Ahead of third wave, India's rural health centres depleted of drugs, staff

Healthcare centre in Maharashtra village shows what rural India could be facing ahead of new variants of the disease.

Farm worker Bildar Pavra has brought his daughter Neeti, 6, to the Telkhedi primary health centre (PHC) at Akrani in north Maharashtra's Nandurbar district to get an infected boil treated. She is running a mild fever, and he too needs to have his eyes checked.

However, the family has to return home, a half-hour walk away in Atharipada, disappointed. There are two doctors at the centre and neither is available. An attendant offers Neeti paracetamol to ease the fever though he is not qualified to medicate. Doctors are never available at the PHC, complains Pavra, and neither is its ambulance. All his daughters were delivered at home and one died in a drowning incident.

It is the third week of June, and the Covid-19 second wave is waning in Maharashtra, but the rise of more infectious variants and a possible third wave could put its rural healthcare system under severe strain again. But the Telkhedi PHC showed few signs of being prepared to handle Covid-19, or even more routine medical needs such as Pavra's.

The Union health ministry's standard operating procedure (SOP) on Covid-19 containment and management, released on May 16, 2021, has special guidelines for peri-urban, rural and tribal areas. These guidelines should apply to Nandurbar, a predominantly tribal district. The SOP places critical pandemic responsibilities on PHCs, including the supervision of Covid care centres for asymptomatic and mildly symptomatic cases. If need be, primary centres are also expected to transform into Dedicated Covid Health Centres (DCHC) with oxygen support for moderate Covid-19 cases.

However, when we visited five PHCs and three sub-centres in three Nandurbar talukas, we found basic infrastructure missing and protocols, including drugs inventory management, in tatters. We found expired drugs in three of five PHCs including one where injections used to treat an adverse reaction to Covid-19 vaccines were well past their expiry date. These injections are part of an Adverse Event Following Immunisation (AEFI) kit prepared and kept ready at vaccination centres.

When questioned, medical officers heading the PHCs told us that they are all struggling with an acute staff shortage, especially pharmacists who are supposed to monitor drug inventories. We also found other issues related to staff deputation at these centres, leading to poor accountability.

"In Nandurbar, 30% of our posts are vacant. Medical officer posts may have been filled but pharmacists and other posts are vacant. Accommodation for the staff is not as per their expectations, so people avoid coming here for postings," said Rajendra Gawde, the CEO of Nandurbar's zilla parishad.

PHCs offer the first and most fundamental level of healthcare in India's villages. In this first of two stories from Nandurbar, we examine the flawed management of pharmacies at PHCs, essential to the rural population because private pharmacies are few and located mostly in big villages. Also, those availing PHC facilities mostly cannot afford to purchase drugs elsewhere. In the second part, we will investigate the delivery of other medical services by PHCs, especially during emergencies such as deliveries and snake bites.

Maharashtra has reported 6.11 million Covid-19 cases by July 7 and has lost 123,531 people to the virus. Niti Aayog, the government think-tank, describes Nandurbar as an aspirational district--undeveloped and in need of additional attention. It had reported 220 deaths until March 1, 2021 a figure which moved up to 948 by July 7. By April 1, the district had recorded 18,498 cases and by July 7, this soared by almost 20,000 cases, pushing the district's total to 39,038.

Expired stock, missing pharmacists

Yogesh Kalkonde, a public health researcher who works in Gadchiroli district, was of the view that PHCs and community engagement could play a significant role in the battle against Covid-19, taking the pressure off intensive care units. PHC staff and ASHAs--accredited social health activists--should be trained to triage and isolate patients and determine if they need to be referred to other facilities.

"Oxygen concentrators need to be allotted for villages or at least PHCs: It is difficult to station ventilators in villages because they require highly trained personnel but concentrators can be sourced," he suggested.

All this, along with the training of ASHAs and rapid capacity building based on protocols created in collaboration with village leadership, should have been under way already, Kalkande pointed out. But, on the ground, there are no signs of any kind of preparation.

The Telkhedi PHC, which caters to a population of 19,304 people distributed over seven villages or 41 hamlets, was to have shifted to a new building five years ago. But the contractor abandoned work over allegations of corruption and the unfinished building lies unused. The out-patient department (OPD) at the PHC is supposed to be operational six days a week but the day we visited the centre, we were told that it had been three days since doctors dealt with out-patients.

Latika Rajput, a Nandurbar-based activist, accompanied us on our visit to some PHCs. As a member of the state's core committee on malnutrition, headed by the chief secretary, she was able to inspect the stock of medicines and found expired stocks of several drugs (see table below).

At the Telkhedi PHC, also a Covid-19 vaccination centre, drugs used to treat the side-effects of vaccines too were past their expiry limit. These included hydrocortisone sodium succinate injections stamped with December 2020 as expiry date and adrenaline bitartrate injections, November 2020. Since India's Covid-19 vaccination drive began only this year, it would appear that no PHC staff had since checked the expiry date on this AEFI kit.

