UP healthcare crisis Part 3: Per-capita health expenditure of India's most populous state is half the national average

Editor's note: Uttar Pradesh had been in the grips of a healthcare crisis long before Gorakhpur and Farrukhabad put the spotlight on the state's ailing public health system. The state's infant mortality rate is comparable to that of strife-torn African nations. There is one doctor for every 19,000 people; according to WHO, there should be one for every 1,000. This is the third of a four-part series that explores the state's policy paralysis and places it against the larger backdrop of a systematic public health failure.

"I was shocked to see my baby die half an hour after the doctors told us that he was going to be fine and that there was nothing to worry about," said Vyas Gupta, a resident of Deoria district, who lost his four-month-old child to the Gorakhpur tragedy in Uttar Pradesh in August.

Gupta is not alone as state-run Baba Raghav Das Medical College and Hospital proved to be a death trap for 300 children that month. The hospital has seen 1,256 child deaths until August this year. And not so far behind, in Farrukhabad's Dr Ram Manohar Lohia Hospital, 49 children died in September alone.

A woman comforts her child who is suffering from encephalitis at a hospital in Gorakhpur. Reuters

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Dr Abhay Shukla, a public health policy expert and a programme coordinator at Support for Advocacy and Training to Health Initiatives (SATHI), said although local factors did play a role in the Gorakhpur tragedy, it was not just limited to that. Since the survey shows that most people in Uttar Pradesh die of something as common as diarrhoeal diseases, the quality of public health facilities in the state warrants serious attention.

The decade-on-decade population growth of India's most populous state is 20.2 percent, which is higher than the country's 17.7 percent. But its health infrastructure has failed to cope with the growing population.

In 2015-16, Uttar Pradesh spent 3.98 percent of its budget on healthcare, which is Rs 12,104 crore of an overall expenditure of Rs 3.04 lakh crore. The next year, the state spent 4.6 percent of its budget on healthcare and for 2017-18, the estimated expenditure is 4.46 percent. Dr Shukla said the money allocated for health policies serves as "oxygen", which is hardly made available to Uttar Pradesh.

He said, "The proposed budget for 2016-17 demanded Rs 30.4 crore for healthcare, of which only Rs 10.19 crore were approved by the Centre. In 2017-18, the demand was cut to Rs 20.01 crore but the Centre managed to further slash it to Rs 5.78 crore – barely 29 percent of the proposed amount."

A report published by data journalism portal IndiaSpend earlier this year highlighted how Uttar Pradesh's per capita expenditure on health, at a mere Rs 452, is 70 percent of India's national average. "The state, which has more than 16 percent of the country's population, gets only nine percent of India's public health spending. We need more per capita spending in the health sector to support the crippled public health policies," Dr Shukla added.

Misallocation of resources

When it comes to the state of its public health institutions, Uttar Pradesh disappoints again. The healthcare infrastructure has cracks right from the bottom – from sub-centres to district government hospitals. Uttar Pradesh has 20,521 sub-centres and not one of them meets Indian Public Health Standards. Almost 32.5 percent of the sub-centres don't get regular water supply, 35.9 percent face trouble when it comes to electric supply and 30.2 percent are without all-weather motorable approach road.

Almost 91 percent of Public Healthcare Centres (PHCs) do not have a female doctor, 60 percent do not have a functional operation theatre and 56.6 percent are devoid of a labour room. Many centres don't even have a regular supply of common drugs. This points at gross misallocation of resources and wastage of public funds. "If the PHCs function properly, people won't have to run to district hospitals. This means the infrastructure at the hospitals won't have to deal with more patients than it can handle," added Dr Shukla.

The 2016 Rural Health Statistics' list of lack of staff in Community Healthcare Centres is unending — specialists are short by 84 percent, lab technicians by 77 percent and radiographers by 89 percent. Uttar Pradesh faces the most severe shortage of medical staff among other states in the country. Gupta said that when he cried for help at the BRD Medical College, there weren't enough doctors to attend to all the patients. "Only nurses and other hospital staff members attended to my baby," said Gupta.

Dr Kailash Dulani, the only paediatrician at the 100-bed Ram Manohar Lohia Hospital in Fatehgarh of Farrukhabad district, said he is forced to double as an obstetrician-gynaecologist (OB-GYN) and help deliver about 16 children a day at the hospital. "I see patients, go on rounds and also sit in the out-patient department (OPD) but other than that I can be called to the hospital anytime because there is no other child specialist," he said.

To deal with this acute shortage, the Yogi Adityanath-led government has extended the retirement age of doctors in state-run hospitals from 60 years to 62 years. The move is likely to benefit more than 11,000 doctors. Siddarth Nath Singh, health minister, Uttar Pradesh, told the Legislative Council that there was a shortage of about 7,000 doctors in the state.

Director, epidemic and vectorborne diseases, Uttar Pradesh, Dr Badri Vishal, said one of the ways to address the doctor shortage issue is to train Ayush (Ayurveda, Yoga, Unani and Siddha Healing) doctors so that they will also be able to write allopathic medicines. He said they should be posted at the CHCs at the block level. "After the Gorakhpur incident, the government has formed various committees to address the healthcare issues. It (Gorakhpur incident) was mismanagement as there was no one to monitor the work," he said.

Failure of steps to ensure no failure

Under the National Health Mission, a provision for Rogi Kalyan Samiti or Patient Welfare Committee (PWC) in PHCs was included. The aim of the PWCs is to ensure that the centres meet the country's healthcare standards. But how many of them exist?

In UP, 86.8 percent of PHCs don't have PWCs. The state has a surplus of CHCs but less than half of them have a functioning X-ray machine and more than half of them don't have a functioning stabilisation unit for newborns.

From low health budget, misallocation of that budget to the failure of policies meant to resolve the grave issue and to the perennial problem of shortage of staff, the state is mired in problems that have left its healthcare system in tatters.

Read Part 1: Chronic shortage of doctors, overdose of apathy have left govt hospitals comatose

Read Part 2: With only 78,000 doctors for 21 crore people, state has turned playground for quacks

The author is a Pune based freelance writer and a member of 101Reporters.com, a pan-India network of grassroots reporters.