By Col Mukesh Pokhriyal (Retd)
The last twenty-five years of sick political health of Uttarakhand has had a concomitant effect on the public health system of the state. Health is a state subject, hence either political will nourishes it or brings it to dire straits – a condition that is being witnessed by the hill districts of UK. The ecological disequilibrium has added to the woes, besides posing potential health hazards. The framing of health policy, which itself is polarised around conflicting viewpoints such as preventive vs curative services, selective vs comprehensive primary health care, or Integrated vs vertical programmes limits the options largely to actions that can be carried out directly by the Ministry of Health. Health policy development involves three complementary tasks. First, identifying the major disease problems, assessing their social-economic consequences and evaluating the costs–effectiveness of alternative strategies. Second, designing health care delivery systems including establishing human and physical infrastructure, providing for drugs and logistical support, developing managerial capacities and funding mechanism. Third, defining and choosing what government can do through the full range of policy instruments that are at their disposal in the areas of persuasion, taxation, regulation and provision of services. How has the state fared in these three tasks? Unfortunately, the who’s who in the state could not look beyond their noses. The result – the jaundice eyed health system of the state continues to move back and forth in a simple harmonic motion between PPP mode and state owned! It faces the wrath akin to Mohammad bin Tughlaq’s farman.
Having travelled and trekked to the farthest and the remotest villages of Uttarakhand, coupled with first hand interaction with communities, two things emerged. The natives dread two kinds of medical emergencies – the medical management of pregnant ladies and accident trauma management. It has historical reasons, for, the common hill folk generally maintain good health and majorly do not require medical intervention on a day to day basis. The biggest challenge is faced by the pregnant women – lack of road connectivity – non availability of transport/ambulances – non-functional PHCs/CHCs-inadequate gynaecologists, which plague the system. Perforce, many a time, deliveries’ happen en-route to health centres, all at the mercy of the Almighty! Next come emergency and trauma cases – given the road conditions and unregulated overloaded traffic in the hills, the death tolls due to accidents is at par with, if not more than disease caused deaths. With rising traffic density due to floating population, increased number of landslide zones/sinking zones, the threat perception on this count is ever increasing. The PHCs / CHCs /district hospitals, due to lack of basic emergency and trauma infrastructure, besides non-availability of general surgeons, often act as post offices – referring the cases to THCs! The Alma Ata conference on primary health care in 1978 introduced the principle of “Health For All” by year 2000. Conceptually this encompassed all health problems in the population was community based and involved all sections of the government. The broad political-administrative and community participation in devising solutions leaves much to be desired in the state of UK. The inter-sectoral coordination between the different wings of the state government is at its lowest, wherein the basic “Sanitary Reforms” started in England in early nineteenth century are yet to see the dawn of day in the state. To illustrate, even district headquarters/cities in the state are gasping hard for clean drinking water supply and garbage/refuse disposal management, leave alone the tehsils or blocks or panchayats of the state. Thus, public health sanitation, be it in rural or urban areas, has got a solid beating in the state. No wonder, Rajdhani Dehradun itself grapples with dengue and other vector borne diseases.
The way forward is back to basics – strengthen the PHCs and CHCs in the rural hill areas. The large hospitals are more ivory towers of diseases than centres for the delivery of comprehensive health services. Rising costs in maintenance of these large hospitals and their failure to meet the total health needs of the community demands time tested models of health care delivery, with a view to providing health care services that are reasonably inexpensive and have the basic essentials required by rural population. Emergency care should begin at the accident site, continued during transportation and concluded in the hospital emergency room. At any of these stages a life may be saved or lost, depending upon the skill of health care workers, availability of needed emergency equipment. To achieve these ends, there should be an accident services organisation/first responders, akin to a quick reaction team, at the tehsil level. Equip the district hospitals with state of art trauma centre along with adequate number of surgeons. It is time to walk the talk, stop the rhetorics of all is well. It is not, rather for now, it is all in well! The state of helplessness amongst the hill population towards repetitive government apathy, has made them believe that what cannot be cured has to be endured. It is time for deep introspection by those entrusted with the responsibility of providing medical health care to the population. Maybe it is time for metanoia for the who’s who!
