Reasons for under-utilization of health services--a case study of a PHC in a tribal area of Bihar.

Despite the growth of the Indian health and family welfare program in the last 30 years infant mortality has changed little in the last decade and maternal mortality remains high. This study examines the primary health care (PHC) in an unnamed area in Bihar in 1982. Data was obtained by participant observation and interviews with doctors PHC staff and the community. The study area is 1 of the least developed in Bihar. The public health infrastructure consists of a PHC and 8 subcenters. In the 8-day observation period an average of 27 patients came to PHC per day. This is a much lower average than more developed areas such as Gujarat and Kerala which average 69 and 84 per day respectively. About 48% of the patients were aged 0-14. The proportion of female patients was lower in all the age groups except those over age 45. 71% of those over age 5 were illiterate. The average family size was 5.7. Most patients came from within 3 km to the PHC; 97.7% walked. Patients waited an average of 72 minutes to see the doctor for an average of 1.4 minutes. During the month of the study no patient came for maternal and child health or family planning care. There were supposed to be 4 doctors at the PHC but only 1 ever came. That one was supposed to be at the PHC all day but spent the morning until 11/am in his own private practice. Some patients went to see him in private practice instead of the PHC. Women preferred to go to the nearby Missionary Hospital where they could see female doctors for maternity and gynecological problems. The client/worker ratio for the PHC was too high; it was physically impossible to serve the needs of most people. The doctor said that training was insufficient; none of the workers had family planning skills. Medicine supplies never met the demands and needs of the patients. PHC provided services for vasectomies pills and condoms but not for IUDs and tubectomies. The PHC did not have a vehicle so all field work was done on foot. The extension work was poor; the subcenters were almost non-functioning. The supervision of the subcenters was almost negligible. Workers had little or no interest in working in rural areas. The main problem was the sociopolitical structure of the state. Some recommendations are 1) PHC doctors should stop their private practices 2) the power structure should be decentralized 3) better transport facilities should be provided 4) workers should be retrained in family planning work 5) a female doctor should be provided 6) proper staff accommodation should be provided and 7) adequate supply of medicine should be available.