Thousands of sub centres, PHCs and CHCs across rural India don't even have basic facilities like regular water supply, electricity and toilets. (Photo: Reuters file photo)

On October 2, 2014 when Prime Minister Narendra Modi launched the Swachh Bharat Mission (Clean India Mission), he said the aim was to improve India's sanitation. Besides general cleanliness, PM Modi laid emphasis on constructing toilets, saying nearly 60 per cent people in rural India were still defecating in the open. He termed this practice as a "blot" that India must clean itself of.

Since then, the government has repeatedly showcased Swachh Bharat Mission as one of its successes.

But, while the government may pat its back with its claims of constructing over 9.5 crore toilets across India since 2014, an IndiaToday.in analysis of the latest data on rural health infrastructure reveals that 38 per cent government health centres in rural India don't have toilets for their staff.

This data was accessed from Union Health Minister Dr Harsh Vardhan's written reply in the Lok Sabha on November 22, which in turn is based on 'Rural Health Statistics 2018', a report prepared by the central government.

In 10 states and three Union Territories, more than 50 per cent government health centres in rural areas are without staff toilets. These include large states like Telangana, Rajasthan, Gujarat, West Bengal and Madhya Pradesh.

These health centres include sub centres, primary health centres (PHCs) and community health centres (CHCs)--the backbone of India's public health services.

If we breakdown this data, we find that as on March 31, 2018, at least 60 per cent sub centres, 18 per cent PHCs and 12 per cent CHCs in India were without staff toilets.

Sub centres are the smallest units in India's rural health infrastructure. They are under the charge of an ANM (auxiliary nurse midwife) and have been set-up to ensure availability of last mile trained medical services in rural areas. They provide all primary healthcare services.

A PHC on the other hand is a government hospital that acts as the first contact point with local community and generally caters to around 25 villages. It is under the charge of a qualified MBBS doctor who is assisted by a pharmacist, 4-5 nurses and other medical staff. PHCs treat patients with routine illness and are also equipped to handle delivery cases, organise sterilisation camps etc.

Meanwhile, a CHC is a much bigger hospital, generally with 30 beds and 5 medical experts, including a surgeon and more than 10 nurses. A CHC covers nearly 120 villages.

STATES: WORST AND THE BAD ONES

Among major states, Telangana fares worst when it comes to toilet facilities at health centres. The state has 4,744 sub centres in rural areas and none of them have a staff toilet. Overall, 86 per cent government health centres in rural Telangana don't have such toilets. (The overall figure includes data for PHCs and CHCs.)

The situation in Telangana is diametrically opposite from its parent state, Andhra Pradesh, where all 7,458 sub centres have staff toilets. Not just this, all PHCs and CHCs in Andhra Pradesh too are equipped with such toilets.

Throughout the campaign for a separate Telangana state, leaders from Telangana alleged that the region was neglected and faced discrimination that stunted its progress.

Besides Andhra Pradesh, Himachal Pradesh is the only other major state to have staff toilets in all government hospitals. Uttar Pradesh, the most populous state in India, too fares far better than most states. Only nine per cent government health centres in rural Uttar Pradesh are without toilets for staff.

On the other hand, Rajasthan and Gujarat, two big and important states, fare poorly on this count. In Rajasthan, 85 per cent sub centres in rural areas don't have staff toilets while the figure for Gujarat is 73 per cent. The condition in West Bengal, Madhya Pradesh, Jharkhand, Uttarakhand bears a similar resemblance.

WHY DO HOSPITALS NEED STAFF TOILETS?

Hospital staff works in shifts of long durations during which they attend a number of patients. In absence of toilets, they are often forced to wait for hours before they can answer nature's call. This physical inconvenience can have an adverse impact on their concentration, which in turn has cascading effects on their work.

Besides, it is important for hospital staff to have separate toilets to protect them from pathogens in patients' waste.

In a 2019 report on water, sanitation and hygiene at health care centres the World Health Organisation (WHO) said 20 per cent of these centres globally don't have sanitation facilities, thus impacting close to 1.5 billion people.

The WHO says basic sanitation facility at a health care centre should include at least one toilet dedicated for staff, at least one sex-separated toilet with menstrual hygiene facilities, and at least one toilet accessible for people with limited mobility.

"No one goes to a health care facility to get sick. People go there to get better, to deliver babies, to get vaccinated. Yet, hundreds of millions of people face an increased risk of infection by seeking care in health facilities that lack basic necessities, including water, sanitation, hygiene and health care waste services," the report said.

Sanitation conditions at a primary health centre in Bihar. (Photo: GettyImages file photo)

Stressing on the need for proper sanitation, WHO report said absence of such facilities can spread disease instead of preventing them. Calling sanitation a human right, it said such services in health care facilities are essential to deliver high-quality care that improves health, welfare and dignity of patients and staff, besides improving health outcomes.

