AES in Bihar: A case of rural healthcare in crisis


The recent outbreak of acute encephalopathy syndrome (AES) in Bihar, which claimed lives of more than 170 childrenportrays a crippling rural healthcare system grappling with shortage of health providers and proper infrastructure.

The brain fever in Bihar has not established as encephalitis at the moment, hence its called encephalopathy — ‘itis’ indicates that the syndrome is an infection, while the cause is yet to be ascertained ‘pathy’, on the other hand, indicates that the cause is unknown.

Acute encephalitis syndrome, on the other hand, is a broad term and includes viral infection (encephalitis) and hypoglycaemic encephalopathy — low sugar levels as a result of malnourishment and lack of proper diet. 

AES is a brain fever that gets manifested in the form of seizures and needs to be treated speedily — time plays a crucial role in reducing mortality rates.

“The onset of AES is not from seizure but alteration in brain, which causes fever and begins much early. A pateint may have four hours from there till the onset of seizures,” said Shefali Gulati, a specialist in child neurology at AIIMS-Delhi.

“The beginning of seizures indicates that the brain is swollen. A child must reach a health facility within five-seven minutes of the seizure, for the treatment to be effective,” Gulati said.

“The primary healthcare centres (PHCs) must be stocked abundantly with anti-convulsant drugs, IV fluids and other necessary drugs for correction of hypoglycaemia (low blood sugar)in AES-affected children,” she told DTE.

Claims vs reality

In a bid to curtail the disease, the Bihar government had in 2016 prepared a standard operating procedure (SoP). It was subsequently revised in 2018. The SoP clearly mentions that PHCs have to be prepared with anti-convulsant and other drugs. It defines role of PHCs, community health centres (CHCs), district hospitals as well as medical college hospitals.

While the Bihar government claimed adequate preparation in accordance to the SoP, Down To Earth (DTE) found stark difference between ground reality and the claims made.

In early June, Vijay Kumar from Bahadurpur village of Muzaffarpur district arrived at the PHC in Kanti block, with his son who was convulsing. But his son was refused admission in the PHC. Kumar then had to take him to Sri Krishna Medical College and Hospital (SKMCH) in an auto, where he later died.

“My child was convulsing badly, his face had deformed and was unconscious. We had absolutely no idea as to what was happening. But the compounder in this very PHC refused to admit him saying he would not be able to do anything. Had the doctors here helped, I would have perhaps saved my child,” Kumar rued.

Kumar is yet again at the PHC with his ailing wife, who however, has been admitted.

The PHC has a ward dedicated for AES and has two beds. Kumar, however, claimed that the ward came into existence much later after the deaths peaked by mid-June.

Muzaffarpur has borne the brunt of the deadly fever with more than 100 deaths and 544 cases. Kanti is one of the four most affected blocks of the district.

Suraj Das from Jamalabad village of Muzaffarpur’s Meenapur block narrated a similar story. Das told DTE that there was nobody in the PHC, when he came with his four-year-old child, early in the day.

It may be mentioned here that the children with AES fall sick between 4 am and 7 am in the morning, and it is the only time of the day when there is even a chance of getting a healthcare provider in the PHC, as less than one-fourth PHCs in Bihar run around the day, according to a Niti Ayog report. 

While both Kumar and Das tried going to PHCs, others did not, owing to poor experiences earlier. There were also cases when medicines ran out of stock in the PHCs.

“We don’t have faith on PHCs because they are never functional. We prefer to take our children to the SKMCH,” Mohammad Sharif Alam of Madhopur Machhia village, Muzaffarpur who lost his four-year-old son, told DTE.

Poor infrastructre

More than 70 per cent PHCs, out of 2,012 PHCs in Bihar, function without a medical officer and a nurse. Hence, they have been deemed non-eligible for any grading, according to the Union health and family welfare’s Health Management Information System (HMIS) for 2018-19. The mandatory criteria for considering a PHC eligible for any grading is at least a medical officer and a nurse.   

In Muzaffarpur alone, 98 out of 103 PHCs were found unfit for grading while another five, which were found fit for grading, scored zero (based on availability of laboratory services, ambulance services, OPD rooms and availability of drugs and other supplies) on a scale of five. Sitamarhi’s 45 PHCs out of 57 were ineligible and East Champaran’s 83 out of 102 shared the same condition.

In the case of CHCs in Bihar, only 19 per cent got a grade above four (based on immunisation and family planning methods) in 2017-18, decline of one per cent point from last year. 

Bihar is also infamous for not being able to spend a large part of funds provided under the National Rural Health Mission.

The Bihar government took 191 days in 2017-18 to transfer the fund from state treasury to implementing agency, according to Niti Ayog. This is the highest across all over India. In Uttar Pradesh, the corresponding figure was 118.

Lack of human resource

Besides crippling infrastructure, Bihar also faces shortage of health providers.

Unavailability of doctors is the biggest problem grappling the state. In 2017-18, the state had only 3,679 doctors, against the sanctioned number of 9,558, according to the Bihar Economic Survey 2018-19.

Worse, instead of adding, the state is also witnessing a decline of doctors: Bihar had 4,106 doctors in 2016-17. 

The state has only 2,508 nurses, against the sanctioned posts of 6,423; 19,901 ANMS (Auxillary Nurse Midwives) against the sanctioned posts of 34,446.

This comes at a time, when the state government is in a bed-increasing spree for its medical college hospitals.

After the AES outbreak this year, chief minister Nitish Kumar announced to increase the bed strength in SKMCH to 1,500 from 610.

The government has also decided to increase up to 5,000 beds from the existing strength of 2,500 in Patna Medical College and Hospital, the biggest hospital of the state.

“This is absurd. When all indicators say that they have to put stress on improving rural health infrastructure, their entire stress is on increasing tertiary care. Moreover, from where will they get doctors? The state has not enough doctors to serve current government health facilities,” Ranjit Kumar, an office bearer of Bihar State Health Services Association, told DTE

“This is so because the recruitment of doctors on regular posts in government sector takes ages in Bihar, but even those working in government sector do not get promotion in time. Why would doctors want to stay in in Bihar then,” he added. 

The announcement by CM Kumar is also seen as a knee jerk-reaction in the wake of current outbreak as the deadline seems unrealistic. 

“It is impossible to do it in one year time and it would take a minimum of two years. It takes two years to convert a 6-bedded PHC to 30-bedded CHC, so how would it be possible to convert 610 beds to 1,500 in a year,” a senior health official told DTE, on condition of anonymity.