A Survey of Public Health Administration in Bihar

Ind. J. of Applied & Clinical Sociology 10 (4), 2015, 5-12 ISSN: 2230-9772 (Print); 2347-5927 (Online) : Human Development & Welfare Institute A Survey of Public Health Administration in Bihar Dr. Krishna Kant Sharma Abstract: This paper is based upon my postdoctoral research at PG Department of Sociology / Social Work, Patna University sponsored by Indian Council of Social Science Research (ICSSR). The summary of the findings published as paper identified structural and functional aspects of public health administration in Bihar. The public health achievements in Bihar was deficient though there were certainly signs of recovery post 2005 or since launch of the National Rural Health Mission. Introduction: A summary presented on the Public Health Administration in Bihar inclusive of demographic trends, risk factors, disease prevalence, epidemiology, surveillance & preparedness, public health laws, institutional arrangements, services & coverage, workforce & medical education, policy, planning, budgeting, public health management, additional tasks, and finally achievable, targets and achievements. Statement of problem: The poor state of public health services in Bihar was not just easily perceivable however also reflected and substantiated through data of different agencies. World Health Organization country s statistics for India exhibited poor state of affairs in Public Health in Bihar. At the time of establishment of the first democratic government in Bihar in the year 1947, only 33 percent of the population had physical access to any public health services. Significantly, the overall coverage of population by the public health services not improved. Considering a situation that existed in Bihar that almost 230 women die delivering child every 100000 live births, similarly almost 47 newborn babies die per 1000 live births in a year, and even further worse another 60 children per 1000 live births were having the probability of dying prior completing fifth birth anniversary. Further, only 37 percent of total pregnancies were able to receive full antenatal care, any skilled workforce only attended 47 percent births and just 31 percent of the total population was using improved sanitation. The public health administration had the responsibility for developing public health leaderships, allocation of funds, making policy, and implementing programs. Aims and objectives: If public health services of a territory repeatedly fails then reasons could be both structural and functional deficiencies of the Public Health Administration. The public health administration different functions required implementation in synchronization irrespective of spatial and temporal consideration and if it would fail then there would be problems as hinted in last paragraph. Therefore the main objectives were to study and present various functions of public health administration. Research questions and hypothesis: The study primarily pursued following main research questions or hypothesis:- Q 1. How the Public Health Administration in Bihar was structured and functioned? Q 2. How Public Health Administration in Bihar delivered? Q 3. What were public health achievable and achievements for Bihar? H 1. The Public Health Administration in Bihar is neither structured and nor functioned accordingly. H 2. Public health services in Bihar were delivered through various public health organizations, associations and institutions. H 3. The core public health objectives in Bihar were achievable however not achieved. Methodology: The project implemented during September 2013 to September 2015 has surveyed 193 public health institutions, organizations, and facilities in Bihar. A qualitative methods were opted for this research that included case studies, interviews, and survey of literature. Survey of health facilities 5

and institutions was preferred over survey of beneficiaries or population because certain spatial and temporal considerations. Findings: The study found Public Health Administration in Bihar largely deficient. There were major structural deficiencies resulting in functional inaccuracies. Several public health functions either entirely ignored, or not implemented accordingly and sufficiently. Some of the mandatory functions like vital registration, surveillance, epidemiology, demography, medico legal, and public health data were not adequately performed in Bihar. There was no universal patient registration system and even patients registered at different facilities were not compounded. There was no distinction of expenditure, contributions, and achievements by respective public and private health care systems. The term Public health administration has two distinct terms; public health and administration. Social medicine, medical sociology or sociology of medicine, sociology of health and illness, and community medicine are both related and distinct terms. The public health administration is an amalgamation of Public Administration, and Principles of Management. It encompassed various experts of medicine, medical administration, medical education, bio technology, medical sociology, ICT, legal and finance. Public health functions included planning, policy & budgeting, workforce education, training and management, arranging infrastructure & logistics, public health data, epidemiology, surveillance, medico-legal, quality - cost control and social determinants of health. PUBLIC HEALTH LAWS A range of laws were in force for practice, conduct, trials, sale, storage, administration of