NO SEPARATE TOILETS FOR MEN & WOMEN

In 2014, when Prime Minister Narendra Modi delivered his first address to the nation on Independence Day, he expressed displeasure at the lack of separate toilets for girls in schools and said it was a key reason that kept many girls out of school.

"All schools in the country should have separate toilets for girls," Modi said, setting a one-year target to achieve this.

However, while the prime minister set a target to build sex-separated toilets at schools, his message failed to have any noticeable impact on health care facilities. (See chart below)

Nearly 61 per cent of all government hospitals in rural India are without separate toilets for men and women.

Basic sanitation facility at a health care centre should include at least one toilet dedicated for staff, at least one sex-separated toilet with menstrual hygiene facilities, and at least one toilet accessible for people with limited mobility. - World Health Organisation

In Andhra Pradesh, while all 7,458 sub centres have toilets, none of them have separate toilets for men and women.

Overall, Kerala and Telangana have the highest percentage of government hospitals without sex-separated toilets (86 per cent each), followed by Andhra Pradesh, Uttar Pradesh and Gujarat.

In 21 states and Union Territories more than 50 per cent rural hospitals don't have separate toilets for men and women. The overall figure includes data for sub centres, PHCs and CHCs.

SOME EVEN DON'T HAVE REGULAR WATER SUPPLY

While toilets are essential for patient care and wellbeing of hospital staff, there are thousands of government health units in rural India which don't even have regular water supply.

As on March 31, 2018, there were 26,360 sub centres and 1,313 primary health centres in rural India that did not have a regular source of water.

A woman collects water using a hand-pump at a Primary Health Centre in Latur, Maharashtra. (Photo: Reuters file photo from 2016)

Stressing on the need of water supply at health care facilities, the WHO says availability of sufficient quantities of safe water is important for health centres to provide quality services.

"Without water, a health care facility isn't a health care facility. Water is essential for cleaning rooms, beds, floors, toilets, sheets and laundry. It is central to patient experiences of health care, as it enables them to remain hydrated, to clean themselves, and to reduce the risk of infections," WHO says in a 2019 report on health care.

"No one goes to a hospital to get sick. People go there to get better. Yet, hundreds of millions of people face an increased risk of infection by seeking care in health facilities that lack basic necessities, including water, sanitation and hygiene. - World Health Organisation

The WHO estimates that globally around 25 per cent health care facilities don't have basic water services impacting around 2 billion people.

Data for India show 45 per cent PHCs in Jharkhand are functioning without regular water supply, while in Nagaland and Manipur the figures are 44 and 43 per cent, respectively.

When it comes to sub centres, there are states where more than 50 per cent sub centres don't have regular water source. Manipur leads this list with 79 per cent sub centres devoid of regular water supply, followed by Mizoram (62 per cent) and Meghalaya (60 per cent).

Among large states, Bihar has 49 per cent sub centres without regular water supply, Jharkhand (53 per cent), Rajasthan (34 per cent) and Odisha (30 per cent).

Uttar Pradesh, Telangana, Goa and Tamil Nadu are among states where all sub centres have regular water supply.

OUT OF POWER

Besides construction of toilets under the Swachh Bharat Mission, the Modi government also counts rural electrification among its success. The government in 2018 claimed it has achieved the arduous target of 100 per cent rural electrification, a claim contested aggressively by the Opposition. Media reports also don't support the government's claim.

These tall claims aside, records show nearly 40,000 government health units (39,122 sub centres and 823 PHCs) across rural India are still operating without electricity supply.

In absence of electricity supply, these health centres have limited utility in helping people in villages during emergencies, especially at night and under unfavourable weather conditions when travelling to bigger hospitals is difficult-something that is common in remote areas.

In villages, a PHC generally is the closest government health facility with a qualified doctor. Most pregnancy cases at the time of delivery are taken to PHCs and only when there is a complication, the case is referred to a CHC or district hospital. As such, it is important for PHCs to have round-the-clock electricity supply.

The situation is particularly alarming in Goa and Jharkhand where 60 and 43 per cent PHCs respectively don't have electricity supply.

The National Family Health Survey (NFHS)-4 revealed that nearly 25 per cent childbirth in rural India don't take place inside a hospital.

In Nagaland, 76 per cent deliveries in rural areas don't take place in hospitals. In Arunachal Pradesh this was 56 per cent, in Jharkhand 43 per cent, Manipur 40 per cent, Bihar 37 per cent and in Uttarakhand 36 per cent.

The high prevalence of non-institutional deliveries in these states makes the role of sub centres very important. The sub centres are under the charge of trained ANMs who are skilled to handle normal delivery cases. A sub centre generally caters to 4-5 villages and is easily accessible to villagers, even in harsh weather conditions.

Against this backdrop, when thousands of health centres in rural India are bereft of even basic amenities like regular water supply, electricity and toilets, healthcare of the common people in rural India gets seriously compromised, besides exposing patients and medical staff to greater risks.

(The author tweets at @mukeshrawat705 and can also be reached on Facebook.)

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