The Covid-19 vaccine's operational guidelines require that an AEFI kit, with hydrocortisone and adrenaline, be available at all times at immunisation centres. "The medical officer at the PHC… ensures adrenaline ampoules at the session sites are within expiry dates," as per the guidelines.

However, the pharmacist employed at the Telkedhi PHC, D.P. Pavra has been on deputation since May 15, 2021, and neither the medical officer in-charge nor the second medical officer were present at the time of our visit.

After the inspection, Rajput sealed a sample of the expired drugs and wrote a detailed panchnama, or report of findings. The staff present on the occasion signed the panchnama and the list of sealed medicines. The panchnama, along with the expired medicines, were then submitted at the district health office for further action.

"Every citizen of this country should have the right to check if the drugs they are administered are within the due date and whether public health systems are in shape, the way RTI Act allows us to access information," said Rajput. "But people neither have the time nor the access to do this. Ideally, people should not even have to do this and there should be internal safeguards within our systems. What I do is I write a spot report and file a record of the evidence, then the district administration can take a call on the findings."

We saw similar problems at the Mandvi PHC where people from neighbouring hamlets have lined up seeking treatment for various problems and vaccination as well. Some of the expired medicines found in this PHC included ciprofloxacin 250 mg used to treat dysentery, Ciprobact eye/ear drops and atenolol tablets. Rajput repeated the process of issuing a panchnama and sealing of drugs here too.

In Shahada's Padalda PHC, medical officer C.K. Samudre was busy collecting swab samples from people with Covid-like symptoms while his wife and second medical officer Swati Sadaphule oversaw the day's OPD. The PHC started an RT-PCR facility to test Covid recently and caters to a population of 29,000 spread over 18 villages. Despite being located in a taluka that is not as remote as the others, this PHC too had a stock of expired medicines including ascorbic acid tablets and benzyl benzoate application to treat lice and scabies.

Healthcare in shambles

"It is a sorry state of affairs when expired medicines are found not only in PHCs in extremely remote areas of the district but also in PHCs located in the relatively developed Shahada taluka," said Rajput. "To find medicines used for treating AEFI expired during a pandemic is very serious. There is a process in place for disposal of expired medicine stock and it is the most important duty of the pharmacist. People should not have to fight for something so basic. The tender process means actual procurement of vaccines happens very slowly because of which there is a demand and supply gap."

On a June 4 inspection round at Mandvi and Pimpalkhuta PHCs, Rajput said she found dated drug stocks and submitted a panchnama to the district health office. Based on this, the zilla parishad CEO Gawde had issued a show-cause notice to both centres. After the inspection at the three PHCs featured in our story, Gawde recently issued notices to them as well.

Medical officers at all these PHCs claimed that expired drug stocks are disposed of as per protocol. "I had given repeated instructions to [the staff to] check [the] medicine stock every month. I have also asked staff to keep an inventory of all medicines along with their expiry dates," said Rahul Munde, medical officer of the Mandvi PHC.

Santosh Pavra, the medical officer at the Telkhedi PHC, reasoned that the centre's pharmacist has been on deputation for two months. On the Pavra family from Atharipada that had returned home untreated, he said: "I was on Covid duty that day and the other doctor was on leave."

C.K. Samudre, the medical officer of Padalda PHC, cited similar issues. "The pharmacist V.M. Patel allotted to our PHC has not reported to work for almost a year," he said. "We desperately need a pharmacist, even if it is on deputation. It's a key post that is responsible for medicine inventory. We only have one nurse who is looking into this as an additional responsibility."

'Need last-mile solutions'

The challenges of PHCs and our public health system in Nandurbar could be representative of rural areas across the country, said experts.

"Be it testing, vaccination or last mile delivery of health services, nothing is happening," said Shobha Suri, senior fellow (health) at the Observer Research Foundation. "The [Covid-19] SOP says a lot but in reality, our health infrastructure has always been in a shambles even though people are largely dependent on it. There is an acute lack of manpower and monitoring mechanisms due to which they themselves don't know what is in their medicine stock and what has expired. Manpower shortage is their biggest issue. There are too many responsibilities on ASHAs and AWWs. We need practical solutions keeping in mind our ground realities, solutions that actually reach the last mile."

Rural health specialist Kalkonde pointed out that these are chronic issues. "Our public health system was always decrepit and has an additional burden of Covid now," he said. "PHCs were never made for high-level clinical care. They were created as a peripheral hub under the millennium development goals for maternal and child care to reduce mortality. PHCs are a relic of that era and suddenly we are asking them to deliver Covid services."

Zilla parishad head Gawde said his office is prompt with taking action against truant PHCs. "Also we held a meeting to give instructions [on rules and protocols] and ensure this doesn't happen again. We have sensitised our staff a lot, I am surprised that expired medicines were found there," he said.

At Telkhedi, as Pavra prepared to return home with Neeti, he spoke about the death of his fourth child. "She died when the barge she was in with her friend toppled in the river. They announced a compensation of Rs 2 lakh but we never received it. For my wife's deliveries done at home, we were supposed to receive Rs 500 [paid under Janani Suraksha Yojana for home births] but we never did. It is always like this for people like us. Nobody cares."