drugs, training, medical research, ethical treatment to animals, safety of patients and medical professionals. In addition, laws related to labour, human rights, citizen charter, gender nondiscrimination, and work place prevention for patients and women were applied in public health sector of Bihar. SIGNS OF IMPROVEMENTS Several health indicators in Bihar has improved significantly over the last 10 years because of the fact that there was considerable downward movement in infant mortality rate, maternal mortality rate, sex ratio whereas there was significant increase in number of IPD/OPD cases, institutional deliveries, and ambulatory services. No polio cases reported for the last four successive years however, it required sustaining the efforts because polio reemerged in 28 countries where it declared eliminated. The OPD cases have increased from a level of 39 per PHC per month to a level of almost over 1000 per month. The immunization coverage has increased from a level of almost 18 percent to over 60 percent. There was marked improvement in ambulatory and referral services and no polio cases reported after 2011. Institutional delivery in Bihar was estimated at 51.9 percent out of that 36.7 and 15.1 percent delivered at governmental and private institutions respectively. Mothers who did not receive any post-natal care were estimated as 20.7 percent. 35.2 percent pregnant women provided assistance under Janai Suraksha Yojna. A total of 61.5 percent registered in Bihar. Rogi Kalyan Samiti constituted at all district hospitals, PHCs, CHCs and FRUs. Over 8 lakh ASHA appointed in Bihar and almost 2400 new doctors aided to the system. 3 new medical colleges are in process to begin. DEMOGRAPHY, MORBIDITY, AND MORTALITY Close to 85 percent of the population lives in villages. Almost 58 percent populations of Bihar are below the age of 25 which is the highest proportion in India. There were almost 14 major cities in Bihar which were having population around 0.2 million or more. The state capital Patna was the most populous city in Bihar having a population of more than 2 million. The demographical pattern of Bihar was more similar to the Contemporary or Delayed Epidemiologic Transition Model where morality rate and fertility rate both declining slowly but steadily. However, it was apposite to the Classical Epidemiological Transition Model that applied to most developed countries. The total population of Bihar as per 2011 census reports was 100.38 million with a decadal growth rate for the period 2001-2011 was recoded as 17.64 percent against 25.07 percent during 1991-2001, hence a decline in population growth rate has been recorded. The Crude Birth Rate, Crude Death Rate, Natural Growth Rate, Infant Mortality Rate, Maternal Mortality Rate, Total Fertility Rate, Sex Ratio, 6

and Child Sex Ratio were recorded respectively as 27.7, 6.7, 21.0, 44, 261, 3.6, 916 and 933 respectively against the national averages of 21.8, 7.1, 14.7, 44, 212, 2.4, 940, and 914. The improvement in child sex ratio could be a welcome sign however overall sex ratio was even below the national average of 940 that could be a matter of concern. The best sex ratio in Bihar at birth was exhibited by districts like Buxar, Aurangabad and Banka that measured at 997, 985 and 978 respectively by the Annual Health Survey Report for the year 2011-12 while lowest sex ratio at birth was recorded for districts like Kaimur and Purnia at 871 and 878 respectively. The total literacy rate for male and female were recorded as 73.39 percent and 53.33 percent respectively against the national average of 82.14 and 65.46 percent respectively. The mean age of marriage in Bihar was estimated at 23.5 years. The estimated number of people suffering from any kind of disabilities per 100000 populations was 1617. The number of injured persons per 100000 populations was estimated at 231 out of that 198 suffered from major injuries. The numbers of persons suffered from Diarrhea/dysentery, Acute Respiratory Infections, fever of all types, and others types of acute illness was estimated at 1900, 4199, 7421, and 14178 respectively out of that a total of 98.2 percent expected to get treatment. However the percentage of people taking treatment at government health facilities was estimated as just 4.8 percent that could term extremely low. Per 100000 populations almost 12003 people suffered from any chronic illness. 354 people were diabetic, 757 suffered from hypertension, 330 infected with Tuberculosis, 117 suffered from Asthma or Chronic Respiratory Diseases. However just 49.5 percent people got treated out of which only 8.5 percent got treated from any governmental facilities. The percentage of pregnancy involving women aged 15-49 years resulted in abortion was estimated at 5 percent. 43 percent of the Currently Married Women (15-49 years) used any contraceptives. Just o.3 percent male used any kind of contraceptives. Respectively 3.6 percent, 0.2 percent and 4.2 percent used condoms, oral pills and any traditional methods of contraceptives the unmet needs of contraceptives was estimated at 33.5 percent.. 