1

A view on

(Health Services)

In Bihar

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Sl. No

Particulars

Page No.

1.

Bihar State Health Budget : Overview

3-6

2.

Bihar : Current Health Scenario

7

3.

Diseases : overview

8-10

4.

Bihar Areas of Focus

11-13

5.

Conclusion

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Table of Contents

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Bihar Deputy Chief Minister, Sushil Kumar Modi presented Rs 65,325.87-crore annual budget for 2011-12 in the Assembly on 25th February 2011, with road construction, human resources development, Health and water resources cornering major part of the expenditure.

The road construction, human resources development; Health, water resources will continue to be the thrust areas in 2011-12 too and announced an allocation of Rs 5,075 crore, about 21.15 per cent of the state plan of Rs 24000 crore.

The major Funding is coming from NRHM (National Rural Health Mission), Besides NRHM, DFID (Department of International Funding) and BMGF (Bill and Melinda gates Foundation).

The total financial requirement projected in the project implementation plan is around Rs. 1975.37 crore. So we have an excess of budget as per the projection for fiscal year 2011-12.

• Universal Access to Primary Health Care

State’s Vision, Goal and Strategy For 2011-12

The State’s vision for the overall development, in general, and accomplishment of the desired set of goals in health sector under NRHM for the current year is as mentioned below:

• Provide affordable Health Care Services • Decentralized Health Services • Community Participation in Health Care • Enhanced performance of Public Health System by improving quality and ensuring client satisfaction • Strengthen Health Management Information System • Encourage participation of Civil Society Partners in health service delivery • Private Sector Participation in Tertiary Health Care • Promotion of AYUSH Services and their mainstreaming • Mobile Medical Services for difficult areas to improve access • Environment conservation (Bio-Medical Waste Management)

Bihar State has set targets and goals of reducing IMR (Infant Mortality Rate) from 52 to less than 45, MMR(Maternity Mortality Rate) from 312 to 200, TFR(Total Fertility Rate) to 3.7 from 4.0 and improves the rate of Institutional delivery to 70% by the end of FY 2011-12. In addition, it is aimed to reduce Birth Rate from 28.5 to 27, Death Rate to 6.7 from 7 and increase CPR from 28.8 to 45.

These goals clearly indicate that the State is planning to drastically upscale availability, accessibility and utilization of RCH (Reproductive and child health) services. These goals will be attained by a set of processes that empower local communities to take decisions, plan and implement strategies that provide equitable access to quality

Bihar State Health Budget: Overview

4

affordable health care services, that are gender sensitive and that are directly or indirectly contributing to improved health indicators for the state.

• Reproductive and Child Health priority areas under RCH-II flexible pool (Sub-Components – Maternal Health, Child Health, Family Planning, ARSH, Urban RCH, Vulnerable Groups, Innovations/PPP/NGO, Infrastructure and Human Resources, Institutional Strengthening (HMIS, M&E), Training, Procurement, Programme Management).

The Project Implementation Plan for the year 2011-12 has the following components and consists of following sections-:

• Additionalities under NRHM (ASHA, Infrastructure, Contractual Manpower, PPP-Referral & Emergency Transport, Diagnostics, Data Centers, Procurement, Planning)

• Routine Immunization • National Iodine Deficiency Disorders Control Programme (NIDDCP) • Integrated Disease Surveillance project (IDSP) • National Vector Borne Disease Control Programme (NVBDCP) (Malaria, Kalazar, JE, Dengue, Chikungunya,

Filaria) • National Leprosy Elimination Programme (NLEP) • National Programme for Control of Blindness (NPCB) • Revised National Tuberculosis Control Programme (RNTCP) • Inter-Sectoral Convergence • National Tobacco Control Programme (NTCP) • Non Communicable Diseases (NCD)

Main Strategies proposed to be adopted

The strategies will be rolled out by the vast network of health care institutions and its staff under National Rural Health Mission and its yearly implementation plan.

• Focus on quality antenatal care to all pregnant women by increasing the access through existing Govt. facilities.

