Apathy ails the public health network

An overhaul of the healthcare network is not tall order, provided we fix gaps in intent, policy and practice

When Chandbi (29) entered the Yadgir District Hospital last Sunday, she was buoyant with the thought of holding her newborn. In a span of thirty minutes, her hope morphed into fear when her husband Nawaz was unable to secure the attention of medical personnel. A recent diagnosis by a Primary Healthcare Centre had warned Nawaz about his wife’s low white-blood-cell count, aggravating his worries about a complicated delivery.

Too late to seek out another hospital, Chandbi was forced to give birth in the corridor, on the floor. “I felt so helpless,” Nawaz recollects those harrowing moments. “Only after my baby was born did I get a bed and medical attention,” says Chandbi.

A week after the incident, Nawaz is grateful that both mother and child are healthy but is disheartened with the treatment they received at the hospital. “How can doctors not care even when my wife was on the floor, giving birth?” he asks.

Consecutive instances of denial of necessary emergency care, compounded with personal experiences of shortage of staff and absenteeism, lack of hygiene, corruption and mistreatment have cemented public opinion on the ailing public health network. It is no surprise that patients seeking government healthcare have dropped from 55.1 per cent in 2016 to 49.9 per cent in 2021, according to the National Family Health Surveys. Those surveyed cited “poor quality” as a reason.

Despite such drawbacks, government hospitals remain trusted and integral to addressing the health concerns of the poor. Private care remains largely out of reach.

Yet, even at the stage of approaching hospitals, patients are bogged down by hurdles. Even though Kamala* was a member of the staff at S N R Government Hospital in Kolar, she had to use the influence of agents to help her daughter-in-law get a bed in the maternity ward. “I had to pay Rs 1,400 in total for the bed despite qualifying for free service with my BPL card. From the level of cleaners to nurses, I had to give everyone something,” she explains.

Corruption is a pervasive malady of the healthcare system, and does not spare even Asha workers. Kavyamma*, an Asha worker from Tumakuru, who accompanies pregnant women to the district hospital for deliveries, details how women she accompanies are referred to other hospitals if they do not go through middlemen. “They refer to private hospitals or speciality hospitals in Bengaluru citing complications. When the women reach these hospitals, they have completely normal deliveries,” she says.

In fact, about 24 per cent of Indians have paid medical officials bribes and 35 per cent have used personal connections to access treatment, says a 2020 report. This has earned India the dubious distinction of being the second-highest country in medical bribes.

“Those without money or political connections do not fare well in public healthcare,” explains a Mysuru-based doctor.

A majority of people seek to use money and influence as public health institutions remain aloof to civil realities. “After having travelled for about four to five hours, patients are sent back either because of minor errors in documentation and ID proof,” explains a Mysuru-based doctor, who works with people at the grassroots level.

Government hospitals remain unresponsive even in the face of vital healthcare emergencies, which adds to their disrepute, he explains. Last month, a woman in labour, pregnant with twins, was denied admission by the district hospital in Tumakuru. The reason — she failed to furnish her Thaayi and Aadhar cards. At home, the woman and newborns soon after delivery due to excessive bleeding.

Staff shortages

While some medical staff attribute such incidents to chance, others chalk them up to perennial shortages of medical staff. Deficiencies in staffing plague most fields of medicine, including paediatrics (41 per cent), general medicine (50 per cent) and ophthalmology (50 per cent) in government hospitals. Across all fields is a dearth of doctors and nursing staff, affecting the delivery of even basic procedures.

In the Kalaburagi district hospital, for example, due to the heavy inflow of patients, the maternity wards especially grapple with an insufficient nursing team. Close to 30-35 babies are delivered daily, a nurse says. However, out of a requirement of 130 nurses, the hospital has filled only 60 positions. In Kolar too, there is a paucity of nurses with only 46 per cent of sanctioned positions being filled in the hospital.

Persisting vacancies also mean that nurses who normally are recommended to tend to four patients have to take care of 40 patients. Nurses are also compelled to work more than their stipulated eight hours of duty due to high workloads. “When the volume of care required increases, the quality of care is impacted,” says a senior nurse at a BBMP-run hospital in Bengaluru.

Across Karnataka, 30 per cent of auxiliary nurse and midwife and 10 per cent of staff nurse positions remain unfilled. Government recruitment drives for nurses, however, remain few and far between.

Hospitals often have to make do with the workforce they have. Research has concluded that nursing shortages and high patient loads could be directly linked to medication errors and interruptions, which can pose a moderate to severe risk to patients.

Infrastructure and drugs

In the state’s district hospitals, there are only 33 beds per 1 lakh people against the stipulated 300 beds per lakh people. Even these facilities, rare as they are, are uneven in distribution, with North Karnataka falling way behind in the distribution of hospitals and beds, according to a report by the Karnataka Health Vision Group.

Not all districts in Karnataka have district hospitals. Out of 30 districts, only 22 have district hospitals in the state. In these locations, people would have to depend on taluk-level hospitals or travel to hospitals in neighbouring districts. “People have got used to non-working government hospitals and are so heavily dependent upon the private health care sector,” says Dr Gopal Dabade, President of the Drug Action Forum in Karnataka.