65.7 percent currently married women registered for ante natal care out of which 84.7 percent received any ante natal care. Surveillance, epidemiology, and demography was more or less symbolic. Data not collected and compounded from each public and private laboratories in Bihar. There was no any Geographical Information System (GIS) based data on disease prevalence. It was planned under the National Rural Health Mission to integrate the functioning of municipalities with the public health administration however that was not a case in Bihar. The vital registration accomplished by municipalities was not adequate. Lack of comprehensive and universal vital and patient registry in Bihar was hurting the public health data as Infant Mortality Rate (IMR), Maternal Mortality Rate (MMR), Crude Death Rate (CDR), Crude Birth rate (CBR), and many others were based on sample surveys conducted by different agencies. ENTITIES FOR PUBLIC HEALTH To promote the public health services in Bihar a separate department headed by a cabinet minister/ chief minister was set up in Bihar. That has been divided in government and directorates, as separate directorates and nine regional directorates were functional in the state. Under the aegis of National Rural Health Mission since 2005 onwards State Health Society, Bihar, District Health Societies, and Rogi Kalyan Samitis made operational. There were several tiers of health service providers starting from Health Sub Centre to Additional Primary Health Centre/ Primary Health Centre, Community Health Centre, First Referral Units, District Levels. Above all those there were regional, super specialty and medical college and hospitals. The tertiary level of public health system in Bihar strengthened with establishment of All India Institute of Medical Sciences. SERVICES & COVERAGE At the time of establishment of the first democratic government in Bihar in the year 1947, only 33 percent of the population had physical access to any public health services. However, surprisingly this survey has also found that the coverage has still not improved and remained around that figure of 33 percent. The coverage of public health services in Bihar has been ensured and extended to all citizens irrespective of caste, religion, and income level. However, some benefits extended only to people belonging to Below the Poverty Line or BPL. Large part of the health services 7

including OPD, IPD, Immunization, and Ambulatory Services extended across the all sections of society. However, several schemes such as health insurance, funds for institutional deliveries benefitted to BPL families. BPL families could also avail several paid services such as ambulatory, diagnostics, and other paid services at reasonable rates. The Out Patient and Inpatient Department services were largely free of cost at most public health services however at some place a low amount has been charged as registration amount. An amount of Rs. 5/- and Rs. 10/- are charged as registration amount at several hospitals including Medical College Hospitals. However home care services, services for old age persons, medicinal guarantee of all kinds, diagnostics of all kinds, population health, mental health, dental and physical therapy services, rural and indigenous health programs, and health services for war veterans were not ensured and therefore they largely not covered. Likewise, the AYUSH was not adequately functional at any location in Bihar and it raised a great question how the mainstreaming of AYUSH functioned in Bihar. This scheme largely appeared highly unproductive and a great loss to exchequer. However several ayush institutes attracted certain service seekers. Likewise, no ambulatory services, surgical facilities, free medicines and foods, diagnostics like pathological, ultrasound, MRI, CT scan could not ensure at several district hospitals. At least it was expected that they would be regularly available at each district hospitals. Such services were still unthinkable for most sub district hospitals. Those facilities one could find ensured at medical college hospitals to an extent. The Bihar Government was also planning to start paid clinics where patients can take the services of reputed doctors after paying a fee. Fees charged in this manner would equally distribute between the concerned doctor and hospital. By doing so it has been expected that such efforts would prevent private practice by government doctors, as many such doctors remained engaged in private practice despite taking non-practicing allowance from the government. Several such doctors have been punished recently however lack of any regular concerted efforts impact was very limited and private practice by government doctors in Bihar still continued unabated without any hindrance. This has turned to be a great issue in Bihar considering the fact that it has great potential to damage the overall public health progress in the state. 2.4 million Vials of anti-rabies vaccines usually consumed annually in Bihar every year almost costing approximately Rupees 300 crores at current rates. Such huge wastages could have been limited by checking and quarantining stray dogs and monkeys. If the municipalities had functioned well in all the districts then several water borne and vector borne diseases may have been also restricted and such failures caused numerous damage to life and economics. A healthcare system must allow individuals to choose their specialist for out-of-hospital care. However most of time patients are compelled to visit doctors not wished by them. The reason could be attributed to the fact that OPDs of several reputed doctors remained highly overcrowded. Several reputed doctors usually provided consultancy to almost more than 100 patients in their 6 hours of OPDs. Therefore it was required to limit the number of patient would be consulted by one doctor and it required adequate regulation. Even doctors could not seek extra money for more patients. However it has been also proposed that a certain amount would be also paid to the respective doctors in case