Lesson from Gorakhpur: Fix the public healthcare system, here and now
For decades, we have talked about increasing government spending on healthcare to 2.5% of the country’s gross domestic product (GDP), but it continues to hover around 1.3%. A country like China, with a GDP five times that of India, spends more than 3% of its national income on public health.
The recent tragic and unacceptable deaths of children in the BRD Medical College in Gorakhpur has angered many across the country. In part, what further inflamed the popular mood was the inability of the governments – both at the Centre and in the State – to grasp the difference between natural deaths and those caused by negligence.
Instead of showing remorse and quickly acting to sort out issues of blame and matters of medical emergency, the political managers of the Bharatiya Janata Party and its phalanx of ministers spoke in contradictory voices and proffered conflicting explanations. Questions about the lack of oxygen, the failure to pay bills in time, a cover-up effort with a police raid and a certain air of arrogance, all that added up to complicate the tragic deaths and the grief overwhelming the hospital wards in Gorakhpur.
The most striking observation from the children’s deaths in Gorakhpur, however, is that an inherited policy failure turned into a political liability for the otherwise smug BJP government. The politics of death is always fatal for any ruling dispensation and Gorakhpur might not be an exception — unless, politics is quickly redeployed and reoriented to correct flawed policy.
What happened in Gorakhpur was shocking, but not without precedent. New-born children and infants routinely die at hospitals around the country for reasons that are systemic and rooted in years of neglect of public health.
From inadequate financial resources and a shortage of qualified doctors to the lack of accountability and poor regulation of medical practices; successive governments have failed to plug the systemic deficiencies that threaten to make India the “sick country” of the world.
While more will be written in Hindustan Times as part of a deeper investigation into the state of healthcare in India, sample this for now:
For decades, we have talked about increasing government spending on healthcare to 2.5% of the country’s gross domestic product (GDP), but it continues to hover around 1.3%.China, with a GDP five times that of India, spends more than 3% of its national income on public health. That means an average Chinese gets 10 times more than an Indian does in government spending on health. The numbers for developed countries like the US and the UK are even higher.
Government spending in healthcare in India is split 2:1 between the states and the Centre. Given the states’ ability to raise new revenues are limited, the onus of any significant growth in public health spending rests largely on the Centre. It is worrying that the Centre’s health spending has remained largely unchanged in real terms – at around Rs 15,000 crore annually – for the past seven years, as a recent study published in the Economic Political Weekly showed. Yet, finance ministers keep announcing new schemes year after year, letting populism overtake real concerns around the state of healthcare.
Worse, a high and rising proportion of budgetary allocations goes unspent every year. Between 2011-12 and 2015-16, actual spending was about Rs 21,000 crore, or 12%, less than what was allocated in annual budgets during this five-year period. Such shortfalls can be attributed to flawed design of the health plans, inflexible rules and bureaucratic red tape, all of which were at play in the context of Gorakhpur.
A bigger concern relating to the trend in public health spending stems from a rising share of salaries and campaigns at the cost of supply of medicines and in-patient treatment. According to former union health secretary K Sujatha Rao, the share of salaries in what all the states spent on health increased from 47% in 2007-08 to 55% in 2011-12. The combined share of medicine supplies, equipment, hospital infrastructure and maintenance fell from 20% to 15% during the same period.
It would be safe to assume the share of salaries has risen further, following the implementation of the Pay Commission report, and that the resources for subsidised medicines and in-patient treatment have shrunk through these years. At this rate, we aren’t far from a situation when government hospitals will run out of medicines, equipment or facilities to treat patients. The Gorakhpur tragedy was perhaps the strongest warning in this respect.
Fixing the public healthcare system needs nothing short of a war cry. Ignoring it, or being in denial, will have serious consequences for India’s economic ambitions. For hundreds of millions of Indians living on the margins, falling sick is a double whammy. They lose wages, a loss that is compounded by healthcare costs that a dysfunctional public healthcare system fails to take care of. A 2010 research study estimated at least 6% of India’s population falling below the poverty line because of the impoverishing effect of the expenditure they incurred on account of healthcare.
At 70%, the share of out of pocket (OOP) health spending in India is one of the highest in the world. OOP expenses are what an individual spends on his own to get treated. Its rising share in the Indian context also brings into focus the danger of mixing populism with blatant privatisation. As the public healthcare system slipped from bad to worse, the business of health has flourished during the same period, making India’s private healthcare industry among the most profitable and fastest growing in recent years. It, however, caters to the interests of only a privileged few, while impoverishing millions who can’t afford the cost but have nowhere else to go.
It is time policy makers and political parties stopped treating public spending on health as just welfarism. For India, spending on healthcare should be more about investing in growth.
Rajesh Mahapatra is the chief content officer, Hindustan Times.
Follow him on Twitter @RajeshMahapatra