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Part II- { . t : t a l tV , : ' :LF,V(LS

When the much-focussed and heralded public health services for preventiondiseasessuffer from such gross deformities, the state of the curative services can webe imagned. We have seen n section 5 that only a small fraction of the patients viited the public health centres for healthcare. An absolute maioriw of the sufferin

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people depended upofl private providers in general and quacks (UMPO in particular.Sfhile asked whether any member of the sampled households visited the publ,ic

health centres during the year preceding the survey only 30 percent in Birbhum and28 percent in Dumka responded in the affirmative. Of the total number of visitors,more than 90 percent visited either the hospitals or the pdmary health cefltres.

From the graphic below, it can be seen that a considerable section of ruralhouseholds visited the hospitals. Most of the respondents put this down to the factof (1) accessibility to the hospitals and Q) almost zero service delivery at the grassroot level and poor service deJiveryat the PHCs. In many cases,PHCs routinely referpatients to hospitals because of the non-availability of healthcare facilities in thePHCs. Many of the respondentssaid hat they preferred to visit the hospitalsdirect-ly to avoid wasting time at the PHCs. "The PHC doctor will send the patient to hos-pital anyway,so why not go to it straight away?" In most casesthe pHCs were ill-equipped, particularly regarding diagnostic services and supply of medicines. Theproblem is further aggtavatedby the reported carelessness f the PHC staff. As wesaw at a block PHC in Birbhum, one of the two doctors engaged n private practiceduring his duty hours. He did not bother to hide his practice and displayed a boardhighlighting the time of private practice ftetween B AM to 1 PA! for the benefit ofpatients!The sole doctor left at the PHC, who was perhaps consideredby his col-leagre to be a fool, was completely unable to manage the crowd of patients."Sometimes I feel frustrated since I cannot do justice to the patients," he said, Insuch a situation, patients often found it more useful to visit private practitioners.

In Dumka many of the respondents complained that not only did the pHCsrefuse to give them any medicine, but some of them also charged money fot treat-ment. And in many casesdoctors or other health staff did not even bother to listento the patient, - "atyamhonba anjomak'."

In addition to such attitude and functioning, the negligence that people experi-enced made them skeptical about the PHCs. In a village ofDumka district a sudden outbreak of drarrhoea claimed 11lives in a span of 3 days. (Ihis happened during the period ofour study.) People reported matters to the PHC immediatelybut to no avail. The outbreak spread Jike prairie fire. Afterthree consecutivemessages.wereent to the PHC, six bottlesof saline were given to the villagers to administer to patients"with the help of local quacks". Another incidence of suchan outbreak was reported to the Sadar hospital, which,according to some respondents in Dumka town, acted onlyafter the district administration took a serious view of thematter. In this casesome of the villagers could approach thedistrict administration through a person known to them wholived in the townl and who had strong political and bureau-cratic clout. A third incident: In Gariapani, one of our sur-veyed villages,during the year preceding our survey 35 people

Chart 8.1[Jse of Different Public Health Servicesby any member of Household

7060504t)30201 00

Govt. Govt. PFIC/RuralFlospital Dispensary l-Iospital

Sutr. Govt.Centre N{obile Clinic

WBltbhuntfidillDumka

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died of rrralaia (Plasnodiamfatcifarun),locilIy called "brain malaria". As reported bythe villagers, when the patients were dving the local PHC was sent repeated requestsfor help. No action was taken. In the end villagers lodged a complaint to the con-cerned BDO. Still no action. Mention may be made that the village is inhabited bypoor and mainly i-lliteratepeople who have no political or bureaucratic connections.

These incidents say a lot about the relationship of class and utilization of pub-lic facilities. The complaints of the poor (and illiterate and socially backward) remainunheeded while the powerful can make the services functional to a large extent.

