INDIA: Cradling his minutes-old baby and riding pillion astride a motorcycle, Mr Devendra Kashyap rushed to an unregulated private hospital.
He had just been told by the hospital that had delivered his newborn that it couldn't treat his son’s breathing problems, and he had to find help elsewhere.
But the next hospital turned out to be as badly equipped and ill-staffed as the previous one. “That night, the assistants ignored the needs of my child. They were busy (listening to) music,” he said.
“At 1am, one of them gave him an injection, after which he turned blue. The injection caused an infection, which killed my child.”
Too heartbroken and poor to take legal action against the private hospital, Mr Devendra is one of thousands whom India’s healthcare system has failed.
Private hospitals and clinics, which have stepped in to plug a gap left by inadequate public hospitals, are not well-regulated - resulting in poor medical care, malpractice cases, overcharging and touting.
Many government hospitals, on the other hand, are overburdened owing to a lack of funding, which has caused a shortage of doctors, nurses, beds and equipment.
While India’s population has increased by some 15 million annually, the healthcare budget has not increased by the same proportion.
Professor K Srinath Reddy, president of the Public Health Foundation of India, told the Channel NewsAsia programme Get Rea! that public healthcare funding had stagnated at around 0.9 to 1.2 per cent of India’s gross domestic product for several decades.
And though it has inched closer to 1.4 per cent today, it is still inadequate and is a cause for concern, he added. (Watch the episode here.)
NO MONEY, NO OXYGEN
In one of India’s worst health tragedies, public hospital Baba Raghav Das (BRD) Medical College in Gorakhpur, Uttar Pradesh, which was struggling with money problems, ran out of liquid oxygen, causing the deaths of over 60 children in August 2017.
“It was a system failure which resulted in the deaths of those children,” said Prof Reddy.
While each state determines how much of its budget to allocate to different government departments, poorer states like Uttar Pradesh tend not to prioritise healthcare, and the per capita health spending is low.
Local journalist Manoj Singh, who often reports on health issues, said that at the BRD Medical College, which provides free treatment for some 50 million people, “everything lacks money”.
Salaries aren’t paid for months. There isn’t enough medicine, oxygen or equipment. The air-conditioners don’t work, the fans don’t work.
In last year’s incident, he was tipped off by a source in BRD that its liquid oxygen supplies were running out. The hospital had defaulted repeatedly on its payments to the supplier, which then halted its supply of liquid oxygen.
“This was a very alarming piece of information. In the months of July and August, there are (usually) about 300 to 350 children admitted. Their lives would have been in danger,” said Mr Singh.
He published the story immediately on his news portal and tried to contact BRD’s chief medical officer and its principal, but neither took his call.
BRD is a key centre for treating Japanese encephalitis, which causes breathing problems, among other things, and hundreds of children are struck by it each year in Uttar Pradesh.
And when the hospital released the death reports, it turned out that in just five days, between Aug 7 and 11, more than 60 children had suffocated to death.
Mdm Rihanna Khatoon, mother of victim Khushi, aged five, said: “We had taken her to the hospital thinking it would save her, but in less than 24 hours, it was all over.”
News of the tragedy provoked nationwide outrage, and the state government arrested seven people, including the paediatrician in charge, accountants and the oxygen suppliers. The legal charges ranged from irregularities and negligence to lackadaisical attitude.
Irresponsibility and the lack of oxygen killed my child. I’ll remember that for the rest of my life.
“Even if my worst enemy asks me about the BRD Medical College (hospital), I’d tell him not to go there. They’re butchers. They treat patients like animals," said Khushi’s father, Mr Mohammed Zahid.
WATCH: Greed that exploits the system's failures (3:39)
HEALTHCARE WOES RUN DEEP
Social worker Vandana Prasad, an expert in the field of children’s health, said India’s public healthcare system is failing not only because of a lack of funding.
The country, she explained, has a tiered medical system starting with sub-centres at the village level, rural primary healthcare centres, district-level facilities and teaching hospitals at the top.
Most of the reforms and investments, however, had been focused on the teaching hospitals.
“That means many people, at great cost and trouble to themselves … go to tertiary care hospitals when they could have been treated closer to home,” she said.
But critics also allege that the state-run primary healthcare centres, which are supposed to provide basic care for villagers and leave the big regional hospitals to tackle more difficult cases, are not pulling their weight.
At one typical centre close to BRD Medical College, which the Get Rea! team travelled to, it is not even run by a doctor but by pharmacist Renu Chauhan, who is unqualified to diagnose patients.
The centre has been without a doctor for seven months because none would take the job, choosing to work in urban hospitals for better pay.
When (patients) come and see a pharmacist in charge, they have no choice but to be treated by me,
said Ms Chauhan. “If a patient wants to be treated by a doctor, then he or she would have to visit the CHC (community health centre), which is eight kilometres away.”
The inadequacies of many of the primary healthcare centres force patients to turn to the bigger government hospitals, some of which are severely understaffed.
Over in Gumla village, there is only one nurse for the 100-bed hospital, with a trainee to help her.
There is no night duty shift, and if there is an emergency, the patients would have to look for the nurse or doctors for help. The patients may also have to buy medicine from outside the hospital.
There are not enough light bulbs either, which makes administering drips for children tricky. “There’s a (power) generator, but the light is insufficient for us to see the (children’s) veins,” the nurse told the district’s child welfare committee.