Irregular drug procurement has also left hospitals struggling without essential medical supplies and even common drugs like paracetamol. “By providing free medication, we can improve patient footfall by almost 30 per cent like the neighbouring Tamil Nadu,” explains Prasanna Saligram, a public health and community health researcher with Jana Swasthya Abhiyan Karnataka.

However, mismanagement and delay in procuring drugs have left patients at sea, pressing them to spend out of their pockets. Archaic accounting systems have also not allowed for a steady replenishment of drugs, he adds.

At the primary level, even the basic requirements of a clean water source and uninterrupted electricity supply are elusive. About 34 per cent of all sub-centres and 11 per cent of PHCs in the state have no regular water supply. Close to 40 PHCs functioned without an electricity supply.

Even district hospitals are not free of such misfortunes. Sitting beneath a ceiling with damp patches and peeling paint in the orthopaedic ward in Kolar’s SNR government hospital is Rahim*. Having spent about three days at the hospital, he has one complaint. “There is no guarantee of water. The condition of the washrooms will obviously be pathetic without water,” he says.

A solution?

Recognising these challenges, two years ago, the Niti Aayog unveiled a plan to hand over district hospitals to private companies that would attach medical colleges and run them on a Public Private Partnership (PPP) model.

Replying to an unstarred question in the Legislative Council in September this year, Karnataka Minister of Medical Education Dr K Sudhakar confirmed that the model would be pursued in four districts primarily — including Kolar, Udupi, Vijayapura and Davangere.

This announcement was met with extensive criticism from the public and health experts who say that there was evidence that PPP model would cause more harm than good.

“Each venture in the state under the PPP model has been a bigger disaster than the last,” says Dr AkhilaVasan, convenor of the Karnataka Janarogya Chaluvali.

The Rajiv Gandhi Super Speciality Hospital (RGHHS) in Raichur, for example, was handed over to be managed by a private entity in 2002. In the ten years under the PPP model, “there were many protests as BPL card holders were unable to access free services,” says Syed Hafizulla, Vice President of the Bharatha Jnana Vijnana Samithi in Raichur.

Built with funds granted from the Organisation of Petroleum Exporting Companies, one of the hospital's aims was to provide quality healthcare to patients below the poverty line (BPL). However, a government report details that in the ten years of its functioning, only 25 per cent of the in-patient and 15 per cent of the out-patient services had been employed by BPL patients over the decade.

Also privy to misappropriation of funds and double-charging BPL customers, the state government refused to renew its contract with the private company. The experience, experts say, was a masterclass in what could go wrong and characterises how corporations are rarely committed to public interest.

The very objectives of the public and private health sectors are antithetical, making the success of partnerships like the RGHHS unlikely. While the aim of public healthcare is to extend both preventive and curative care equitably, “for private hospitals, the bottom line matters. They are profit-driven,” explains Karibasappa, the organiser of the Committee Against Privatization of Chigateri District Hospital, Davangere.

Reconciling the two would need the creation of robust regulatory systems with autonomous monitoring bodies like Canada or the UK.

“With an understaffed public health sector, monitoring complex PPPs is difficult. Overall, PPPs raise the cost of outsourced services” says Bijoya Roy, Assistant Professor, the Centre for Women's Development Studies.

In the absence of such regulations, preventive and promotive care would suffer under the PPP model. "Private systems can only provide some health care after a person has contracted the disease," says Saligram. The public healthcare systems are designed to combat secondary diseases like malaria and tuberculosis which are common across the country.

In profit-driven ecosystems, there is also a push for surgeries like hysterectomies and caesareans, even in cases where they are not required, explains Bijoya.

PPP models are touted as the only simplistic solution for systemic problems. "In reality, we are sawing off the branch we are sitting on," Saligram says.

The way forward

Instead of looking for silver bullets, the need is to upgrade and strengthen the existing vast network of public healthcare, ensure that drug procurement and infrastructure are up to the mark and vacancies are filled on time. To see an immediate improvement in the reach of hospitals and the footfall of patients, Dr Prashanth N S, a doctor who works with the Soliga community in B R Hills, explains that there is a need to make public institutions less intimidating. “We can have help desks that will explain to patients what kind of documentation they would need to bring,” he says.

Hospitals, currently handled by senior medical officers, need the expertise of hospital management cadres, as is the standard in private hospitals. “These professionals specifically see to it that hygiene, equipment and other medical standards are met,” explains Dr Prashanth. Patient welfare committees can also be formed, to involve and understand community demands for healthcare, he adds.

A case in point of satisfaction with the public health infrastructure is Redyappa Kyalooru, a patient with kidney disease, who undergoes dialysis thrice a week at the Kolar hospital. The room is clean and the medical team works with him to fix a time so he does not have to wait. “I went into serious debt after going to three private hospitals,” he explains. His case provides an insight into the demands of the public, on the ground. There is a need for dignified care at every stage of the public health network — not a tall ask.

(With inputs from Vittal Shastri in Kalaburagi, Yadgir, and Ram Rakshith in Bengaluru)