Maternal Health:

• Quality improvement of the ANC through reorientation. • To increase awareness amongst mothers and communities about the need of ANC. • Focus on 24-hour institutional delivery with basic emergency care in all PHCs and referral of obstetric

emergencies. • Social mobilization for institutional deliveries by involvement of Mahila Mandals, PRIs through orientation

to motivate pregnant women and their families for institutional delivery. • Focus on operationalisation of CHCs (across the state) in order to help them become venues for

comprehensive emergency obstetric care. • Strengthening and upscaling transport and referral systems. • Identification and involvement of Pvt. Sector hospitals to deliver basic & comprehensive EmOC. • Ensuring clean home deliveries by skilled birth attendants in difficult and inaccessible areas. • To reduce unsafe abortion by increasing access to safe abortion in Govt. & Pvt. Facilities and promoting

awareness about harmful effects of unsafe abortion amongst women.

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• Community, PRIs. • To increase institutional delivery by continuing with the JBSY Scheme.

• To provide routine immunization including the booster dose to all children by strengthening sub-centre level services and increasing access through Govt. and Pvt. facilities.

Child Health

• Prompt and ensure appropriate community level care for all sick children and neonates and prompt referral where indicated.

• To increase awareness amongst mothers on benefits of immediate breast feeding and need and importance of exclusive breast feeding for 6 months and supplementary feeding from 6 month onwards.

• Adequate referral arrangement and strengthening health facilities for treating a sick child or neonate when it requires hospitalization.

• To standardize case management of sick newborn and children under IMNCI.

• To raise awareness amongst couples, communities and PRIs about contraceptives and advantage of small family.

Family Planning:

• Increase the number of service delivery points and to promote contraceptive use through social marketing.

• Focus on quality male & female sterilization and conduction of sterilization camps in uncovered areas. • To improve the number and skill of service providers by training of doctors on lap sterilization and NSV,

training of GNMs to assist lap sterilization and ANMs on IUD insertion. • Public Pvt. Partnership for increasing contraceptive use and sterilization. Bihar NRHM PIP 2011-12

• To educate and raise awareness amongst the adolescent boys and girls about human physiology, RTI, STI, HIV/AIDS and safe sex.

Adolescent Health:

• To open adolescent health clinic at block level.

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Assigned Budget: RS. (In Crore)

Budget 2006- 2007

% change

Budget 2007-2008

% change

Budget 2008-2009

% change

Budget 2009-2010

% change

Budget 2010-2011

% change

Budget 2011-2012

% change

346.94

N/A

849.25

145%

692.26

-18%

1508.34

118%

2104.5

40%

2704.82

29%

Source: Summary Bihar Budget Document

2009 – 2010 (Actual) 2010 – 2011 (BE) 2011 – 2012 (BE)

Percentage of Health Budget Vis-à-vis State Budget

The Current percentage Health budget holds in the Entire budget is 4.14%

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The improved governance has led to an economic revival in the state through increased investment in infrastructure, better health care facilities, greater emphasis on education, and a reduction in crime and corruption. Indian and global business and economic leaders feel that Bihar now has good opportunity to sustain its growth, economic development and as such have shown interest in investing in the state. A BBC article titled "Where 'backward' Bihar leads India" talked about how the state has made strides in the areas of women's empowerment, judiciary reforms, tax reforms, and public safety.

Despite efforts in the last few decades to stabilize population growth, the state’s population continues to grow at a much faster rate than the national population. The ratio of the rural and urban population is approx. 84:16. The population of Scheduled Caste households as per NFHS 3 is 18.7% and of Other Backward Class is 58.6% respectively of the state’s total population. BPL population is 56.48% (Source: Deptt. of Rural Development, GOB-2007). 44% of the population in Bihar is under age 15; only 5% is aged 65 or above Outcome Analysis of PIP of 2009-10 and 2010-11

