PHCC posting…

Our medical school has opted CBLE (Community Based Learning and Education) as a strategic approach to make its medical graduates ‘community oriented and advocates of disadvantaged’. (Why so? I will talk about that in my next blog). Recently we 4^th year students were posted in different PHCC (Primary Health Care Centre) of Makwanpur and Lalitpur district for our 6^th CBLE. I am sharing few of interesting experiences during my posting at Chhatiwan PHCC, Makwanpur.

First of all, villagers had wrongly received message that some senior doctors from Patan Hospital are visiting them. Thus we put on our card indicating “MEDICAL STUDENTS” and we introduced our self as same wherever required.

Government of Nepal doesn’t have adequate human resources. This was true in our PHCC too. A medical doctor with MBBS degree was supposed to be there but not even an HA(Health Assistant) was present. The PHCC was run by a team of motivated staffs leaded by a senior AHW (CMA).

There were some admirable tasks done by community. HFOMC (Health Facility Operation Management Committee) had established a laboratory where some basic investigations could be done. This helps up to some extent for right diagnosis and management. DPHO(District Public Health Office) had managed an extra ANM (Auxillary Nursing Midwife) as well. The 3 ANM is still not enough for PHCC services and 24 hour maternity service. Yet they are doing it. I highly admire their job.

Our PHCC was doing somehow fine(?) job for Family planning, Safe motherhood, Immunization, Reproductive health, Curative services etc. But a health facility with limited medications, inadequate lab, no basic facilities like ECG, X-Ray, USG (Video X-Ray) could hardy give proper care to its patients. There were many things unacceptable for me.

I found that patient safety was not cared at all. In the dressing room, the used instruments should be well sterilized. Do you know how is that done there? The instruments were washed with soap and tooth-brush, and rubbed with spirit before use. Amazing!! Isn’t it? An autoclave is not that expensive machine and is easy to use too. Unless it is managed, the instrumented can be boiled in water. But who cares?

Let me tell you, any patient visiting the facility with fever due to systemic illness were given treatment of malaria and typhoid both. Though it was an endemic reasion of these diseases, one of the diagnoses was compulsorily wrong and both might be wrong for some patients. They are receiving over treatment. People are receiving antibiotics not needed to them. Such practice will make organisms resistant to antibiotics we have, and we won’t be able to manage those disease because of unavailability of new antibiotics in future. I was not satisfied, but nothing could be done. This is how these health facilities run. And I was just a trainee there to understand how things are.

I also noticed that such centers are acting like non referral center. They refer very very few patients. Even patients with significant problem requiring visit to higher center were managed haphazardly. I feel that there is serious need to train these health professionals to identify RED FLAG SIGNS and get patients with those signs referred to higher centers.

I remember a patient of mine. An 18 year old unmarried lady visited me with some problem. Her problems were suggestive of Sexually Transmitted Infection (STI). But she denied having a boyfriend or any unsafe sexual activity. Urinary Tract Infection (UTI) was another differential diagnosis, but it was less possible and urine microscopy as well was not suggestive of it. Other investigations were not available. I got confused and consulted my supervisor, the AHW of PHCC. Do you know what he did? He gave medications for both the disease. This lady too got overtreatment.

You have to make a record of every patient, diagnosis and treatment in specified registers of HMIS (Health Management Information System). In the chart provided, COPD (Chronic Obstructive Pulmonary Disease), a respiratory problem, was kept under cardio vascular disease. I wonder how did the experts in ministry made such blunder and distributed all over the country.

During my posting at ANC (Anti Natal Checkup i.e. Medical and nursing care of women during pregnancy) I found that most of the women being pregnant for 1^st time were 15-17 years of age. It clearly shows early marriage in our communities. I asked the age of marriage to those mothers. Most of them answered 14 or 15. Along with smoking, alcohol and drug abuse, we are also worried about problems of premature sex in big cities of our country. But this is socially rampant in rural too. This is definitely going to adversely affect the heath of these mothers and their children too. I asked to all the mothers visiting me in ANC care room about their contraceptive use as well. Almost half of them replied that they didn’t use any, other half said that they didn’t need it because their husbands were in foreign. These examples clarify why our CPR (Contraceptive Prevalence Rate) is stagnant in below 50 % (Source: DHS 2011).

A really nice calendar like pamphlet is designed for pregnant mothers. Danger signs during pregnancy, delivery, peurperium, infancy and Maternal and new born care is well explained there. See  photo below. Since most of the patients are illiterate, PHCC staffs suggest those mothers ask someone to read it for them in home. I don’t think this is going to help. I suggest: the health facility staff should themselves read and explain it to the mothers.

Army officers, coming there for the security of different programs related to upcoming election were staying in new maternity building of the PHCC (not used yet). I remember our last evening there. We went to canteen for our dinner. Different varieties of alcohol are available even in canteen of the PHCC. Some army officers were drinking there and the whole canteen smelled really very bad. We waited outside for long, until they left. Smoking, drinking etc. is banned by Government of Nepal in public places like hospital. As always we have made admirable rules and regulations but failed implement it. I was many times disturbed by bad smell of cigarette as well, by local people (mostly female) even inside emergency of PHC.

Chhatiwan is large VDC. Providing health service to entire VDC is not possible by single health facility. Thus the PHCC runs other SHP in parallel. This is good step for public welfare. The government doesn’t has the provision of keeping two health facility in one VDC. Thus they have divided the human resource in PHCC for two facilities. Single health facility is enough in VDCs of hill with population of less than 5000 population or so. The VDCs in terai are comparatively larger with more than 10,000 population each. I think, running parallel institution, as done by Chhatiwan PHCC could be an option to solve such problem in large VDCs with comparatively more number of population. 

Thank You