Did a dearth of public health centres exacerbate the second Covid wave in Telangana?

The extent to which the second wave of Covid tore through rural Telangana can be gauged by the story of Ekmamidi, a village 65 km from state capital of Hyderabad. Located in Vikarabad district, Ekmamidi, which has a population of 10,000, reported nine deaths to Covid in the span of one month.

The Pasha family bore the brunt of this trauma, with three family members dying in eight daysy. The first victim was Syed Khaja Pasha, 37, who died on May 18. The oldest son in the family, Syed’s death was followed by his mother Fouzia Begum, 55, on May 23 and his father Syed Fateh, 62, on May 25.

On paper, Vikarabad district seemed adequately equipped to handle the pandemic, or so the state government claimed. But the second wave exposed its deficiencies. According to data from the 2011 census, the district has five government hospitals and 22 primary health centres for a population of 9.27 lakh. This roughly translates to 46,000 people per PHC.

This mismatch was exacerbated by the fact that the PHCs did not receive a steady supply of rapid antigen test kits from the state government during the second wave. Testing across April and May this year was erratic; locals wondered whether tests were done to detect cases or fulfill a daily quota.

“Three PHCs and one government hospital denied us a test,” said Syed Khadar Pasha, the youngest son in the family who got Covid but survived. “They did not even check his [his brother] fever or oxygen levels or give medicines. We saw the kits lying there with them but they just told us to come and stand in the line the next day when 50 tokens would be distributed.”

The family then took Khaja to a private hospital where they were charged Rs 1,000 for a rapid antigen test. The test came back negative.

“They declared it wasn’t Covid and put him on IV fluids and other medication, suspecting typhoid,” said Khadar. “They gave many other tablets and discharged him in a few hours.”

The next day, May 12, was Eid. At home, Khaja became breathless and his family took him to Mahavir hospital, the biggest private hospital in the district. There, Khadar said, Khaja was administered an RT-PCR test which came back positive. Khadar believes this delay cost his brother his life.

K Rajashekhar, a doctor at Maa Sharada hospital in Vikarabad, told this reporter that it’s common for registered medical practitioners in rural areas to recommend “typhoid, dengue and malaria tests for all fevers”.

“Incidentally, several patients’ reports happen to show high typhoid levels. This is because typhoid is quite endemic in the country and so many have high salmonella bacteria levels in their bodies,” Rajashekhar said. “But the real culprit for fever and other symptoms continues to be Covid, which only gets diagnosed when the breathlessness sets in.”

Khadar now sits with a stack of medical records and death certificates belonging to his father, mother and brother – a testimony to a failed system.

Since the beginning of the pandemic last March, Telangana’s approach to testing has come under scrutiny for its inconsistency. Until April 2021, the state conducted barely 50,000 tests per day, most of which were rapid antigen tests, which are a less accurate method of testing for Covid as compared to RT-PCR tests.

Eventually, between April 15 and April 27 this year, the state conducted upwards of one lakh tests per day. But by May 3, this dropped yet again to 50,000-odd rapid antigen tests per day. By May 11, when the Pasha family was struggling to get Khaja tested, it marginally rose to 75,000 tests a day.

But why did this happen? For a large part of May 2021, the government maintained a “treat first” approach, where in lieu of tests, it would conduct fever surveys and give medicine to symptomatic individuals.

As of May 27, 2021, 8.6 lakh people with flu-like symptoms were identified and given medicine – but they were not tested for Covid.

Too few PHCs to handle a wave

Data from the India Data Portal on Mission Antyodaya Survey of 2019 points at the poor state of public healthcare in Telangana’s rural areas. According to the Mission Antyodaya Survey of 2019, an annual survey of facilities at gram panchayats in India, only 27 percent of villages in Vikarabad have access to a PHC, a community health centre, or a health sub-centre. This is lower than the state average of 34 percent, and places both Vikarabad and Telangana in the “critical” category.

Critical category is the lowest a district can be ranked and implies very poor infrastructure presence. The survey gauges villages on parameters such as the presence of either a sub-centre, a PHC, or a community health centre. In Vikarabad district, nearly 600 villages are not linked with public health infrastructure.

Graph 1 - In Telangana, a major chunk of villages are not connected to any government health centre. This graph on the India Data Portals shows the availability of health centres in each district, as per Mission Antyodaya 2019 data.