of paid clinics only. Anyway such provisions not always well regulated and never benefitted people in impartial manner. There was not any facility for afterhours care at any public health centres in Bihar. In many countries of world doctor agrees to participate on a roster to provide appropriate after-hours medical care to people in the territory. The Home and Community Care program definitely not put on even agenda under the National Urban or Rural Health Missions so far. Palliative care services were also not provided by government or any nongovernmental providers to people in their own homes, in community-based settings such as nursing homes, in palliative care units, and in hospitals. The National Palliative Care program also not started in the country. Mental health care largely ignored in Bihar especially in public sector. It was required to set up a dedicated mental hospital in Bihar 8

since only such kind of hospital situated at Kanke, Ranchi now fall in Jharkhand state due to state s reorganization in the year 2000 creating a separate state of Jharkhand carving out 18 districts out of Bihar mainly hilly and tribal areas. A variety of mental health care services providers required to deliver mental health services in Bihar. Non-specialized services and specialized services are required through psychiatrists, psychologists, community-based mental health services, psychiatric hospitals, psychiatric units within general acute hospitals, and residential care facilities. Mental health related General Physicians and specialist consultations are required in Bihar. Community services including crisis, mobile assessment and treatment services, day programs, outreach services, and consultation services readily required in Bihar. Non-governmental organizations also required to provide information, treatment, and advocacy services for mental health care in Bihar. Despite all claims no specialized healthcare facilities such as kidney, liver and other organ transplant functioned at any specialty or super specialty hospitals. People suffered and waited long even for dialysis. Even diabetes and cardiac care were not so streamlined at any district or sub district hospitals. HEALTH INSURANCE Under the National Health Insurance Scheme, almost 7 million families were covered. The overall expenditure on this scheme was estimated at Rs. 2500 crore annually and Bihar Government was paying an amount of Rs. 82 crore per annum. During 2014-15, Bihar government had allocated an amount of Rs.57 crore in this regard. Eight insurance companies were engaged in this scheme. Cholamandalam General Insurance Company was extending this service in Begusarai, Khagadia, Araria, East Champaran, Katihar, Munger and Patna. United India Insurance extended services in Jeahanabad, Purnea,Saharasa, Kishanganj, Arwal,and Bhagalpur. ICIC Lombard in Samastipur, Banka, Sheikhpura, Siwan, Chapra, Madhepura, Nalanda and Muzaffarpur districts. Tata AIA extended services in Bhojpur, West Champaran, Gaya, and Supaul districts. Apollo Munich in Darbhanga, Sheohar and Vaishalli districts. HDFC Argo in Kaimur, Buxar, Aurangabad, and Rohtas districts. MAX Bopa in Madhubani and Gopaganj districts. Reliance in Sitamarhi district. Under the scheme, a Smart Card provided to head of the each family after realizing a contribution of Rs. 30 only. The Smart Card accepted in almost 400 government and private listed hospitals in Bihar. Free diagnostics, treatments, and medicines ensured. Government policies have encouraged people to take out private health insurance early in life: however, there were numerous corruption cases reported in Bihar of false claims made and payments of insurance amount to fake claimants and nursing homes. It was estimated that such swindle could have caused a damage to almost 5000 crore to the government. Several private insurance companies benefitted by governmental insurance policies, never extended any coverage to the people, and worked just on paper works. Therefore, health insurance schemes in Bihar must require well regulated in Bihar in order to enable benefits to genuine people. The health insurance coverage program must start at the early age and I would suggest starting it from the birth. People during early ages could insure at lower premiums. Government could also think paying full, part, or subsidized premiums. PUBLIC HEALTH FINANCING The state government has earmarked Rs 5,085 crore for health-related facilities in the financial year 2012-13, up from around Rs 1,000 crore that it was spending on it in 2005-06. Moreover, the government has planned to spend up to 2.5 percent of the GDP on health services in five years since then, against the current expenditure of only 1.2 percent of the GDP. For the year 2013-14 expenditure for health sector is estimated at Rs. 3356.84 crore as against Rs 3085.99 crore for the year 2012-13. During the year provision of a higher amount by Rs 270.85 crore over the previous year has been made. For the year 2013-14 the total amount includes Rs 2317.62 crore Non plan, and Rs 1039.22 crore Plan scheme including Rs 629.23 crore under State Plan and Rs 409.99 crore for Centrally Sponsored Scheme. Nongovernment sources provided almost 0.9 percent of health expenditure in 2010 11, including out-of-pocket spending (mostly spent on medications, dental services, aids and appliances, and copayments). Private health 9

