The story behind a crumbling healthcare system

The public health system in Maharashtra, India, is crumbling due to staff vacancies, lack of funds, and a lack of streamlined medicine procurement systems. The state has a doctor-to-population ratio of 0.84:1000, far below the World Health Organization's recommended ratio of 1:1000. The government has approved the construction of 10 new hospitals and is seeking funding from the Asian Development Bank.

Mumbai: The 35 deaths witnessed in two days at the state-run Dr Shankarrao Chavan Government Medical College and Hospital in Nanded, and 18 deaths in 24 hours at the Chhatrapati Shivaji Maharaj Hospital, in Kalwa in August, are symbolic of the state’s crumbling public health system.

18 patients died in 24 hours at the Kalwa hospital in August. (HT Archives)

This is the inside story: the public health machinery has been marred by over 15% vacancies in medical and administrative staff, lack of funds, absence of a streamlined system to procure medicines and overburdened hospitals. All 25 medical colleges, in as many districts, and hospitals attached to them are beset with a similar fate.

The government approved 10 new hospitals for nine districts in July this year, which include Palghar, Ambernath (Thane), Gadchiroli and Amravati. Ahmednagar is the only district without a medical college. Each medical college has an intake capacity of 100 students, and is attached to at least a 430-bed hospital. Their purpose is to strengthen the health services in the districts.

In 2018, the World Health Organisation (WHO) mandated the population to doctor ratio at 1:1000. Maharashtra is currently at 0.84:1000. “The sanction of more medical colleges is expected to improve the ratio,” said an official from the medical education department.

But this is the ground reality now -- of the 490 sanctioned posts of professors in colleges, 56 are vacant. Likewise, 95 of 1126 posts of associate professors and 360 of 1765 sanctioned posts of assistant professors are unfilled. Despite the government’s recent advertisement to fill 884 posts of assistance professors only 525 could be filled.

“The doctors are not interested to serve in government hospitals for various reasons, which leads to the acute shortage,” added the officer.

Similarly, around 10 to 15% of administrative positions are vacant. “Given the poor response from doctors for government jobs, we have appointed a committee headed by the commissioner of the health department, to chalk out a plan on the incentives and perks that can be offered to doctors to woo them to government hospitals,” said another official from the department.

Poor fund distribution

At the heart of the shortcoming is both an inadequate kitty allocated by the government for spends on public health and the assigned funds not being released.

Dr Avinash Bhondve, past state president of Indian Medical Association (IMA), pointed out that the government spends between 1% and 1.25% of the GDP on health infrastructure – a practice for many years. “Patients are made to buy medicines from private suppliers as there is no timely procurement of medicines nor are positions filled. Even after the pandemic exposed the public health system’s poor health, no steps were taken to augment the infrastructure,” he said.

On the other hand, while the state government proposes to procure medicines worth ₹850 crore annually, the figures remain only on paper. A former health secretary, who did not wish to be named, broke down the numbers for HT. He said, “Of the corpus, the public health department is expected to procure medicines worth ₹470 crore, medical colleges are supposed to get ₹150 crore and other departments like tribal and municipal corporations take up the rest. In reality, suppliers have stopped supplying medicines to BMC and other government hospitals as they have huge outstanding dues. The outstanding at the Nanded hospital is ₹1 crore. In such a backdrop what else you expect.”

Elaborating further, Dr Pravin Shingare, former director of medical education said “The deans are allowed to procure only 10% from their allocated budget, while remaining procurement is traditionally done by Haffkine Biopharmaceutical Corporation. In the absence of the manpower and funds, Haffkine has not been able to procure medicines, hospitals are not able to maintain machineries like CT, Ultrasound, MRI scanners or appoint doctors and nurses. In the last four years the government created six new medical colleges – they are all without doctors and nurses. Manpower from existing medical colleges and hospitals are diverted here, compromising the infrastructure at both hospitals.”

Given Haffkine’s inability to procure medicines, this year respective deans of hospitals were allowed to procure 30% from their kitty. It wasn’t possible in Nanded, as the hospital is without a dean.

Shingare added, expensive healthcare in private hospitals, has increased the pressure on ICUs of government hospitals. The ICU numbers have gone up from the earlier 5% to 15% now, he said. “Expenditure on each ICU patient is ₹5000 per day, but the hospitals have no money to spend.”

Medical education minister Hasan Mushrif however declined that there is any shortage of medicines in government hospitals. He said, “The fatality rate in Nanded and other government hospitals is high because serious patients are transferred here at the list minute or when patients run out of money.”

Meanwhile, a cash-strapped state government has now proposed to raise ₹4000 crore from Asian Development Bank to fund the construction of the newly proposed medical colleges. The department has also proposed to implement super specialty services in the government hospitals on public private partnership basis.