suspected Covid-19 patients to the Covid Care Centre, 22 km away from the PHC.
While most patients are transferred through ambulances, some travel on their own, risking the spread of the virus. “Many who are allowed home quarantine don’t follow rules and roam outside,” the health worker said, adding that they had to call the police to warn two such patients. “In rural areas, the farther a patient is asked to go, the more reluctant they get. Equipping PHCs for Covid-19 care is a good idea but manpower will be crucial to run them,” he added.
Meanwhile, Amravati officials have identified 20 PHCs that will simultaneously function as isolation centres for mild patients. The isolation wards, however, will be set up in halls and schools near the PHCs to ensure that other patients are not at risk.
“We have finalised the premises for the isolation wards and are in the process of setting up the beds,” said district health officer Ranmale. “The isolation wards will start functioning in another week’s time.”