Graph 2- Telangana has far more sub-centres than PHCs, but most districts do not conduct Covid tests at sub-centres. This graph shows the average distance people have to travel to reach a sub-centre.

Additionally, according to data from Rural Health Statistics, a database on rural healthcare systems and infrastructure for the year 2018-19 collated by ministry of health and family welfare, a single PHC in Telangana caters to roughly 32,000 people across 17 villages on average. This is the highest in south India. For contrast, a public health centre in Andhra Pradesh would cater to 30,000 people while the numbers for Tamil Nadu and Karnataka are 25,000 and 17,000, respectively. Kerala performs the best: a single public health centre attends to 13,000 people.

In times of a pandemic, this data becomes even more important, since the public health centre is responsible for tracking, tracing and testing.

Umar Rafi, the sarpanch of Ekmamidi, told this reporter that residents overly rely on corporate hospitals in Hyderabad when they fall sick. This is true of most of Telangana’s rural areas.

“Those taking treatment in government hospitals are dying, and those who go to smaller private hospitals are also dying,” he pointed out. “It’s as if nothing works unless you spend lakhs in a corporate hospital.” Rafi himself tested positive for Covid in April 2021 and was admitted to a corporate hospital in Hyderabad where the bills for a week-long stay easily go upward of Rs 7 lakh.

The second tier of public healthcare – community health centres – is also inadequate.

While a PHC caters to a few villages, a community health centre caters to a couple of mandals and has more specialist doctors and beds.

According to data from the Telangana Vaidya Vidhana Parishad, a division of the state health ministry, Telangana has 42 community healthcare centres with 1,600 beds, 30 district hospitals with 3,600 beds, 19 area hospitals with 2,000 beds, and seven teaching hospitals. This is a total of 25,000 beds across 33 districts. During the first wave of Covid, all the beds were fitted with oxygen support, some even with ventilators.

But in the absence of a referral system – where a patient is sent from a lower-level health facility to a higher-level facility based on the severity of their symptoms – most patients became too ill to be managed by district hospitals. Furthermore, in the absence of a triaging system that narrows down emergency cases, those in need like Pasha’s family were forced to turn to private hospitals, as government hospitals got choked with too many serious cases not attended to early on by lower level centres.

Community health centres also have their own issues. According to data from Rural Health Statistics 2018-19, the number of community health centres in the state are in a deficit of 53 percent as compared to what the population needs. Many of them also are not staffed with enough specialists, physicians, lab technicians, and others.

Yet health officials in the state believe they’re prepared for a third wave.

“The state is readying nearly 14 labs in the coming week which will ensure all 13 newly formed districts, which came post the formation of Telangana, will have an RT-PCR lab of their own,” said Dr G Srinivasa Rao, director of public health in Telangana. “These can test nearly 300 samples in a day, if the need comes. Testing is pre-eminent and will be the only solution to counter the pandemic.”

Dr Ramesh Reddy, director of medical education and chairman of the Telangana Vaidya Vidhana Parishad, said the state government is forming a “pool of all available MBBS graduates”.

“Every year, nearly 4,000 students [in Telangana] graduate from medical colleges,” he said. “Another 600-800 come from foreign countries after completing their education in medicine. We are making a pool of these from which respective district collectors can hire as their need arises.”

Aftermath

But for Khadar, the pandemic has already taken its toll.

“We spent nearly Rs 8 lakh on my brother’s treatment and eventually lost him,” he said. “Above all this, the responsibility to take care of his three children, along with my own six-month-old child, is now on me. I have a job earning Rs 12,000, which barely meets my own needs.”

On June 1, the Telangana High Court had pulled up the state government in the context of private hospitals overcharging for Covid treatments.

“People are having to mortgage gold to pay bills,” Chief Justice Hima Kohli had said. “Cancellation [of hospital permits to treat Covid patients] will not be of satisfaction to those whose money is blocked with these hospitals. You could have directed a refund at the ultimatum of cancellation. Now, hospitals will not even bother to entertain the patients' request because the worst has already happened.”

One of the four hospitals Khaja was shunted between – Padmaja Hospital in Hyderabad’s Kukatpally – was found guilty of overcharging patients and lost its permit to treat Covid patients. Many families, Khaja included, now want justice, or at least a refund of their money.

This report is published as part of the Newslaundry-India Data Portal Data Journalism Fellowship 2021.