Gorakhpur deaths: Why India’s poor public health delivery system is a killer
It’s not the lack of oxygen that kills hundreds of children in hospitals of Uttar Pradesh each year, it’s India’s abysmal public health delivery system.
“Gorakhpur is the symbol of the collapse of the primary health care system. Why should people be forced to travel 200km to get treated at a medical college when fever and anticonvulsant medicines, basic oxygenation and monitoring fluid balance should be available at the primary health centres and the community health centres, if not the health sub-centre?” asks Dr K Srinath Reddy, president, Public Health Foundation of India.
Deaths from acute encephalitis syndrome (AES) and Japanese encephalitis (JE) are higher in India than neighbouring Thailand because the disease is poorly managed, with most children reaching hospitals for treatment after convulsions have set in because of swelling in the brain.
“There are serious challenges and systematic failures in delivery of care during acute illness not just in Gorakhpur but across India. Many of these deaths can be prevented by simply following established disease management protocols at primary and secondary level, communicating and raising community awareness and not wasting time and resources on investigations and medications that are not needed,” says Sujatha Rao, former health secretary and author of Do We Care? India’s Health System.
India’s public expenditure on health is rising, but not as fast as its burgeoning population of 1.3 billion, which grow by 26 million each year. Resources are not just scarce but their use is often not rational and optimal.
Over the past two decades, successive governments at the Centre, and lately, the National Health Policy 2017, have promised to raise India’s public health expenditure to 2.5% of the GDP, yet the current spend hovers at 1.4%. States account for 0.9% of this expenditure, with Centre’s share being an abysmal 0.6% of the GDP.
“India’s new National Health Policy envisages health systems strengthening by increasing public health expenditure to 2.5 % by 2025 and increasing state health spending to more than 8% of their budget by 2020, but I don’t see it happening. Data shows that state expenditure still averages under 5%, with some states like West Bengal and Karnataka registering falls,” said Dr Reddy.
India’s total health expenditure as percentage of GDP is around 4.7%, with out-of-pocket spending accounting for around 63% of this spend.
Each year, 63 million people — close to the population of the United Kingdom — are pushed into poverty because of catastrophic health expenditure. They are forced to abandon jobs because of ill health or have to sell their land and assets to pay health care costs. With more than 9 in 10 people self-employed, private and employer-provided health insurance covers only a fraction of the population.
The impact of the existing programmes is often lost because information is not shared with the community and more shockingly, with the health workers implementing the programme on the ground. Though Gorakhpur and Kushinagar are the epicentres of the government vaccination and awareness campaigns around JE/AES, even doctors and vets (pigs are the natural hosts of the JE virus) know little about the infections.
A review of the knowledge, perceptions and practices of community and health workers, including doctors, NGOs, pig owners, farmers, community leaders and students showed that while JE/AES were perceived as deadly diseases, they were not regarded as major health problem. Sanitation, hygiene and mosquitoes were associated with JE/AES; pigs were not seen as a source of infection and government health workers played a minimal role in the first-contact care of acute Illness, reported a qualitative study in BMC Public Health last week.
“On the upside, there was no social or cultural resistance to JE vaccination or mosquito control, no gender-based discrimination in the care of acute Illness, and funds available with local self government were utilised, which shows if the communication gaps are met, people can get treated in time in public health centre close to home,” said study author Dr Manish Kakkar, senior public health specialist, PHFI.
Strengthening rural health systems is not getting the priority it needs. “Why do we have to look further than the All India Institute of Medical Sciences, Safdarjung and Ram Manohar Lohia hospitals in Delhi, where close to half the people being treated are from other states? Everyone going there doesn’t need heart transplantations or other complicated surgeries, they need treatment for pneumonia and tuberculosis and diabetes, for which you don’t even need a district hospital. These can and must be treated at the PHC and CHC level,” says Rao.
A review of AES surveillance data of 812 cases between January 2011 and June 2012 in the Kushinagar district neighbouring Gorakhpur showed 23% illogical entries and incomplete records for laboratory results (available only for JE, not AES) and vaccination history, reported a study in the journal, Emerging Infectious Diseases.
Quality surveillance is what helped India control new HIV infections and eradicate polio. “You need good data to mount an effective response, otherwise it’s just throwing public health resources money down the drain,” says Dr Kakkar.
“It has worked and brought down HIV infection, and there is no reason why it shouldn’t work for infectious diseases that occur with seasonal regularity,” insists Rao, who has also served as director general of National AIDS Control Organisation.
The Centre’s Rs 160,000 crore National Health Assurance Mission promises more than 50 free drugs, a dozen diagnostic tests and insurance cover to all by 2019. Similar programmes have delivered on a smaller scale. The Vajpayee Arogyashree Scheme, which provided health insurance for catastrophic illnesses to households below the poverty line in Karnataka, lowered death by 64% and halved out-of-pocket spending on hospitalizations, found a study of more than 60,000 households in close to 600 villages.
“While providing free essential drugs and diagnostics is a start, it cannot happen without infrastructure, manpower and resources to support delivery, and clear targets and data for course correction,” Dr Reddy told HT.
This is Part 1 of a series on what ails India’s public health systems. In Part 2, we look at another gap: Where are the doctors?