Robert Frost’s left out road is much like the one, patients at Beltar PHC opt not to take. The reasons differ in some meaningful way. A child referred for evaluation and further management of sepsis after primary management is taken back home. The result is a misfortune, we usually blame to 49.2 kilometers of the road not taken the distance between Beltar PHC and a tertiary care hospital at Dharan. A severely anemic patient who clearly requires evaluations far more advanced than Beltar could offer was referred to a tertiary care. A day later, news of her demise at home ignited a discussion that has been going on since the establishment of the PHC itself. My intentions today are to discuss the possible reasons transport in rural areas is such an over looming problem. Some reasons are generic, while others are more specific to Beltar.
I vividly remember a case I suspected of stroke and decided to refer to a higher center. There are myriad of decisions and hurdles to work around in order to make the referral smooth. I remember being worried about my patients back in internship about not getting the 30 minutes earlier slots for CT scan. That compared to sending my patients to a different city for the scan seems like a funny worry. Even when you convince a patient that a referral is necessary, which is in itself a rigorous and overwhelming process for both the health practitioner and the patient party, there arises many hurdles to the process. Convincing a patient that half of his monthly income is worth the ambulance ride to a city with CT scan facility that will cost him his other half of the salary can never be an easy process. That combined with the possibility that the CT will come out to be normal is paradoxically a nightmare. Hurdles start to emerge from the least expected places. Spinal board to transfer patient to the ambulance, a simple start to make sure the patient does not move when the ambulance speeds on a bumpy road, oxygen cylinder for the travel, all are privileges that patients at Beltar PHC scarcely have.
Rivers surround Beltar; that means during the rainy season, transportation is very limited. So much so that, “We are referring your patient to a higher center” is a euphemism for, “We are sorry, that is all we can do here.” A gravid mother with thick meconium liquor was once referred in coordination with the municipality with the use of an excavator to cross the river. A proper functioning bridge across the river can solve this problem. The story of Beltar is many things; what it is not is a story without solutions. A common theme rather is a logical solution not implemented. Some reasons behind it are painfully obvious; others are yet to be explored.
Beltar PHC offers one ambulance at the subsidized fee of Rs. 4500 (US$ 39) for patient transport. It also has a fund of Rs. 50000 (US$ 432) for patients who can’t afford the fee for an ambulance. One ambulance is surely not enough for a PHC looking after 150 patients a day. What we could come up with is contacting the private vehicle owners of the area and using them in place of an ambulance. Although not as equipped, an oxygen cylinder tied to the back seat and the seat folded enough so that the patient can lie down converts any vehicle into a functioning ambulance. They charge more fare for the transport, which is another hurdle patients at Beltar face.
Many who visit the PHC view it as an alternative to more expensive and time-consuming tertiary care centers. That belief roots in the lack of knowledge about the hierarchy of medical care provided. This ties into the problem with rural transport because these patients view referral as a horizontal transfer rather than an upgrade of care.