NRHM under the Ministry of Health and Family Welfare, (MOHFW), Govt of India has recently (2008) brought out a document entitled “India Guaranteeing Quality Primary Health Care for All: An Agenda for Action”. In this book, key public health challenges have been identified state wise and have been furnished in a tabular form. For Bihar the indicators where there has been higher incidence or the performance has been low and requires greater thrust are-

• Infant Mortality • Maternal Mortality • Very high out of pocket expenditures in Government hospitals • High TB Cases/suspected cases, chest symptoms • High TFR • Full immunization • Tobacco and alcohol • Age at marriage • Spousal physical or sexual violence

• AIDS

Some of the major Diseases in Bihar are:

• Anaemia • Blindness • Cancer • Dengue • Diarrhoea • Diptheria • Encephalitis

As per a recent sample study, nearly 31% of population in Bihar is suffering from Blood related disorder.

Bihar: Current Health Scenario

• Filaria • Guineaworm Diseases • Hepatitis • Kala Azar • Leprosy • Malaria • Measles • Plague

• Pneumonia/Fever • Polio • Rabies • Sexually Transmitted Diseases • Tuberculosis

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Some of the Diseases for which GIOSTAR provides treatment are:

• Diabetes type I • Lupus • Multiple Sclerosis • Crohn’s • Vasculitis • Scleroderma • Myasthenia Gravis • Amyotrophic Lateral Sclerosis • Sickle cell anaemia • Leukaemia • Lymphoma • Thalassemia • Alzheimer's

Diabetes Type I

There is an increase in concern over the rise of diabetic patients in Bihar. Though no state-specific data is available

with regard to actual number of diabetic patients in Bihar, around 10 percent of total 50.8 million diabetes patients

in the country are from Bihar, the health department sources said.

As per the sources in Patna Medical College and Hospital (PMCH), "Lately, there has been spurt in diabetic cases in

the state especially the Type 1.

Bihar government has recently taken several initiatives to check diabetes which involves signing of a MoU for an

innovative project under diabetes management programme, 'Changing Diabetes Barometer Project' with the Novo

Nordisk Education Foundation (NNEF) founded by Noble laureate Novo Nordisk.

The total estimated cost of the project stands at Rs 2.5 crore which aims to undertake massive diabetes control

programmes in Bihar by creating mass awareness, screening, education and treatment of common man along with

helping those suffering from diabetes to lead a healthy and hassle-free life.

The project was initially launched in three districts: Patna, Nalanda and Bhagalpur, and will cover the entire state

gradually. The state government has set a target to cover around 50 lakh people under the initiative. Nearly,

23,000 people have been screened till date with 13 percent prevalence of diabetes detected.

Diseases: Overview

• Parkinson's • Cancer • Heart and Retinal degeneration • Neuropathy • Osteoarthritis • Paralysis • Strokes • Spinal Cord Injuries • Skin Burns • Spinal Muscular Atrophy • Autism • Anti-Aging Treatments

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The state government under the Government of India (GOI) scheme, to check non-contagious diseases, had also

launched a programme on pilot basis in two districts: Vaishali and Rohtas."

Bihar, meanwhile, has become the third state in the country after Tamil Nadu and Delhi where pregnant women

are being tested for diabetes and treated free of cost.

The Bihar Foundation UK is also working to create awareness through Medical Camps and free medical support.

Source: PMCH

Vasculitis

Retinal Vasculitis

As per a sample study for Retinal vasculitis nearly 78.6% patients belonged to the state of West Bengal, 10% patients are from Bihar and 5.7% were from Jharkhand and Orissa each. 85.7% patients were male and 10 14.3% were female. Range of age of the patients was 12-62 years and mean age was 32.9±11.4 years. Mean age of male and female cases were 33±11.1 and 32.4±13.6 years respectively. Among males, 38.3% cases of retinal vasculitis were noted in third decade of life while among females, 50% cases were seen in fourth decade of life.Retinal vasculitis was bilateral in 61.4% and unilateral in 38.6% cases. 60% males had bilateral retinal vasculitis and 40% had unilateral disease; whereas in female group, 70% and 30% subjects had bilateral and unilateral disease, respectively.

