Harsh lessons of the Gorakhpur tragedy
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The death of over 30 children within a span of 48 hours at the government-run Baba Raghav Das (BRD) Medical College hospital in Gorakhpur last week is in equal parts tragic, shameful and outrageous. But what is perhaps more galling than the death of little babies is that what happened in Gorakhpur was neither the first nor will it be the last. Remember Malkangiri and Malda?
Since 2012, 3,000 children suffering from Japanese Encephalitis have reportedly died at BRD Hospital, which serves as the nodal point for all such cases in the region. This time around, the fatalities have attracted more attention because the state’s callousness seems to have touched a new low. According to initial reports, many of the children died because their oxygen supply was cut off as the hospital hadn’t paid its dues to the supplier—though the Uttar Pradesh government has denied these allegations and the matter is under investigation.
But even if these allegations are found to be true, the fact is that what has happened in Gorakhpur isn’t merely about oxygen cylinders and unpaid bills—it is a symptom of many deeper problems.
At the top of the list is India’s abysmally low public spending on healthcare. That at least partly explains why the country’s healthcare system is in a shambles. Public spending has increased but only marginally over the past two decades—from 1.1% of gross domestic product in 1995 to 1.4% in 2014. The infant mortality rate in India in 2015 was 38, according to the World Bank—far better than the 165 in 1960 but lagging comparable countries such as Bangladesh (31), Indonesia (23) and Sri Lanka (08). And the situation in even worse in some large states such as Uttar Pradesh, where around 50 out of every 1,000 children die before they reach the age of five.
Another problem with India’s healthcare system is acute manpower shortage. The country has only about one doctor for every 1,700 patients whereas the World Health Organization (WHO) prescribes at least one for every 1,000 patients. In other words, there is a shortage of about 500,000 doctors. The Medical Council of India (MCI) will have to reform the entire medical education system if this gap has to be filled, but that will be easier said than done. In the meantime, more healthcare providers need to be brought into the system, including nurses, optometrists, anaesthetists and AYUSH (ayurveda, yoga and naturopathy, unani, siddha and homoeopathy) workers. Nurses especially can and should be empowered so that they can take off some of the load from physicians.
A third problem is that a vast majority of people do not have health insurance in a country where the public health system has collapsed. Health shocks are one of the biggest reasons why people slip back into poverty. India’s efforts to extend coverage over the past decade or so have borne few fruits, even as other countries such as Germany, Japan and Thailand have built effective healthcare systems by insisting on some form of pre-payment and pooling of resources, either through taxation or insurance. India’s inability to find a workable model for itself has left its poor particularly vulnerable.
Even for those who can afford better, the choices are limited. Most state-run facilities are so poorly managed that they aren’t really an option. Private facilities may offer services, but there are serious quality issues when it comes to the poor. The government has been talking about a stronger partnership with the private sector in the field of healthcare but there has been little progress on the ground.
The problems and solutions are not new. The lack of political will to fix the healthcare system unfortunately means that Gorakhpur-like crises will continue to happen with morbid frequency across the country. The real question to ask is: will these children’s death galvanize the people to demand that their leaders fix the country’s broken healthcare system? Will it force the politicians to make healthcare a serious campaign platform?
Here, there is some soul-searching to be done. The public debate is more about the inadequate supply of healthcare than the lack of demand for it. Indian voters prefer private gains via subsidies rather than public goods such as clean water or good sanitation. There is an entire ecosystem of patronage politics based on this.
As mentioned in these columns earlier, Monica Das Gupta, a research professor at Maryland Population Research Center, has pointed out in a research paper that voters typically prefer public funds to be used to provide private goods (such as medical care), rather than public goods (such as sanitation measures to protect the health of the population as a whole). The non-democratic regimes of East Asia achieved better outcomes by directing scarce resources on public healthcare measures rather than on providing advanced medical care.
Harsh, but true. The challenge is to make the provision of public goods a central feature of our democratic politics. That should be the deeper public policy lesson from the Gorakhpur tragedy.
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