Goa has 19 primary health centres, five community health centres and a number of sub-health centres. Of these 13 PHCs and all CHCs provide 24 hour healthcare and have gynaecological and paediatric facilities, says U. K. Worah, the state's Secretary for Health. The establishment of this network has kept Goa's health indicators considerably better than the national average for as long as anyone can remember. Notwithstanding this, however, several studies now suggest that in recent years, there have been few new gains; indeed, on many counts the state appears to be losing the ground gained earlier.
In August 2006, Goa's local newspapers carried a series of reports on the inadequacies of the state's primary health system. Patients testified to the loss of family members due to lack of access to health services in their vicinity. Kushawati Gaonkar, who lives in a village in Corla, Quepem, is 35 kms from the nearest health centre. Four years ago she lost her baby because she could not access its services in time. In another instance, Srikant Devidas of Sulcorna could not be saved when he collapsed while working in a Quepem field. The nearest health centre was 32 kms away. In these interior districts of Goa there is a wide need and availability gap - the 41,000 residents of Canacona have recourse to no more than 60 beds at the health centre. The centre's x-ray machine has not worked for over a year; the kidney dialysis machine is rendered useless by unreliable electricity and the absence of a generator.
These myriad problems result in health services that do not match up to the investments made in buildings and equipment. A large number of vacant posts, ill-motivated staff and non-availability of essential drugs undermine curative services at the PHC. According to Raj Vaidya, a pharmacist whose family runs Hindu Pharmacy, the oldest medical store in Panjim, the state still does not have a rational drug policy which ensures that essential drugs relevant to local needs are made available to the network of health centres across the state. "We see a lot of prescriptions from the Government Medical College for iron and calcium tablets which are costly and should not be prescribed to the poor. A slum woman would be better off spending that money on vegetables and fruits instead," he points out.
Compounding this is constant political interference. At the Sanquelim PHC in Bicholim taluka, for instance, all the administrative staff was recently transferred to the Valpoi PHC in Satari taluka, an official reveals. "This trend started with the earlier government when everyone from the doctor to the peon was transferred", says an official at the PHC, who did not want to be named. "Now this continues with a new government in power. The local MLA is helpless to prevent it because he belongs to the party that initiated the first spate of transfers. They are making a mess. Everyone is new here and knows nothing about this area," he says.
Admitting there is a shortage of medical staff, as is the case elsewhere in the country, Worah says health staff are unwilling to stay in interior districts despite being given staff quarters. The government hopes to tackle the issue by contract appointment of doctors and para-medical staff, while offering them higher remuneration.
New challenges
But tackling the woes in the state's health care system will be no easy matter. Social and economic changes are rapidly bringing in a new set of problems. The state is witnessing a rapid rise in chronic diseases such as cancer, heart disease, and mental health problems, and addressing these requires far more than mere infrastructure and rudimentary support.
Goan women in the rural areas face a particularly difficult time accessing health services. According to the NFHS-2 , for almost 30 per cent of rural Goan women, a primary health centre is 10 or more kms away.
"The last decade has seen a tremendous increase in the incidence of breast cancer in Goa," says Shekhar Salkar, an oncology surgeon at the Manipal-Goa Hospital in Dona Paula. "In 2005, 10 patients were detected at this hospital in the age group of 20 to 39 years," he says. Although there is no official data available on cancer incidence in Goa, Salkar says the state records around 250 new cases of breast cancer every year. Older age of marriage and late childbirth are both linked to a higher risk of breast cancer. The mean age at marriage for women in 1993 was 25.1 for Goa, compared to a national average of 20. The percentage of married women in the age group of 15 to 44 years in 1981 was 59.21 in Goa and 80.51 for all-India. (Goa, 2001. Shaila D'Souza, Centre for Women's Studies, Goa University).
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"It is vital that the Goa government initiate a pilot study to estimate the actual number of cases detected in a field survey," says Salkar. The health system must be geared to early detection and prevention of non-communicable diseases like cancer, diabetes and hypertension," he says.
The prevalence of coronary heart diseases is also on the rise and Goan women are more prone to it, according to preliminary findings from a recent study conducted by the Goa branch of the Voluntary Health Association of India (VHAI) in collaboration with University College, London. The study examined 1,556 patients attending the clinics of 10 general practitioners in Goa, of which 626 were male and 930 female. The prevalence of coronary heart diseases was found to be very high, with rates of four to six per cent in men and six to 11 per cent in women 40 years of age and above.
