Tackling effectively the maternal and child health emergencies
The piece has been authored by Tapasvi Puwar, Associate Professor and Dileep Mavalankar, Director - IIPHG
India accounted for estimated 35,000 maternal deaths or 12% of global maternal deaths in 2017 as per United Nation (UN). At the same time, as per UN, in 2019 about 16% or 8,24,000 deaths of under five children occurred in India. This is much more than about 5 lakh Covid deaths in India. Sustainable Development Goal (SDG) 3 says to reduce Maternal Mortality Rate (MMR) to 70 per 100,000 live births, and under-five mortality rate by 25 per 1000 live births by 2030 meaning fewer than 18,000 maternal and 6,25,000 deaths of udder five children per year. As Covid is now waning we must look at maternal and child deaths which has been neglected in last two years due to pandemic.
To achieve SDGs Indian needs to strengthen emergency medical services provided to mother and children. First referral units (FRU) plays vital role in India to provide emergency medical services to mother and children. District Hospitals (DH), Sub District Hospitals (SDH) and Community Health Centers (CHC) are designated as FRU by Government of India. For provision of emergency medical services, doctors specialised in obstetrics, pediatrics and anesthesia are required at these FRUs to perform emergency cesarean section, and newborn care. As per the Rural Health Statistics report 2019-20 of government of India, there are 3,313 FRUs as on 31st March 2020 providing these emergency services. Out of these, 1,706, 821, 668 and 118 are at the level of CHC, SDH, DH and Medical Colleges respectively.
It is also important to understand that all DH and SDH are designated as FRU. At the same time not all CHCs are designated as FRU. It is as per the local requirements state governments designate CHCs as FRU. So out of total 5,813 functional CHCs in the country only 1,706 CHCs are designated as FRU.
There are 3,195 FRUs in the country which are CHC, SDH or DH. The norms for staffing at these facilities is governed by Government of India. As per government norms, standards for human resources at DH and SDH depends upon their bed size which is variable as per the local requirements. As per Government norms for human resources at CHC, there should be 4 specialists (obstetrician, pediatrician, physician and surgeon). As per Indian Public Health Standards (IPHS), in addition to 4 specialists, one anesthetist and one public health specialist posts are added making number of required specialists at CHC to 6. This is the minimum level of staffing of the CHC. We must point out that one obstetrician cannot provide 24x7 emergency services 365 days a year.
As per RHS report, there are total 5,813 CHCs functioning in the country. Thus, as per the government norms there should be 20,732 specialists required at these CHCs. However, as on March 2020 government has sanctioned only 13,206 (64%) posts of specialists at the CHCs. Out of these only 4,957 (38%) posts are filled. So, governments need to sanction remaining 7,456 posts of specialists on priority to improve emergency medical services for 70% rural population of India. Another priority is to fill the 62% posts of specialists which are vacant immediately. One can only imagine how the rural health centers function with such large deficit of specialists. And what is the difficulty rural people face due to such shortfall in staff.
For every CHCs there should be one obstetrician available. But 3,475 posts are sanctioned, while only 1,591 (46%) positions are filled leaving huge vacancies for obstetricians. Even there are vacancies for Obstetricians at FRU designated CHCs which are 1706 and there are only 1,591 obstetricians posted at FRU designated or non FRU CHCs. Vacancies for pediatricians are much more. Out of 5,813 functional CHCs, 3,015 CHCs have sanctioned position for pediatrician. Out of this only 1140 (38%) posts are filled leaving huge vacancy even at CHCs designated as FRU.
It is not possible to reduce maternal and newborn mortality in the absence of specialised care for treating complications. Thus, to achieve SDGs in time government needs to prioritise filling up vacant post of specialists. Well-functioning primary health care system with general doctors and specialists are required for improving health of people of this country.
Under task-shifting efforts to address the shortage of these specialists in the country, the Government has trained many MBBS doctors in short courses for doing Caesarean sections and providing anesthesia to these mothers during the operation. However, data on such trained doctors is not given in RHS report. There are issues regarding proper postings of these trained MBBS doctors, provision for special incentives after these trainings and re-designation of their duty as specialists. Such policy level issues need to be solved on priority by government to achieve SDG for the country.
Another point to ponder is 24X7 working of FRU for tackling emergencies effectively. FRU can only functions effectively if all components of FRU are in place. For this all human resources including obstetrician and pediatrician should be available all the time. Many FRUs have only one specialist posted which will not make these FRUs functional on 24X7 all year round. Thus, the RHS report should also mention human resources available at FRUs and how many FRUs have all the required staff for round the clock operations.
As a country India needs to prioritise postings of specialists and task shifting at FRUs to achieve SDG goals.