The condition of the hospitals was not found to be very different, though forsome cases,particulady for the complicated ones, they were reported to be unavoid-able. Both in Birbhum and Dumka respondents reported that most of the hospitaldoctors had their private practices and they took much more care at their respectiveprivate chambers than in the hospital. Yet, for many of the poor patients even thepraal and crippled services become important'\Wecan see from the following table the services sought by patients. While for100 percent the purpose of visits to the public health system was treatment of ail-ments in both the districts a considerable number of households in Birbhum visitedthe public health units fot child delivery. Since alarge majority of our respondentsbelonged to low income groups, it was neady impossible for them to afford the costof nursing homes for childbirth. Although most of the households made manycomplaints against the conditions in the hospitals (including poor maintenance,unsympathetic behaviour, not giving medicines, etc.), the service was still utilised forit was far less expensive than that of a ptwate clinic or nursing home.

In Dumka, however, approaching the public services for child deiivery was notfound to any significant degree. This was mainly because of the inaccessibility of

THr DoctoR'sHotrtouR\Xrhenpatients who come to health centresare treated with such indifFerence, he siruation oF field visits and med,ical reat-

ment at patienrs' homes can well be imagined. A combination of sheer unconcern towards their scrv.ices nd utter skepticismabout rhe health delivery system irself 61*ap. the skepricism is to def,end heir indifFerence)has created a siruarion of totalstundstill. lhile askedriour rt.,. fi.ld r.ivic"rieiivered by do.tor. and health workers, a doctor in a block level PHC of Dumkasarcasdcally said,'Ab ta daktor logon o haalja me bantlagii karna parega l\ow the doctors have to work the way the petry radersdo in rhe weeldy markets)." The reason for this sudden outburst was a circular issued by the health department of thei"*..*"", of jhrrkhand thar direcred PHC doctors to distribute ani-malarialdtugs in the weekJymarkets (baafia).Such move,he thought, was insulting towards the 'noble professioir' of doctors Al l the PHC doctors we visited severelycriticized the gov-ernmenrFor le tdngthedoctorsdownbeforethepubl . ic ye."Hamaru iy

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hospitals (the PHCs of Dumka were not equipped with adequate child birth facili-ties and the family planning and reproductive health programmes to generate ^.ware-ness wefe comparatively much less successful).

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9 , 6 0 , . !,;i-b0'.0q:.'l7,70 ' !:qiij

t.z:: S,OO. 1+O,Qo. ' l:: 'i,zo55i . j ' t t . . ,not mutuallj exclusive);Let us examine some other aspects.Of the total number of households who vis-ited the public health delivery system:' only 14 percent in Birbhum and 13 percent in Dumka reported to have gotthe prescribed medicines from the health centres / hospitals.' As much as 49 percent in Birbhum and 53 percent in Dumka complained thatthe public health servants did not spend enough time with the patients.' Ooly 43 percent and 42 percent in Birbhum and Dumka respectively explicit-ly said that the public health servants behaved nicely with them.' rn 23 percent cases n Birbhum and 27 percent cases n Dumka, health work-ers other than doctors or nurses examined the patients at the pubJic health centres.The above findings clearly indicate that people have many different reasons forcomplaining about the public health delivery system,particularly in Dumka but alsoin Birbhum in general. The frusration that has grown from the poor performanceof the system have pushed them to the private secto! which promotes unequal deliv-ery and is often an unethical, incompetent and corrupt system based only on money.The rush to seek services from private doctors - mainly quacks - is not onlyassociatedwith the poor quality of services provided in the concerned public insti-tutions but also, as mentioned by many doctors of the pHCs and hospitals, due totheir limitations owing to poor infrastructure and equipment, poor staff strength andshort supply of medicines.Most of the patients,as reported, had to buy the medi-cines and to get their diagnostic tests done from outside the public health system. Inaddition, the increasing trend of introducing user charges, or the hospitals, as a doc-tor mentioned, was gradually building up repuision (towards the public hospitals).1sThe opinions of doctors in both the districts concerning the functioning of thepublic healdr delivery systems nclude the following:

(1) Poor accessibility to the PHCs and hospitals, which are the main points forcuiative services. In most of the cases connectivity (in terms of road links, tele-phone, etc') was found to be abysmally poor. Ambulance facility was not available nany of the three PHCs visited in Dumka. In Birbhum, though this faciliry was avail-

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