End under-funding of PHS

learn from Gorakhpur

The death of over 70 children at a government hospital in Gorakhpur has yet again brought India’s deficient healthcare system under a harsh spotlight. Sadly, in situations like these, the imperative of making some heads to roll and popular demands for easy scapegoats take over. The root causes behind the tragedy is rarely addressed because of the frequency of such tragic events in the country. As BJP president Amit Shah said darkly, such tragedies have happened before and, one can assume, will happen in the future. The sorry reality is that no systemic revamp is discussed, unless the scale of the tragedy is huge.

It is worthwhile to take a good look at the reasons cited. Prima facie, the gas company supplying oxygen to the hospital stopped doing so – a charge denied by the vendor since – because Baba Raghav Das Medical College had not cleared bills of over Rs 68 lakh that was pending for months. What caused the delay in paying the vendor and whether it had to do with graft, or whether some doctors at the hospital were engaged in private practice and had been negligent towards their duties at BRD hospital merit investigation.

Chief Minister Yogi Adityanath blamed encephalitis as the cause of most deaths among new-borns, while his health minister put the blame on low birthweight, pneumonia and kidney failures, besides viral infection, accounting for the deaths.

In view of the record of encephalitis having claimed more than 10,000 lives since 1978, the year of the first major outbreak, and the vulnerability of the eastern districts of Uttar Pradesh to the disease, it is clear that successive governments have not set and implemented long-term policies and strategies to prevent the disease and avert the deaths of hundreds every year.

The most important drivers of infant, child and maternal mortality being haemorrhage, sepsis, abortion-related complications and hypertensive disorders, there is an urgent need at the community level for clinic-based obstetric and emergency care and hospital-based emergency care in proximity. Such facilities in Kerala and Tamil Nadu, for instance, have delivered better outcomes with regard to infant mortality rate (IMR) and maternal mortality rate (MMR).

From what transpired in Gorakhpur, therefore, what is of concern is the monumental apathy and neglect that, by and large, bedevil our public health system. Why countries such as Denmark, Finland, Sweden and Norway, with a long history of democratic socialist or labour governments, have excellent and universal healthcare systems, top-class educational systems, and how they have fared better in eliminating poverty and creating far more egalitarian societies than we have, merits attention.

In India, the healthcare sector is growing at a compounded annual growth rate of 16.5% and is projected to be worth $280 billion by 2020. This growth in business is accounted for by a rapid privatisation of healthcare, particularly in secondary and tertiary healthcare services, while the overburdened and underfunded public healthcare system languishes.

Since 1980, global agencies like the World Bank, new powerful players like the Bill and Melinda Gates Foundation, and at times even the World Health Organisation (WHO), have played a role in promoting so-called “market reforms” in healthcare, which have effectively incentivised a philosophy of profit over service.

In India, if the problem with government health facilities is extreme pressure, lack of funds and medical equipment, lack of accountability and so on, the problems of private hospitals have been identified mostly to be inflated or fictitious bills, negligence, allegations of unnecessarily putting patients on ventilation, refusing to release patients who are unable to afford treatment in a particular hospital, holding bodies to ransom if bills are not cleared in full, and the like. The bottom line is: 70 years after Independence, we are yet to fully resolve issues of healthcare and sanitation.

Weak system

Yogi Adityanath was not off the mark when he said that infants in eastern Uttar Pradesh are suffering from encephalitis due to lack of hygiene and open defecation in the region. A good system of regulation that can reduce exposure to disease through enforcement of sanitary codes — for instance, water quality monitoring, slaughterhouse hygiene and food safety — is fundamental to successful public health outcomes. A weak public health system is often the result of a wide gap in enforcement, monitoring and evaluation.

Gorakhpur may be a symbol of the state of our public health system and a poor projection of how far India has met its Millennium Development Goals (MDG) obligations with respect to maternal and child survival.

Our “free” public health system is languishing under the effects of years of under-investment which, according to the WHO’s Global Health Expenditure database, was as low as 1.4% of GDP in 2014, well below the world average of 5.99%. The country has a massive resource gap of over four million health workers, which suggests how, besides being under-equipped, our facilities are also hopelessly understaffed.

Seventy years after Independence, in country with superpower ambitions, incidents like Gorakhpur are scandalous – because they show that we have failed to accord much dignity to human life, and we tolerate the scamsters and the corrupt, our own daily impoverishment and insult, the loot of public money, and we put up with rickety public health and public education systems run by racketeers.