Children receive treatment at Baba Raghav Das Medical College Hospital in Gorakhpur, Uttar Pradesh.

(AP
File Photo)

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In India, there is one government allopathic doctor for every 10,189 people,
one government hospital bed for every 2,046 people and one state-run
hospital for every 90,343 people.
You don’t need an epidemic, however predictable, for the public health
system to collapse. It is a matter of routine that patients share beds and
doctors are overworked.

India has a little over one million modern medicine (allopathy) doctors to
treat its population of 1.3 billion people. Of these, only around 10% work in
the public health sector, shows data from the National Health Profile 2017.

The shortage of health providers and infrastructure is the most acute in rural
areas, where catastrophic health expenses push populations the size of United
Kingdom into poverty each year.

Add apathy and you have bodies of the dead being mutilated by dogs in
hospital morgues, people carrying home the their dead children because the
hospital refused them a hearse, and tragedies like the hundreds of infant
deaths in Gorakhpur’s Baba Raghav Das (BRD) Medical College every year.

BRD Medical College Hospital’s failure to save lives points to a systemic rot
in public healthcare delivery, which is saddled with problems of
mismanagement and inadequate resources — infrastructure and human.

Despite being routinely flagged, these shortages are seldom corrected.

Learning from failure is rare, and course correction after mistakes is rarer.

Read Part 1 of series | Gorakhpur deaths: Why India’s poor public health
delivery system is a killer
This brings us to critical questions: Can such deaths be prevented? How can
India’s public health system deliver quality care? Will public hospitals just
end up being places where the sick go to die?

Where are the doctors?

India doesn’t have enough hospitals, doctors, nurses and health workers, and
since health is a state subject, disparities and inequities in the quality of care
and access to health varies widely not just between states but also between
urban and rural areas.

Where are the doctors?

India has 1 million doctors of modern medicine (allopathy) to treat its 1.3 billion population. Of them, just 1.1
lakh work in the public health sector, to which India’s 900 million rural population turns for treatment.

For example, Maharashtra has 1,53,513 registered doctors, the most in the
country, compared to 792 registered with the Arunachal Pradesh Medical
Council.

In the absence of doctors, the sick make do with whoever is available,

irrespective of their qualifications.
Only one in five doctors in rural India are qualified to practice medicine,
found a World Health Organization (WHO) report on India’s healthcare
workforce, highlighting the widespread problem of quackery. The WHO
report, published in 2016, said 31.4% of those calling themselves allopathic
doctors were educated only up to Class 12 and 57.3% doctors did not have a
medical qualification.

In India, self-styled doctors without formal training provide up to 75% of

primary care visits. “We get very sick babies because most parents seek local
remedies and treatment from quacks before they bring their children to
hospital. We can’t turn anyone away so you’ll often find two to three babies
on one bed or two babies in one incubator. We provide the best of care
possible under the given circumstances, which is not enough at times,” said
the new principal of BRD Medical College, Dr PK Singh.

Infrastructure
Modern medicine (allopathy)
“There are no large-scale surveys on quackery by national statistical agencies
such as the Census of India or National Sample survey Office, which could
form the basis for policy making in this area. The World Health Organization
is the first comprehensive report on the health workforce in India and though
it has been derived by decoding the 2001 Census data, the methodology and
conclusions are sound,” said Shailaja Chandra, former chief secretary Delhi,
who has worked in the Union health ministry and authored the
report, Unqualified Medical Practitioners this year.

“The lack of medical qualifications was particularly high in rural areas. The
report brought out that whereas 58% of the doctors in urban areas had a
medical degree, only 19% of those in rural areas had such a qualification,”
said Chandra.

The way ahead

“Strengthening primary healthcare hasn’t got the priority it needs and the sick
reach hospitals after faith-healers, quacks and other unqualified practitioners
fail to cure them,” said Sujatha Rao, former health secretary, Union Ministry
of Health and author of Do we care? India’s health system. “With early
diagnosis and timely referrals, many lives can be saved,” she said.

Ayush (ayurveda, yoga, unani, siddha and homeopathy)

Training informal healthcare workers who had little-to-no training for nine
months increased their ability to correctly manage cases, found a J-PAL 2016
study on The Impact of Training Informal Healthcare Providers in India.
Trained informal workers provided correct case management in 60% cases
compared to 52% of the comparison group, and 67% doctors at public health
centres. The training, however, did not reduce the use of unnecessary
medicines, found the study.

In the absence of doctors, quacks provide a service and cannot be wished

away, says Chandra. “What we need is an updated assessment of quackery by
state and district, better enforcement to ensure they don’t indulge in high-risk
practices such as use of injections and IV fluids, and selective training so
they cause least harm while improving access to first-line health care,” said
Chandra.

Trained quacks, however, cannot replace doctors, and India is just not
training enough. There are 462 medical colleges that teach 56,748 doctors
and 3,123 institutions that prepare 1,25,764 nurses each year, but with India’s
population increasing annually by 26 million, the numbers are too little.

“India keeps announcing new AIIMS-like institutes in states, but where is the
faculty to train these doctors? Setting up a building and buying equipment is
not enough, you need trained doctors to provide care,” said Rao.

Medical education

Source: National Health Profile 2017, Ministry of Health and Family Welfare.

Even the equipment bought is often not used. A Comptroller and Auditor
General (CAG) report in June revealed a 27.21% shortage for clinical
equipment and 56.33% for non-clinical equipment, of which oxygen supply
is a part. The report found critical medical equipment had not been used for
more than five years because there was no annual maintenance contract.

“Instead of training Ayush practitioners and quacks – every hospital

compounder and ward boy becomes a self-proclaimed doctor after retirement
– to prescribe allopathy medicine, we need to strengthen traditional systems
of medicine to offer first line of treatment and care,” said Dr KK Aggarwal,
president, Indian Medical Association.