insurance (PHI) offered choice among private hospitals, private care in public hospitals, inhospital specialists, and practitioners of ancillary services such as dental care, optometry, and complementary medicine. It also offered choice in the timing of procedures. Post liberalization and especially after 2004, private insurers had been able to cover out-ofhospital services that substitute for or prevent in-hospital care, and disease management programs now offered by most insurers. Private health insurance accounted for 7.6 percent of total health expenditure in 2010 11, and almost 2.78 percent of the population had private hospital insurance and 4.9 percent had general treatment coverage (which included ancillary services). INFRASTRUCTURE AND WORKFORCE The overall public health care in Bihar extended through 9696 Health Sub Centres, 13360 Additional Primary Health Centres, 534 Primary Health Centres, 466 Community Health Centres, 55 Sub Divisional Hospitals, 36 District Hospitals, and 13 Medical Colleges & Hospitals. In addition, there were few specialty and super specialty hospitals, ESI Hospitals and Railway Hospitals at Patna, Hazipur, Saran, Katihar, there also Army Hospitals also functional at Danapur, Gaya, and North Bihar. An All India Institute of Medical Sciences (AIIMS) also became functional since 2014. Despite all those facilities it was estimated that a total of 20760 Health Sub Centres, 3460 Additional Primary Health Centres, 865 Referral Hospital or Community Health Centres, 63 Sub-Divisional Hospitals, 38 District/Sadar Hospitals, and 21 Medical Colleges & Hospitals were required in Bihar as per population norms of the Indian Public Health Standards (IPHS). Almost 16943 Female Health Workers/ ANMs positioned at the all-9696 functional Health Sub Centres in Bihar. This number also included those workers also posted at different Primary and Additional Primary Centres in the State. A total number of 1074 Male Health Workers positioned at the all-9696 Health Sub Centres. A total number of 358 Female Health Assistant /LHV posted at PHCs. The numbers of Health Assistant Male at PHCs were 556. 3532 Doctors were posted at PHCs. In addition 451 General duty medical officers (GDMOs) and 80 Block extension educators (BEE) positioned at PHCs. The numbers of PHCs/APHCs functional in Bihar with four, three, two, and one doctors were respectively could be measured at 421, 32, 62, and 1330 whereas 18 APHCs were without any doctors. Lady Doctors positioned at only 165 PHCs. 212 PHCs were without any pharmacist. However, in 1384 PHCs/APHCs AYUSH facilities created. Only 41 surgeons positioned at CHCs in Bihar and there was a shortfall of 29 such surgeons. Likewise, at CHC level, it was a shortfall of 31 Obstetricians and Gynecologists as they just only functional at 39 CHCs. Physicians, Pediatricians, and Radiographers positioned at only 28, 43, and 13 CHCs respectively. Undoubtedly it could said that in Bihar it was not only that number of health facilities not expanded according to the population norms of IPHS however even existing health facilities were not adequately manned and made functional. QUALITY CARE Two sets of standards were operational in the public health sector of India and also in Bihar. First was the Bureau of Indian Standards and the second was India Public Health Standards. Under the National Rural Health Mission, the norms of Indian Public Health Standards implemented since 2006 onwards. There were qualities control committees at several levels. It was required to set up a national or state level commission on Safety and Quality in Health Care to provide quality care a statutory status. It could publicly report on the safety and quality of health care performance against national standards, disseminate knowledge, identify policy directions, and develop and promote programs. An authority also required to monitor trends in the performance of health service providers against standards set out. There is no compensation for patients in case he/she gets any substandard and low quality services and suffered damage to life and health. Although there have been provisions of quality control committee in each public health hospitals, nevertheless for adequate quality control in health care system accreditation system considered extremely useful. Considering this fact a national level accreditation system was in place namely National Accreditation Board of Health Care System, (NABH) constituted however, as of 10

June 2014, no any public hospital in Bihar could accredit. In fact the overall effort of the state government was to get accredited at least two hospital and they have selected Sub Divisional Hospital of Danapur and District Hospital Buxar. Both those hospitals would upgrade to the tune to get accreditation. However why Danapur and Buxar selected could not be clearly articulated. HEALTH DISPARITIES A great degree of health disparities persisted in Bihar in terms of economic and regional levels. Those disparities could only eliminate by strengthening free and cost effective, and sustainable public health care system. To eliminate regional disparities public health care system must be strengthened and bring much closer the people. In addition, for this sake each Health Sub Centre must made fully functional health facilities with all doctors and referral system. It required moving ahead from immunization and other peripheral services. ELECTRONIC HEALTH RECORDS The status of electronic health records not adequately positioned and developed. There was a provision for online patient registration and maintenance of records however, that no way could term adequate, as a handful of hospitals were able to do so. It was required to connect all government and private hospitals in any such network