Gorakhpur tragedy proves there's urgent need to standardise quality healthcare across the country

The first death that is mourned isn't the first death that happened. Unreported deaths, or those unseen and unheard of, were equally real. The number of children who died at Gorakhpur's Baba Raghav Das Medical College Hospital was lesser in 2017 than it was in 2016, a panel of doctors from Delhi has said in its interim report. The panel had gone to Gorakhpur to look into the deaths of the children and has submitted the report to the additional health secretary. The team said that 200 deaths were reported at the state-run hospital in July 2017 as compared to 292 deaths during the same period in 2016.

Medical experts say the deaths occurred across three wards — 17 in the neonatal ward, eight in the pediatric ward and five in the encephalitis ward — where an acute oxygen supply shortage occurred because the hospital hadn’t paid its oxygen vendor. Owing to the incident, the mosquito-borne viral infection of the brain called encephalitis, in all its scientific trappings, has become drawing-room knowledge. While successive governments must be held accountable for the deaths that occur each year, public health experts tell us that the problem at hand stems from the fact that India doesn’t have strong and standardized quality-controlled healthcare.

 Gorakhpur tragedy proves theres urgent need to standardise quality healthcare across the country

File image from Gorakhpur’s Baba Raghav Das Medical College Hospital. PTI

The Clinical Establishments Act was passed by Parliament of India on 17 August, 2010, to provide for registration and regulation of all clinical establishments in the country with a view to prescribing minimum standards of facilities and services that may be provided by them in order to achieve the mandate of article 47 of the constitution for improvement in public health. The Act has taken effect in the four states namely, Arunachal Pradesh, Himachal Pradesh, Mizoram, Sikkim, and all Union Territories since 1 March, 2012 vide Gazette notification dated 28 February, 2012.

The states of Uttar Pradesh, Rajasthan and Jharkhand have adopted the Act under clause (1) of article 252 of the Constitution. The question arises, why did the Act come into existence as late as 2010 and why hasn’t it been adopted by most states yet?

Uttar Pradesh is one of the states that has adopted the act. Firstpost asked a senior hospital administration, specialist at the BRD Medical College at Gorakhpur, about the knowledge of the act among people working in the healthcare sector. He said, "Nil. There is zero knowledge of the Act. Why just the Act, there are only two people in the city who are trained in hospital management. Ask a cardiac doctor to manage logistics or a hospital kitchen, and the person won’t be able to. Hospitals require multiple skill sets and a variety of trained personnel. Unfortunately, in Indian hospitals, a staff nurse will be on duty in the children’s ward with no knowledge of daily doses and monitoring. Where is the quality control?"

The official, who requested anonymity, added that it was important to understand that encephalitis is a viral disease and doctors can only cure its symptoms. Therefore, prevention is the only cure. "By the time the affected children get to Gorakpur from places like Nepal, Mhow, Kushinagar, Siddharthnagar, Deoria, after spending about two to three hours on the road, they are terminally ill. Even after treatment, they would still have to live with residual paralysis, weakness and retardation. Along with immediate care, the state needs to ensure vaccinations, sanitation, water supply and nutrition to prevent the disease from germinating in the bowl-shaped landscapes of rice fields in the region that allow water to collect in pools," he told Firstpost.

As stated in a Ministry of Health and Family Welfare note titled Operational Guidelines for Clinical Establishments Act: "Healthcare in India suffers from under-regulation subjecting the populace to poor quality of treatment, quackery menace and high costs. This makes it imperative to enforce minimum standards on clinical establishments in both private and public sector. Technical quality of healthcare depends on factors like competence of personnel involved, adherence to clinical protocols, standard treatment guidelines as well as availability of required facility and infrastructure which are ensured in accredited hospitals but remains suspect in non-accredited institutions."

The note accepts that one of the first challenges the countries have faced in planning for regulation and accreditation systems is to gain consensus on the definitions of various forms of regulation and evaluation, licensure, certification. The note further stated that, "Accreditation and Regulation of healthcare organizations with minimum standards has been used in many countries as tools for defining the required characteristics of acceptable healthcare services. Their voluntary or mandatory nature varies as a function of system objectives."

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Courtesy: clinicalestablishments.nic.in

National Accreditation Board for Hospitals and Healthcare Providers, known as NABH, is a constituent board of Quality Council of India (QCI), which was set up to establish and operate accreditation programme for healthcare organisations. Till date, it has accredited 480 hospitals in India, a country that is home to more nearly 80,000 big and small medical facilities.

