In August 2017, the media was splashed with the grim news of the tragic deaths of children at a hospital in Gorakhpur, Uttar Pradesh, owing to alleged medical negligence. In this article, Chandrakant Lahariya contends that there are immediate, knee-jerk responses to such tragedies and everything is forgotten soon after. He highlights possible lessons and action points that emerge from such incidents.
In August 2017, print and broadcast media was splashed with the grim news of tragic deaths of children at Baba Raghav Das (BRD) hospital in Gorakhpur, Uttar Pradesh. Since then, more such incidents, allegedly due to insufficient facilities, improper care, or medical negligence, have been reported from Gorakhpur and other parts of the country. Typically, such cases though reported, are not even noticed much. However, an unintentional outcome of the Gorakhpur tragedy appears to be that we have become even more insensitive to such reports. While the Gorakhpur tragedy received public attention, there was almost no reaction to subsequently reported 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 possible lessons and action points emerging from the ‘Gorakhpurs’ of Indian hospitals. These need not be resource-intensive and could very well be simple and incremental.
First and foremost is the need to build capacity to analyse and document causes of morbidity and mortality at the facility level. The World Health Organization’s (WHO) annual World Health Statistics (2017) reported that in India, in the year 2015, causes were known for only 10% of all deaths. The world average was 48%, and in China, 90% of all deaths were recorded with detailed causes. This information on the causes for which people seek care at a type of facility (morbidity in medical terms) and why people die at a type of facility (mortality in medical terms) – by age groups, referral mechanism, etc. – might appear insignificant but can be operationally useful. Can this be done for BRD medical college in Gorakhpur in the next six months? Can a system be developed to systematically document and utilise this information? The simple answer is yes and this should be the first actionable step from the incident in August 2017. In the next 12 months, the aim should be to put this in place at all medical colleges and district hospitals in India1. This morbidity and mortality profile can help in redesigning and reorganising services, and efficiently allocating all types of resources (human resources, finances, drugs and supplies, and so on). The other areas that require immediate attention are as follows.
It is proven knowledge that social determinants of health contribute to 50% of morbidity and mortality. Therefore, a parallel and equally important step is to understand the community linkage of deaths. Where have these patients been before coming to these facilities? What is the availability of health services in the areas that they come from? What is the care-seeking pattern of the families? What is the socioeconomic environment in which they live? Was there was delay in seeking care? Who was their first contact?
Unfortunately, health services in India are focussed on medical care and not enough attention is given to understanding social determinants and epidemiology. There is a scarcity of epidemiologists and people who can analyse such information in the healthcare system in the country. Collating this information needs the engagement of the departments of community medicine (medical-college level) and trained epidemiologists at district hospitals. Innovative approaches should be explored to address the human resource shortage in this area and bridge the information gap.
Strengthen primary healthcare system and referral linkage
Large healthcare facilities are designed to deliver specialised care. If these are burdened with patients with common illnesses, it is inefficient and defeats the objective of having a tiered healthcare system. The primary healthcare system and rural healthcare facilities in India are almost non-functional, and availability of providers at these facilities is unreliable. People prefer to seek care at district hospitals and medical colleges. The challenges are well-understood and solutions have been proposed. The National Health Policy of India, 2017 proposes that nearly two-third or more of government financial resources should be spent on primary healthcare. At present, almost half of total government spending goes to secondary and tertiary care facilities. The approach has to be simple. For every rupee allocated to establishing an institution like AIIMS (All India Institute of Medical Sciences) or for setting up a medical college or upgrading a district hospital, two rupees should be allocated for primary healthcare. That is the formula to be followed strictly. The approach to service delivery has to be functional referral linkage, establishing a ‘continuum of care’ across the spectrum from sub-health centre to primary health centre, sub-district hospital, and district hospital. Many countries including Sri Lanka and Thailand have followed this path and succeeded.
Allocate more financial resources
The level of government investment in health in India is suboptimal, in spite of stated intentions. The states with the highest need spend the lowest. In 2014-15, as per the National Health Accounts, the per capita expenditure on health in Uttar Pradesh was Rs. 635. This is nearly 40% of what the Kerala government spent that year, and one-sixth of what experts consider optimal expenditure to provide basic health services for all in India. There is no surprise that in India, there is high out-of-pocket expenditure on health by people to the extent of 62% of total health expenditure ̶ among the highest in the world. An estimated 63 million people in India fall below poverty line due to health related expenditures. The commitment to increasing public funding for health is crucial.
Guarantee provision of free medicines and diagnostics
A number of Indian states have schemes for free provision of medicines and diagnostics, as per the state-specific essential list of medicines. 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 understaffed and often do not conduct even basic laboratory tests. Although high-cost equipment and required reagents are provided, either staff is unavailable, or those posted are not qualified or experienced enough to conduct tests or interpret the results. The reports provided by these facilities are often not trusted by the doctors working at these facilities itself, let alone by those at different facilities. Presence of private pharmacies, laboratories, and diagnostic radiology facilities just outside every large government hospitals is proof of the failure of government system, which has free provision.
It is time the government shifts from the ‘entitlement approach’ to ‘guarantee approach’, at least for a few crucial services. People are entitled to free medicines and diagnostics but that is not working and making any difference. The government should consider ensuring that every single prescribed medicine is provided free of cost and that laboratory tests are done in a time-bound manner with assured quality. This can be initially implemented for patients seeking healthcare at large government facilities and then expanded to all other levels of facilities. Considering that 70% of people go to private healthcare providers, the free medicine and diagnostics scheme would only reduce the financial burden and out-of-pocket expenditure), when no matter where the patients seek care (public or private), the provision of medicines and diagnostics would be free. It would need financial resources and an effective supply chain system in the public sector. This could be a boost for the Prime Minister’s ‘Make in India’ initiative as well.
Acknowledging a problem is the first step to finding a solution. A lot many deaths in Indian hospitals are preventable. The health systems in Indian states would improve only if lessons are continuously learnt in a timely manner and actions are taken. Else, people will further drift away from government health system, and more people will fall into poverty due to health-related expenditures. What is most important is political will and a collective desire to make a difference and change things for the better.
- The Indian healthcare system is three-tiered. The first tier comprises sub-centres, primary healthcare centres, and community health centres, and provides mostly non-specialist care. The second tier comprises sub-district and district-level facilities and hospitals, and provides specialist care. The third tier comprises medical colleges and other super specialty facilities.