The deadly killer: The Gorakhpur tragedy ought to be the last of its

kind

A silent epidemic of Japanese Encephalitis is raging through India, and had it

not been for the recent spate of Gorakhpur death reports, a majority of us
would have hardly bothered about the shamefully high incidence of
Encephalitis deaths in India. The number of fatalities caused by the disease is
a testament to the fact that public health does not figure very high in the
priorities of either the Central or the State governments. From 2014 to 2016,
over 5,000 people have lost their lives to the vector-borne disease. In fact,
BRD Medical College, the hospital at the heart of the Gorakhpur tragedy, alone
has the reprehensible distinction of witnessing over 1,657 deaths in those very
years. At the nub of the issue is the collective failure of the past as well as
current regimes in allocating adequate resources in battling the menace.

The Infant Mortality Rate (IMR) of India, as per World Bank data, is 38 deaths
per 1,000 children. Superficially, this is acceptable given that Indias IMR has
reduced drastically by 76 per cent from 165 deaths per 1,000 in 1960.
However, dig a little deeper and the data will tell you that countries which
India trumps in terms of GDP growth fare much better in their IMR vis--vis
India. For instance, Sri Lanka is miles ahead of India, its IMR being an
incredible 8 deaths per 1,000. Even Bangladesh manages to have a better
delivery of health services on this front with just 31 deaths per 1,000. Another
galling problem is the dearth of doctors. Instead of having one doctor per
1,000 patients, we have one per 1,700.

On a nationwide basis, this means that there is a gap of over 5 lakh doctors
that the Medical Council of India (MCI) ought to fill up, and fast. Sadly, the
history of MCI is littered with one too many sorry tales of corruption. A hope
that the MCI will usher in a bottom-up change thereby ensuring that not
just more doctors, but also nurses and other hospital staff are recruited is a
tad bit optimistic, given that its record thus far in battling maladies that have
beset Indias existing medical infrastructure has been quite poor. Apparently,
for the last 10 years, the demands made by BRD Medical College for the
setting up of a special Encephalitis cell that would cost the exchequer just Rs
40 crore have been sidelined. Another demand of Rs 10 crore for upgrading
the paediatrics department has also met with the same fate.
Harsh lessons of the
Gorakhpur tragedy
What has happened in Gorakhpur isnt merely about oxygen
cylinders and unpaid billsit is a symptom of many deeper
problems

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.

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 states 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 hadnt 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 isnt merely about oxygen cylinders and unpaid
billsit is a symptom of many deeper problems.

At the top of the list is Indias abysmally low public spending on healthcare.
That at least partly explains why the countrys healthcare system is in a
shambles. Public spending has increased but only marginally over the
past two decadesfrom 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 Bankfar 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.
Indias healthcare system is in a shambles.
Public spending has increased but only
marginally over the past two decadesfrom
1.1% of GDP in 1995 to 1.4% in 2014
Another problem with Indias 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.
Indias 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. Indias
inability to find a workable model for itself has left its poor particularly
vulnerable.

A vast majority of people do not have health

insurance in a country where the public
health system has collapsed
Even for those who can afford better, the choices are limited. Most state-
run facilities are so poorly managed that they arent 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 childrens death galvanize the people to
demand that their leaders fix the countrys 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.

The lack of political will to fix Indias

healthcare system unfortunately means that
incidents like the Gorakhpur tragedy will
continue to happen with morbid frequency
across the country
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.