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Mainstream, VOL LVIII No 35, New Delhi, August 15, 2020

Bihar faces the wrath of covid-19 | Nisha Mishra

Friday 14 August 2020

by Nisha Mishra

With the legislative elections round the corner in Bihar, and the consequent transfer of two health secretaries within a gap of less than two months has raised questions on the health infrastructure of the state. COVID cases tally on July 1 was 10075 has increased to six fold in early week of August with 62031 positive cases. Recently the death of 12 doctors and the undersecretary to Home department, the government of Bihar, has brought to limelight the ineffectiveness of health system and its incapability to respond to the pandemic. The officer was on duty when he got infected with the coronavirus. His family recalls how they were denied his admittance in the hospital due to unavailability of bed. AIIMS, Patna one of the premier medical institute in Bihar is seen collapsing due to insufficient beds and ICU’s which are less in number compared to the rising number of covid-19 patients.

This is not the first instance when Bihar health infrastructure has failed to respond effectively. Between 2008 and 2014, the epidemic of Acute Encephalitis Syndrome (AES) with unknown symptoms had crept in, which took the lives of 375 children in the adjoining areas of north Bihar, most affected, was the district of Muzzafarpur. This could have been a lesson to be learnt to be well-equipped with such epidemics in future.

With a population of around 103.8 million (Census, 2011), Bihar is the third most populous state in India, constituting 8.6% of the country’s total population. The health sector has had only limited success in delivering equitable, accessible and quality health care services to its citizens. The fiscal and political challenges in Bihar have acted as an impediment in delivering the necessary services. Using the data of National Health Profile (2019), published by the Ministry of Health and Family Welfare, there are only 7 lakh beds in public hospitals across India (Report of Central Bureau of Health Intelligence), with Bihar possessing merely 30857 beds in public and private hospitals with people’s access to one bed per 8645 persons leading to overcrowding of hospitals during this pandemic. There are 771 ventilators (public and private sector) and 1543 ICU beds (public and private sector) in the hospitals across the state, which is considered to be lowest amongst the other states in India. Bihar remains heavily dependent on central funds. A large part of the centre’s contribution to the state health budget comes from the National Health Mission (NHM). The share of NHM (centre and state contribution) in Total Government Health Budget (TGHB) has substantially increased over a period of time, in contrast with the state share in the expenditure. Still, the health expenditure as a percentage of total state expenditure of Bihar was 3.94% during the year of 2015-16. The per capita expenditure on health in Bihar remains low at Rs 491. Paradoxically the low allocation to health in Bihar is accompanied by very less actual spending and poor utilization of funds.

There are at present 6830 doctors working in the state with one doctor for every 17685 persons as against the WHO parameter of one doctor for every 1000 people. The posts of medical officers, doctors and nurses remain vacant, thus leaving the patient dependent on contractual health personnel. There are 9949 sub-centres,1899 primary health care(PHC’s),150 community health centers(CHC’s) in Bihar with 1786 doctors at PHC’s centre,82 total specialists at CHC’s,8624 auxiliary midwife nurses(ANM’s),9413 registered nurses and registered midwives and 571 lady health visitors. `The PHC’s and CHC’s are functioning the worst in Bihar with one doctor looking after 6-7 PHC’s on a shift basis with one or two ANM’s. The people are seen complaining about the negligence of the hospital staffs and doctors in handling of the cases. Most of the health personnel in the government hospitals are reluctant to go near the patient with the fear of getting infected, as a consequence of which over reliance on patients’ attendant to provide patient care. The other reason being they are employed on a contractual basis with no protection and very low pay. Due to high costs of care in private hospitals, access to it is limited to few privileged. In the 2019 Health Index Report of NITI Aayog- a think tank institution, Bihar performed abysmally low on public health indicator showing a negative incremental change in the total fertility rates, sex ratio at birth, institutional delivery mechanism, doctors, nurses and ANM’s vacancies, functional PHC’s, CHC’s, First Referral Units (FRU’S). Despite these shortcomings, the health system failed to bolster up its human resources in an efficient manner.

Role of Accredited Social Health Activists (ASHA) workers in Bihar should not be ignored as they are the unrewarded health workers at the lowest rung of health organizational hierarchy, acting as an interface between the community and the public health care system in rural areas. According to NRHM guidelines, they have been assigned tasks of creating awareness about basic sanitation and hygienic services, counselling women on birth preparedness and escorting pregnant women to nearest PHC’s/CHC’s, providing primary medical for minor ailments, promoting the construction of household toilets under total sanitation campaign. During the pandemic their roles have increased manifold, with conducting door to door surveys, creating awareness among people about the pandemic, contact tracing at block level etc,.They are now facing hardships during this critical moment as they have not been provided with proper remuneration to support their families, lack of training on COVID-19 related fieldwork. The safety gears were provided to them by the government in the early of March after which they were refused to be given. The sanitation workers face caste-based prejudices and discrimination at the workplace and are not even in the position to evade from it because the responsibility of keeping the facilities clean falls on their shoulder.

The testing centres in the state are functioning worst in the country, combined with underestimation in the tests being conducted. Bihar still stands lowest among the other states with regard to testing. Even the small states like Jharkhand and Telangana are doing more tests with 4416 per million and 2637 per million consecutively as against 2197 tests per million in Bihar. A huge crowd is seen outside the testing labs without any norms of social distancing. “The high tests per million being undertaken now in Delhi must be emulated by other states. This is critical. States must be judged on testing. We can succeed against #covid-19 only with 3T strategy of testing, tracking and treating. This is the moment to act and to act fast.” -Amitabh Kant, CEO, NITI Aayog.

Since the phase of unlock began and market place reopened, there was a sudden surge in Covid-19 cases all over the India, with state government extending the lockdown. The question here arises as would extending lockdowns be considered fruitful in controlling the spread of corona virus, because even the lockdowns are not being adequately enforced. Against the backdrop, the opposition party in the state is leaving no stone unturned to topple the government. Since it’s the election time in Bihar, public opinion and vote choice would be framed as to how successful the government was in handling the pandemic. Instead of engaging in blame game, the government of Bihar should take effective measures to control the spread of the disease. The government has also imposed a fine for people without mask in public places, but is not seriously being implemented. Mass awareness of do’s and don’ts regarding the novel corona virus to be executed at local level is the need of time otherwise the situation will arise wherein the government will have to conduct door to door test to identify the cases.


2. Central Bureau of Health Intelligence (2019): National Health Profile, Ministry of Health and Family Welfare, Government of India, New Delhi
3. Covid-19: Bihar’s health workers going door to door screening.
4. Covid-19: testing lowest in Bihar among 19 states, says NITI Aayog CEO
5. Hathi, P; N Srivastava and Priya, A (2020): “our essential workers need essential care”, Economic &Political Weekly, vol 55; Issue No.31.
6. Berman P, Bhawalkar M, Jha R (2017): “Tracking financial resources for primary health care in Bihar, India.” A REPORT OF RESOURCE TRACKING AND MANAGEMENT PROJECT; Harvard T,H Chan school of public health Boston, USA.
7. Karan A; R Nair; A Sharma; R Tiwari and S Zodpey (2018): “Size, Composition and distribution of human resources for health in India. New Estimates Using sample survey and registry data,” BMJ Open, Vol. 9.


Nisha Mishra, PG student in Banaras Hindu University., UGC NET qualified in Political science and Public administration.)

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