"In India, if it is a four unit hospital, in each unit a doctor will prescribe a different drug for the same disease. There is an immediate need to standardise healthcare because our training culture is non-existent," Dr KK Kalra, former head, NABH, told Firstpost. From 2003 to 2012, Dr Kalra headed the Chacha Nehru Bal Chikitsalaya, a super-specialty children’s hospital in New Delhi’s Geeta Colony. Under his guidance, the facility became the first government hospital to acquire accreditation from NABH. "Medical care has to be broken down into specialized segments in even the smallest facilities. At the Bal Chikitsalaya, we have wards for general pediatrics, pediatric nephrology, pediatric gastroenterology, pediatric anesthesia and so on."

Echoing Kalra’s sentiment, Dr Hariram MR, expert in Pediatrics and Neonatology at Bannerghatta Road, said, "In southern states and in places like Delhi and Haryana, infrastructure matches the demand better. But in states like Uttar Pradesh and Bihar, one can find four babies on one bed. An infection like encephalitis spreads rapidly and we can lose babies within days." Dr Hariram said that if crores are given as grants to government hospitals, why isn’t the best equipment bought and used?

In government hospital godowns, he suggested, state-of-the-art ventilators might be just kept. "Public hospitals like AIIMS in Delhi and PGI in Chandigarh are doing a good job because there is accountability towards the patient’s life. It is that accountability that needs to be put into sarkaari hospitals. We, at private hospitals, have sent home healthy babies weighing 650-700 grams, an average government hospital won’t send home a baby weighing a kilo. Nourishment and monitoring is an effort that requires accountability and care," he added, reinstating the need for mandatory and not voluntary certification of hospitals.

The Clinical Establishments Act 2010 cannot be limited to statutes and must be enforced in all states, and must go beyond drug stocks and expiry dates of medicines.

Dr Hema Divakar, former president of FOGSI (Federation of Obstetric and Gynecological Societies of India) said that nearly 45,000 women die during childbirth and there are 40.5 deaths per 1,000 live births in India. "The reason for this is mainly that the staff is not trained in specialized healthcare techniques," she added.

She also mentioned the Navjaat Sishu Suraksha Karyakram launched by the UPA government which helped train nurses in handling resuscitation, prevention of infections, hypothermia and other critical measures. "It is a robust programme for capacity-building, where specialized skills percolated to frontline. We need to re-audit and re-visit this national programme to check retention of skills, train new staff," she explains.

She also noted that forums like the National Neonatology Forum of India, which has developed standardised Teaching Aids through an elaborate process of consultation and pilot testing on newborns, and the Indian Academy of Pediatrics, the most representatives association of Pediatricians, has put in a great deal of effort into building quality newborn healthcare. "They need financial incentives. Quality enhancement in healthcare is a slow and uphill task. Unlike the clinical establishments’ act, which makes big promises on paper, we need to practically understand what is doable and then go ahead and do it. For instance, in FOGSI, out of 240 quality standards for maternal healthcare, we have declared 16 as non-negotiable because we want to scale up from a few hundred to thousands of hospitals," she highlighted.

Meanwhile, back in Gorakhpur, Rajbhar, a resident from Motipur village of Bihar's Gopalganj district commenced a dharna seeking justice after the death of his only son on 11 August, 2017. "My son had to be admitted due to symptoms of fever and stomach ache. The supply of oxygen being administered to him was stopped, due to which he struggled and suffered and died before my very eyes. Rajbhar had come to the hospital to get his son treated but the negligence of the hospital led to the death of the child," father of the baby told Firstpost, who was still present at the hospital along with his two-year old daughter.

Rajbhar isn't the first father to have lost a child to medical negligence within a system ailing with weak and infected policies. In 1973, in West Bengal, there was a large-scale outbreak of encephalitis. In 1978, states like Karnataka, Tamil Nadu, Bihar, Assam and Uttar Pradesh grappled with yet another major outburst. In 2005, in Gorakhpur, 5,737 persons were affected in seven districts of eastern Uttar Pradesh, and 1,344 persons lost their lives. It kills children every year and not just in Gorakhpur. It’s policy and not polity that needs that must be talked about, at least now.

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Updated Date: Aug 16, 2017 16:08:35 IST