In August 2017, the print and broadcast media was splashed with the grim news of tragic deaths of children in a Gorakhpur hospital. Since then, more such incidents have been reported from Gorakhpur and other parts of the country.
Now, our response to such reports is more of indifference. What an unintentional outcome of Gorakhpur tragedy appears to be is that it has made us insensitive to such incidents.
The health sector in India is not known for learning lessons from tragedies and failures. There are immediate, and knee-jerk responses and then everything is forgotten after a short period. If we sit back and reflect, there could be a possible steps and action points from the Gorakhpurs of Indian hospitals. These need not be resource intensive and could very well be incremental and straightforward.
First and foremost is the need is to build capacity to analyse and document the causes of morbidity and mortality at facility levels.
The World Health Organization’s annual “World Health Statistics, 2017” reported that in India, in the year 2015, the causes were known only for 10% of all deaths. The world average was 48%, and in China, 90% of all deaths were recorded with precise causes of deaths. It might appear insignificant, however, if there is information on the causes for which people seek care at a type of facility (considered morbidity in medical terms) and why people die at a type of facility, by age groups; by referral mechanism etc., it can be operationally useful.
Can this be done for the BRD medical college in Gorakhpur, in next six months? Can a system be developed that this will information be systematically documented and utilised? The simple answer is yes, and this should have been the first action from the incident in August 2017.
In next 12 months, all medical colleges and district hospitals in India, should aim to get such a system. This morbidity and mortality profile can help in re-designing and re-organizing services and for the allocation of all types of resources (HR, Financial and drugs and supplies.)
Further areas for immediate attention could be, as follows:
The social determinants of health contribute to 50% of the morbidity and mortality. Therefore, a parallel step is to understand the community linkage of deaths.
Questions such as – where have these patient been before coming to these facilities, the availability of health services in the areas they come from, care-seeking patterns of these families, the socio-economic environment in which they live, whether there was a delay in seeking care and who was their first contact are extremely relevant.
This needs the engagement of the departments of community medicines at the medical college level and that of trained epidemiologists at the district hospital.
Large facilities are designed to deliver specialised care. If these are burdened with patients with common illnesses, the inefficiency defeats the objective.
The primary healthcare system and rural healthcare facilities in India are almost non-functional, and people rely on district hospitals and medical colleges. The challenges are well understood, and the solutions are proposed.
The National Health Policy of India, 2017, proposes that nearly 70% of should be spent on primary health care. However, the the reality is very different. The approach has to be simple. For every rupee allocated towards established institutions like AIIMS, for setting up a medical college or upgrading a district hospital, two rupees should be allocated for primary health care. That is the formula to be strictly followed.
The approach to service delivery has to be a functional referral linkage and establishing a ‘continuum of care’ across the spectrum from village to sub-health centre to primary health care, sub-district hospital and the district hospitals. Many countries including Sri Lanka and Thailand have followed this path and succeeded.
The level of government investment in health in India is sub-optimal, in-spite of stated intentions. The states with the highest need spend the lowest.
In the year 2014-15, the per capita expenditure on health in Uttar Pradesh state was ₹ 635. This is nearly 40% of what government of Kerala spent that year. It is one-sixth of what Indian experts have considered optimal expenditure to provide basic health services for all. The commitment to increase public funding for health has to be the first step.
A number of Indian states have schemes for the free provision of medicines and diagnostics. The reality is that patients do not receive the prescribed medicines from facilities on various accounts. The central pathology labs even at medical colleges, are sometimes understaffed and do not conduct, even the basic lab tests.
Even though high-cost equipment and reagents are made available, the staff is unavailable, and those posts are not qualified to conduct the tests. The reports provided by these facilities are often not trusted by the doctors working at these facilities itself.
The presence of private pharmacies and laboratories just outside every large government hospital in the towns of India is proof of the failure of the government system. It is time that the government move from the ‘entitlement approach’ to ‘guarantee approach, at least for few services.
People are entitled to free medicine and diagnostics, but that is not working or making a difference. Let’s guarantee free and assured access to medicines and diagnostics: the government would ensure that every single prescribed medicine would be provided free and the lab test would be done in time bound manner. This can be initially implemented for patients attending large government facilities. It would need financial resources and effective supply chain system.
Acknowledging a problem is the first step to the solution. Many deaths in Indian hospitals are preventable. The health systems in Indian states would improve only if lessons are continuously learnt in timely manner and actions taken. Political will and a collective desire to make a difference are essential to change things for better, forever.
(Views are author’s personal and should not be attributed to organizations/institutions he has been affiliated in past or at present)