Studies conducted in Goa's primary health setting indicate a rising trend of mental health problems too. Studies conducted by Sangath Society, a Goa-based NGO working on mental health issues, have shown a severe impact of stress and depression on Goan women. In community settings, six per cent of women in the reproductive age group - about 20,000 women statewide - suffer from depression. Further, it was estimated that over a one year period, 1.8 per cent of women in Goa will develop new episodes of depression, which means about 6000 women in this age group will develop a new episode each year. Over a one year period, 0.8 per cent of women will attempt suicide, which translates to 2500 odd attempts each year. Sangath's studies also showed that one in five adults attending the primary health centres and one in four mothers attending antenatal clinics suffered from depression. Other findings showed that in mothers, the birth of a girl child, marital violence and poverty are all common causes for depression after childbirth.
Goan women have also been found to be anaemic. The average haemoglobin of the Goan woman is eight, says Raj Vaidya, whose pharmacy keeps a close tab on all patient prescriptions and offers them counseling. The National Family Health Survey II (1998-99) estimated that 27 per cent of women in Goa are undernourished, with nutritional deficiency being particularly serious for women living in low income households, for younger women, illiterate women and women belonging to scheduled castes or other backward classes. The more recent NFHS III (2005-06) found nearly 37 per cent of women to be anaemic. Overall, 36 per cent of Goan women have some degree of anemia, a serious problem among women in every population group, with prevalence rates ranging from 26 to 52 per cent.
Older battles still to be won
While the complex new problems demand urgent attention, there are still a number of older battles to be fully won. The infrastructure for detecting and responding to many illnesses is much better in Goa than elsewhere in the country. Nonetheless, there is much that remains to be done to ensure that well understood illnesses are properly tackled.
The Revised National Tuberculosis Control Programme (RNTCP) estimates that there are 160 cases of TB per one lakh of population in Goa. The RNTCP began in September 2004 in Goa, and provides free treatment to patients through Directly Observed Treatment (DOT) provided at their nearest government health centre. The health worker at the public health centre ensures drug compliance and follows up if the patient fails to turn up regularly for treatment. The illness is first detected during the patient's visit to a public health centre, where the doctor, upon suspecting TB, refers the patient to one of the 18 designated microscopy centres specially set up by the RNTCP to ensure accurate TB diagnosis. Each TB Unit, covering a population of five lakhs ensures supervision of the RNTCP in their area.
However, many patients are unaware of the RNTCP; those who are seeking treatment often fail to show up because of the distance they have to travel to reach a DOT centre. Meanwhile the programme depends on the Medical Officer in the health centre OPD to identify and refer suspected cases. Any patient having a cough for more than two or three weeks must be referred to the TB programme for sputum tests, but PHC doctors fail to make such referrals, an RNTCP official revealed, also speaking on condition of anonymity. Inevitably, this leads to an artificially low detection rate for the illness.
Yet another disturbing feature is seen in the Infant Mortality Rate, which has risen in the past decade according to the NFHS. The Goa government says IMR in 2003 was 11.67 per 1000 births, considerably better than the all India average of 70 per 1,000 births. But NFHS data from 1998-99 suggests that these figures may be wrong, and if fact there may have been a worsening of the situation in the state in the last deca. Analysing the NFHS data on IMR, researcher Siddharth Ramji notes that despite the decline in the national infant mortality rates between 1988-92 and 1994-98, in eight states incluing Goa, the IMR rates actually worsened. In Goa, the rise is estimated to be from 31.9 deaths per 1000 births to 36.7. (Indian Pediatrics, 2001).
Rethinking public health
Can these problems ever be sorted out? The Indian experience has repeatedly shown that the country will never have enough trained medical professionals willing to work in the rural areas, and that the emphasis on vaccines, allopathic drugs and technology has not turned out to be the promised magic wand. The experience of a number of groups whose work in community health provides invaluable contemporary heritage, may offer an alternative course, one that places the country's neediest at its core. One such approach is developing a cadre of village based health workers trained in preventive and curative health. This is now a key recommendation of the National Rural Health Mission which requires that such a cadre, supported by a strong primary based referral system be created across the country.
But here too, there is a wide gap between the plan and its achievements. Goa has yet to identify this cadre and put such a programme in place, admits Goa's Director of Health Services. For most of the state's residents, their vulnerability to the cracks in the health system is still a long way from being tackled.