Because of limited income of the majority of residents of Bihar, dependent on public health services. In recent years, the state government has taken a number of steps to improve the functioning of the public health institutions and, consequently the number of patients visiting government hospitals has increased significantly (Table 5.7). The average number of patients visiting government hospitals per month was 3077 in 2007, which has become more than three times (9317) in 2011.

The health infrastructure in Bihar consists of district hospitals, referral hospitals, sub division

Hospitals and health centres; within the last category, there are three types Primary Health

Centres (PHCs), Sub-centres and Additional PHCs (APHCs).

During last five years, there has been an expansion in the health infrastructure with the establishment of 3 new district hospitals, 11 new sub divisional hospitals, 49 PHCs, 108 Sub-centres and 87 APHCs. At present, there are 36 district hospitals, 78 referral hospitals, 55 Sub-division hospitals and 11,559 health centres of different hospitals. A broad calculation indicates that a health institution in Bihar serves about 8.9 thousand people on an average.

There is considerable variation across the districts in terms of availability of health infrastructure. The average size of population served by a hospital / PHC varies from as high as 15.6 thousand in Sheohar district to 5.2 thousand in Jamui. The best three districts in terms of availability of health infrastructure are Jamui (5165), Nawada (5598) and Sheikhpura (5772). On the other end, the three most disadvantaged districts are — East Champaran (12,581), Sitamarhi (12,712) and Sheohar (15,641). Here again one can notice considerable variation across the districts.

In 2011-12, three districts with the highest average number of outpatients visiting hospitals per day are Aurangabad (582), Araria (542) and Supaul (474).

At the other end, three districts with the lowest average number of outpatients visiting hospitals per days are Jamui (198), Patna (230) and Madhubani (242). Along with the services provided to outpatients, the hospitals also admit people with serious illness for their treatment. The extent of such services for the in-patient can be judged from the occupancy rate of hospital beds.state, the occupancy rates are 22.6 percent (2009-10), 58.9 percent (2010-11) and 77.1 percent (2011-12), indicating a steady increase.

From the occupancy rate in different districts, one can obtain an idea about the pressure of the health services in different districts. This pressure was the highest in Bhagalpur, where the occupancy rate is 237 percent followed by Araria (194 percent) and Sheohar (174 percent). Some of the districts where the pressure on health services is relatively less are Banka, Begusarai and Bhojpur, in each of which the occupancy rate is 30 percent or below. Except for a limited number of districts, the overall trend of steady increase in occupancy rate is found to be true in the remaining districts.

One of the important dimension of health infrastructure is availability of health personnel doctors, nurses, Auxiliary Nurse-Cum-Mid-Wife (ANM), Accredited Social Health Activist

(ASHA).

As regards doctors, there are now 2472 regular doctors in Bihar against 4851 sanctioned posts, indicating that nearly half the posts are yet to be filled up. In addition, there is also sanction for 2375 contractual doctors, of which 1664 posts have been filled up, indicating a vacancy ratio of 30 percent. With this strength, a doctor in government hospital / PHC serves a population of about 25.1 thousand. There are as many as 9 districts (Rohtas, Siwan, West Champaran, Sitamarhi, Madhubani, Jamui, Madhepura, Kishanganj and Araria), in each of which a government doctor has to serve more than 30 thousand people.

As in the case of doctors, it is also found that the government has not been able to fill up all the sanctioned posts for Grade-A nurses, either regular or contractual. For the state as a whole, the vacancy rate is more than 50 percent. In some of the districts, the vacancy rates are much higher.In contrast to the situation of doctors and nurses, the strength of health personnel is much higher for ANM and ASHA. In March, 2012 the strength of regular ANM was 9,529, against the sanctioned strength of 11,800. This implies that 80 percent of the sanctioned posts are filled up. In addition to regular ANMs, the state government has also sanctioned posts of 11,479 contractual ANMs and 7952 of them have already been employed, implying a vacancy rate of 30.8 percent.

The working strength of ANM in different districts is not uniform, but fortunately inter-district variation is moderate. When it comes to the ASHA workers, it is found that there are all 83.4 thousand of them in the entire state, against a sanctioned strength of 87.1 thousand. This implies that vacancy ratio is less than 5 percent. It is also satisfying to note that, in March, 2011 no less than 86 percent of ASHA workers were trained ones.

Overall, it should be noted about health services that, during the recent years, just as the overall infrastructure has been expanded at one end, its utilisation by the people has also increased because of improved health care facilities. However, the physical infrastructure and personnel for health services are still not enough for the large and needy population of Bihar, particularly in rural areas where the private medical services are extremely limited.