Source: NCBI

Sickle cell Anaemia

Bihar is the 4th state with most cases of sickle cell Anaemia preceded by Gujarat, Andhra Pradesh and Maharashtra and to be followed by Tamil Nadu.

Anaemia has been included in the list of major disease in Bihar by the state government and is being taken as an area of major concern.

Cancer

Bihar has recorded the third highest number of cancer deaths in the country, after Uttar Pradesh and Maharashtra in the year 2011.

The figure of National Cancer Registry Programme of the Indian Council of Medical Research, said that 43,864 people in the state have died of the disease till November 2011.

Health department officials said over 40,000 new cancer cases have been diagnosed in the state in the first 11 months of the year.

At Mahavir Cancer Sansthan (MCS), the largest cancer hospital in Bihar, 26,000 new cases have been recorded this year, the second highest from any hospital in the country.

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Like elsewhere in the country oral cancer is the most common form of the disease among men. About 62 per cent of patients here are women who suffer from cervical and breast cancer.

At Patna Medical College and Hospital (PMCH) and Indira Gandhi Institute of Medical Sciences (IGIMS) the influx of patients is very high.

IGIMS, which has a cancer unit, runs with only three oncologists even as around 75,000 patients come to its OPD for screening every year. A plan to upgrade the centre at an estimated cost of Rs 21 crore has been in limbo for the past one year because of government apathy.

So this could be an area of opportunity as the current system does not have the capacity to hold so many patients.

"On the occasion of World Lymphoma Awareness Day on September 15 it is shocking that at any given point of time there are more than 46,000 NHL (Non Hodgkin's Lymphoma) patients in India. Bihar accounts for 5 per cent of these patients.

Apart from that the other diseases are less prevalent in the region and have been given less focus by the Bihar health department.

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Kala-Azar

Kala-azar has been occurring in India for more than a century and a half in various forms. As a collateral benefit of malaria eradication programme, Kala-azar prevalence was almost zero in 1965. Currently Bihar accounts for more than 76.3% of kala-azar cases and 90.3% of deaths in the country. In the 1977 epidemic of kala-azar about one lakh people died. The epidemic recurred in 1992 due to lack of surveillance and harvested a death toll of almost 2,50,000. The control measures put in place then were subsequently slackened from 1994 because DDT spray and surveillance were discontinued. In 2000 the numbers were low but started rising from 2003. It is a matter of concern that the incidence of the disease has increased in 2005 and further in 2006. According to the Annual Report of the Ministry of Health and Family Welfare, Government of India, 32 districts of Bihar are kala-azar endemic. The district of Muzaffarpur has the highest number of cases, followed by Vaishali, Saharsa, Samastipur, Purnia and East Champaran. The task force believes that continuous spraying of insecticides for at least five years in a phased manner and supervised administration of Amphotericin B could eliminate the disease. Experts say that poor living standards and unhygienic conditions make members of the Mushahar community in Bihar an easy prey to the disease. It has been included as the major thrust area by Dept of Health in its annual Health Budget Malaria Malaria used to be the leading vector-borne disease of the country as well as Bihar at the time of independence. Initial efforts at malaria reduction brought down the caseload from an estimated 75 million to a record 1,00,000 cases in the 1960s. But subsequently, due to various financial, technical and logistical constraints the momentum was slackened. This led to resurgence of malaria in 1976, taking the caseload to 6.4 million. A modified plan of action helped reduce malaria cases by 1984. Efforts towards a further reduction were not successful due to vector and parasite resistance to conventional insecticides and drugs, respectively, in some high endemic areas, as well as continuing financial and management constraints. Malaria resurfaced in 1994, which also included increase in cases of Plasmodium falciparum malaria, the most dangerous strain of malaria, between 1995 and 1999. Some of the high endemic states are Madhya Pradesh, Chhattisgarh, Orissa, Rajasthan, Bihar and Andhra Pradesh. The national programme focuses on reduction of the reservoir of infection in humans by early detection and prompt radical treatment, reduction in vector population through vector control measures, anti-larval measures and enhancement of community based action. This strategy is being implemented across the country along with the Enhanced Malaria Control Project (EMCP), which focuses on the high endemic districts in the high focus states. The malaria control programme today is known as National Vector Borne Disease Control Programme, which includes malaria, dengue, filarial, Japanese encephalitis and kala-azar. Some of the high prevalence districts of malaria in the state are Gaya, Aurangabad, Rohtas, Munger and Jamui.