Other challenges include a shortage of doctors and ventilators. Two newborns were even seen sharing a bed. Said their doctor Kaushalya Kumar: “It isn’t right … but they’ve been kept together due to space constraints and because they’re twins.”
Nationwide, there are not enough doctors for India’s 1.3 billion people. The World Health Organisation’s (WHO’s) guideline is one doctor for every 1,000 patients, but in India, it is one doctor for every 1,600 patients.
In these circumstances, many health workers are overworked. Senior paediatricians like Dr Rajesh Tripathi single-handedly see more than 100 patients a day. He noted: “People are retiring, and those posts are lying empty.”
Only 10 per cent of Indian doctors end up working in public hospitals. Most also prefer to work in the urban areas rather than the rural regions.
And graduating doctors trained in well-equipped medical college hospitals may not be adequately trained to work in the rural primary healthcare centres with limited resources, said Prof Reddy.
“They’re now culturally attuned to an urban environment with social amenities,” he added.
“Going to rural areas where you’re not sure about the quality of schooling for your children, regular availability of water and electricity – there are so many issues that … turn away the doctor who has grown up … in an urban environment.”
India also lags behind most countries in terms of the number of hospital beds: The WHO ranks India among the lowest, at fewer than one bed per 1,000 people.
Dr Prasad said she has even come across a child’s dead body lying on the same bed with a patient who was still alive, simply because there were no facilities to take that body away.
“A sick child seeing a dead child next to it – you can imagine how traumatic that would be for the child as well as the family,” she added.
THE PRIVATE SECTOR PROBLEM
With public hospitals in trouble, it is no wonder that many patients are turning to private clinics and hospitals.
India is one of the few major countries where healthcare is largely privatised – more than 60 per cent of services – even though the private sector is not regulated adequately and the level of care is sometimes poor.
There is the Clinical Establishments Act, which requires every care provider to be registered and meet some standards, said Prof Reddy.
“Unfortunately, this hasn’t been adopted by all the states yet. And where (it has been) adopted, it isn’t being fully implemented,” he added. This means that many unregistered, illegal private clinics have mushroomed across the country.
In Farrukhabad, Uttar Pradesh, the Get Rea! team found more than 50 illegal institutions, from hospitals to backstreet clinics, located within an 800-metre radius of the government hospital.
Outside the government hospital, there were rows of private ambulances, and the drivers are known to lure patients frustrated by the public healthcare to nearby private hospitals. These drivers are paid a commission for every patient they entice.
These unregulated hospitals are also free to charge outrageous fees. According to the Indian Medical Association’s Farrukhabad president, Dr Arvind Gupta:
Operations are taking place, but they don't have even the most essential facilities.
“(They) have operation theatres, but they don't even have central oxygen supplies, multi-parameter monitors or Boyle’s machines required for anaesthesia. Yet they still perform surgeries.”
Outside some of the government hospitals, community village workers called Asha (Accredited Social Health Activists) workers are supposed to help patients find the right treatment at the hospital for free.
They are supported by the government, but some of them are not entirely honest, pushing patients to be treated in private hospitals instead, where they get a cut from these institutions.
Farmer Ravinder Singh is a victim of such corrupt practices. An Asha worker in his village advised him to take his daughter Roshni to a private hospital instead of a government hospital after an accident.
He now regrets his decision. He was told the total medical cost would come up to US$60 (S$80) a day at most, but that budget has been busted.
“Whatever money I had brought has run out. The hospital people are saying, ‘Pay up, or we’ll send you to Lohia (the government hospital),’” he said, adding that he had nearly exhausted his own funds and was now in debt.
What happened to Mr Singh is not uncommon among villagers, and Dr Prasad says that out-of-pocket expenditure is the second-largest reason families in rural areas are indebted.
(It’s) creating catastrophic circumstances where they are having to sell their lands, their animals (and) their assets to go to the private (medical) sector … all with very poor outcomes as well.
THE WAY AHEAD
To address the healthcare challenges, the Indian government rolled out a new National Health Policy last year, which promises to increase public health spending to 2.5 per cent of GDP by 2025.
In addition, the policy proposed free diagnostics, drugs and emergency and essential health care services in all public hospitals, reported the Indian Express. The previous national health policy was issued in 2002.
Some states are also raising the regulatory ante on private healthcare, reported The Hindu Business Line. West Bengal has instituted a regulatory commission, and Karnataka has strengthened its 2007 regulation.
Meanwhile, the Union Health Ministry has written to all states asking them to adopt its 2010 Clinical Establishments framework.
Mr Manoj Singh feels that the media reports about the Gorakhpur tragedy have also brought about change, with people questioning the government about the lack of health service arrangements, doctors, et cetera.
“People have begun to realise that it’s not simply their destiny which has shaped the deaths of their children. They’ve begun to realise that the government, too, is responsible for these deaths,” he said.
At BRD Medical College, members of the All India Human Rights Organisation have been inspecting the hospital since August, and it has improved, said activist Mohammed Khalid.
“The patients are being treated properly. Earlier, (they) would have to buy medicine from outside, but now they’re being given medicines from the hospital itself. All the machines are working properly (too),” he observed.
For Mr Zahid, however, it is a case of too little, too late. He said: “For 24 hours a day, I live with my child’s memory. My health has deteriorated; I can’t eat or sleep. (My wife) cries every day.”
Watch this episode of Get Rea! here.