so that any patient coming to get any kind of treatment to any hospital get Unique ID and then their records remained maintained updated with time so that a case history of each treated individuals could be maintained. COST CONTROL In government hospitals cost is controlled by the philosophy of an entirely free of cost health services and it does not mean that services if free would not be available. For this sake government provided financial allocations to all health centers for expenditure on salary, establishment, infrastructure, logistics, and medicines. The cost control in public health system became important because several services outsourced to private parties and there have been public private partnerships. Therefore a mechanism of minimum charges is introduced whereby no service provider could charge more than fixed charges. The arrangement seems good at first glance however there were several malpractices adopted by those private service providers. In the private sector however, costs are controlled by various market, financing, and managerial mechanisms. Such mechanism considered not suitable for introduction in public health sector. India has so far not turned into a mature generic pharmaceuticals market like many other countries. The Government has to become a near-monopolist purchaser of patent medicines which, combined with tight prescribing requirements, allows it to control pharmaceutical pricing. However, private hospitals not regulated over the price it charge for rendering services. Many private hospitals charges are beyond a common person and that required capped. Diagnostics arrangements are also costly and in government hospital, there is long queue or waiting list for several diagnostics resulting in massive discomfort to patients requiring urgent treatments. HEALTH INFORMATION MANAGEMENT SYSTEM Bihar had a health information system that made functional by State Health Society, Bihar. However, it appeared that it was a part of the national level Health Information Management System. A wide range of data one could find however it was very difficult to access data due to non-development of adequate and wide range data collection and presentation system. The statistics compiled must include HRPH data, though not in a comprehensive manner. Special attention required at both regional and national levels to create an up-to -date HRPH information system. Furthermore, the health management information system scale-up appeared to be limited, particularly in Bihar with limited resources for hiring the health information technicians required to initiate the implementation. The failing public health provisions in the state may be due to three reasons such as nonexpansion of number of health facilities, no creation of infrastructure, logistics and finally arrangement of the public health workforce. All those were required arranging to the tune of the population norms of Indian Public Health Standards. Those failures resulted in lesser amiability of hospitals beds, physicians, gynecologists and para medical staff that happened to be among lowest in the world. The public health planners and policy makers 11

simply missed the opportunity and did nothing to promote work force because workforce was considered major cause of those shortfalls. There were several instances were found of creation of infrastructure and deployment of logistics without arranging work force. MEDICAL EDUCATION Medical colleges in Bihar largely never complied with the terms and conditions required for medical education set by the Medical Council of India (MCI). Medical Council of India based upon its findings time to time kept coming up with several disparities as a result medical education gets hampered in Bihar. Punitive actions of Medical Council of India most often included no increase of medical seats in medical colleges and nongrant of admissions from fresh batches. Some of the most common and specific drawbacks highlighted by Medical Council of India (MCI) in Bihar Medical Colleges usually included: Lack of Professors, Associate Professors, Assistant Professors, Tutors and, Residents, Paramedic and other staff, lack of infrastructure such as galleried study room, common room, hostel, bath and toilet facilities and also library facilities. Non-computerization of medical data emerged as one of the major ***** weaknesses in Bihar Medical colleges. Some other drawbacks noticed were such as lack of Pharmacy Vigilant Committees, lack of e-class, photography units. The total MBBS seats available in Bihar was almost 1000 one of the lowest in the country. Even at the post graduate or more precisely at MD or MS level number of seats were negligible considering the vast population and areas. State leadership and political class must think in this direction because lack of doctors, specialists, and other para medics and technicians the health care system would not sustain itself in regular and professional manner. Impression: The core public health objectives in Bihar were achievable yet not achieved or delayed. The public health planning was not according to the availability of the workforce. Subjects like Public health, Social & Community Medicine, Public Health Management, and Public Health Leadership are not taught at universities in Bihar. There were numbered academic researchers in those areas. Creation of infrastructure and logistics without dedicated workforce has hurt the success. Development of Public health leadership, workforce, and allocation of more funds would definitely turn the situation favorably and quickly. 12