Bihar Areas of Focus

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Tuberculosis (TB) TB has re-emerged as a major public health problem in India and often as an associated illness of HIV/AIDS. In India it continues to be a serious health threat even in the absence of HIV/AIDS due to poverty, high illiteracy and poor sanitation. For the first time, TB prevalence has been reported in health report. Bihar ranks third in TB prevalence in the country (735 per 1,00,000 persons) after Arunachal Pradesh (9096) and Manipur (804). In Bihar 96.1% of men have heard about TB, of which 58.5% have misconceptions about its transmission. The disease still carries a high level of stigma in the state, with 17.2% of those surveyed still wanting the fact of a family member’s TB kept secret from neighbors. Japanese Encephalitis This vector-borne disease is prevalent in about 65 districts in ten endemic states; the annual caseload is about 2500 cases and 500 deaths, mostly of children below the age of five. Nearly 90% of cases are reported from Andhra Pradesh, Uttar Pradesh, Karnataka and West Bengal. But this disease has spread to non-traditional areas as well such as in Kerala. Control strategies continue to focus on early diagnosis, case management, vector control (two rounds of residual insecticidal spraying), fogging by Malathion insecticide, and segregation of pigs and promotion of personal prophylaxis. While high costs limit the use of vaccination, no curative drugs exist. The country as a whole also experienced more number of Japanese encephalitis cases. The no of cases started to rise in 2005. The number of deaths were the highest 64 in 2005 in Bihar. Leprosy Leprosy is endemic mainly in the states of Bihar, Jharkhand, Chhattisgarh, Uttar Pradesh, West Bengal, Orissa and Madhya Pradesh. Of the total 2.66 lakh recorded leprosy cases as on 31 March 2004, 75% cases have been contributed by seven states: Orissa (5%), Chhattisgarh (5%), Jharkhand (4%), Uttar Pradesh (23%), Bihar (17%), Maharashtra (11%), West Bengal (10%). India recorded a prevalence of 57.6 leprosy cases per 10,000 populations in 1981. Lymphatic Filariasis Filariaris declined in the late 1980s in India, but increased from 1989 to 2000. The National Filaria Control Programme provides assistance to all eighteen endemic states, the most endemic being Andhra Pradesh, Orissa, Uttar Pradesh, West Bengal, Tamil Nadu, Kerala and Bihar. HIV/AIDS According to the National AIDS Control Organization (NACO), there were around 120,000 people living with HIV/AIDS in Bihar but only around 40,000 had been identified by the end of 2009, Bihar is in urgent need of expanding HIV testing facilities in the state. A Part of the vulnerability of the state lies in a population where illiteracy is still widespread despite improving educational levels. The state is also a major crossroads for commercial traffic, which is one way HIV is known to spread. Bihar is India’s most rural state with 89% of its population living in rural areas, so that reaching people with essential HIV information is especially difficult. A low level of HIV prevalence presents both an opportunity and a danger. The opportunity to arrest its spread is here today. The danger is that its quiet nature will expand its devastation tomorrow. While HIV prevalence is low at present, the state is considered highly vulnerable by the National AIDS Control Organization (NACO).

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Malnutrition Malnutrition continues to be a predominant problem of the state and its manifestation and consequences are diverse and alarming. The level of malnourishment is quite high. Of all segments of the population children and women appear to be more at risk than are others. Malnutrition is seen to be a major contributing factor in over 50% of child mortality; states with high mortality are also generally those with high levels of malnutrition. Nutritional deficiencies have been observed to affect physical and mental development of children adversely, impairing health and productivity of work.