The recent tragedy in Gorakhpur in Uttar Pradesh and the earlier many such tragedies which occur with predictable frequency, some reported, some highlighted, and mostly ignored and forgotten are the hallmark of present public health system in India. It has once again exposed the criminal callousness of the state authorities and those who rule.
It is a well documented and know fact that the public health system in India is grossly under-funded. The facilities at primary level (if at all present) are understaffed, are ill-equipped and mostly non-functional to provide the necessary medical care and support. As a result people are forced to seek last minute intervention to save life of their near and dear once in the overcrowded secondary and tertiary health facilities, selling off their meager belongings. The hygiene and sanitation conditions in most of these facilities are so poor that, it is cause for rapid spread of infections. A visit to the ESI hospital in Okhla Area of capital New Delhi, will confirm this. Located in the vicinity of a huge garbage dump, it reflects the value and importance the state gives to health of poor in India.
While on the one hand India is home to diseases long eliminated in most parts of world, on the other hand India is emerging as a destination for health tourism, with mushrooming of private “multi-speciality” hospitals with generous support from the state. Following the tragedy at Gorakhpur, the shocking absence of cleanliness, infrastructure and services at the lower sub-center and primary health center (PHC), where majority of people are supposed to seek care, has been exposed yet again. Apart from infrastructure deficiencies, it has been reported that one-fourth of vacancies for doctors unfilled at primary health centre level. Even those which are filled many of them are on contract basis.
The overall the doctor to patient ratio being only 7 doctors for every 10000 population. Most of these doctors are concentrated in the urban areas and further in private practice with only a 10% of the doctors engaged in public health sector. It is estimated that only 2% of doctors are in rural areas - where 68% of the population lives.
The real drivers of the public health system in India – the human resources are one of the most undervalued, discriminated and underpaid, in both rural health facilities and in urban hospitals. As has been pointed out in the earlier issues of Mazdoor Ekta Lehar (Work without a job and wages: Exploitation of women health workers, Issue: May 16-31 2012) the last mile outreach person, the ASHA, is not even recognised as a worker. She is hired as a “volunteer” and paid a meagre stipend of Rs.3000-5000 a month, while she is burdened with fulfilment of targets under several health programmes,
Across several states, ASHAs have been fighting for their rights. Resident doctors who are the backbone of the largest government health facilities have been waging a struggle for better working conditions and along with better facilities and services for the patients. Nurses across various states and at all India level have been waging repeated struggle for fair treatment and better conditions
The callous over-exploitation of the human resources that are critical to any health system has undermined the quality and degree of care required.
The Indian State has not cared one bit for the health of its citizens. It has failed to provide, in all these decades, even the most basic conditions that are required for keeping a population in good health. Both in the cities and in the villages, the working population is subject to extremely unhygienic conditions and lack of water and sanitation facilities. Living at less than decent wages, the nutritional status of the people across the country is abysmally low. All of this makes the working population extremely vulnerable to the most horrific epidemics year after year.
Successive governments have failed in their duty but they want to blame the doctors, nurses and hospital maintenance staff for the absence of care and treatment in public health facilities. This is used to justify the privatization of health care, so that private corporations can make huge profits at the expense of the people.
Drive towards promoting private interest in health
Currently, India’s health-care system is one of the most privatised in the world and its public expenditure one of the lowest. Of the total expenditure on health care in India, only 32 per cent is public expenditure—the 16th lowest among 190 countries (World Bank Report).
There is further thrust towards opening the health sector to reap maximum profits, while the state abdicates it duty to the people. The shift towards a market-oriented policy marked a major shift in the government’s policy towards social sectors such as health. Under the name of containing the fiscal deficit, the government has cut spending and subsidies in social sectors, while providing incentives for foreign investments, privatizing public enterprises, and so on. While the public health outlay and expenditure has been shrinking, investment in private health facilities has been growing exponentially, patronized, protected and provided with generous grant of public resources including land, water and electricity, soft loans, subsidies and tax exemptions under the guise of making available world class facilities, and bridging the gap in health services. These hospitals are infamous for extracting the last pound of flesh, from unsuspecting and vulnerable patients, and their families. They are thriving at the expense of public health system, with active state support through public-private-partnerships (PPP).
Several States such as Rajasthan and Madhya Pradesh are drawing up plans for leasing out existing rural public facilities to the private sector. More recently, NITI Aayog, the government policy think tank, unveiled a grand plan to lease out facilities in government-run district hospitals to private providers for a period of 30 years.
The Economic Survey released by the government on the eve of the budget session in 2017, shamelessly says “a (second) distinctive feature of the Indian economic model is the “weakness” of state capacity, especially in delivering essential services such as health and education”. This is being used to extend privatization even to district level health facilities, which is the latest recommendation of the Niti Aayog! While admitting that system has failed the people, the prescription of promoting private interest in health is only going to worsen the situation (see Box).
All attempts to promote the interests of big capitalists - Indian and foreign, for profiteering from the peoples misery must be opposed. All the health workers including doctors, ASHA, ANM, water and sanitations workers, and technical staff must be enabled, supported and adequately compensated to reach out to every household and locality to ensure good sanitation and primary health care where ever it is needed. The issues raised by them for improving their own working conditions and services for the patients and their families must be immediately addressed. A state that claims itself to be modern cannot shirk away from its responsibility for criminal negligence by declaring such tragedies “natural disasters”.