The frail nature of rural India’s health systems and the extraordinary patient load on a few referral hospitals have become even more evident from the crisis at the Baba Raghav Das Medical College in Gorakhpur. The institution has come under the spotlight after reports emerged of the death of several children over a short period, although epidemics and a high mortality level are chronic features here. Medical infrastructure in several surrounding districts and even neighbouring States is so weak that a large number of very sick patients are sent to such apex hospitals as a last resort. The dysfunctional aspects of the system are evident from the Comptroller and Auditor General’s report on reproductive and child health under the National Rural Health Mission for the year ended March 2016. Even if the audit objections on financial administration were to be ignored, the picture that emerges in several States is one of inability to absorb the funds allocated, shortage of staff at primary health centres (PHCs), community health centres (CHCs) and district hospitals, lack of essential medicines, broken-down equipment and unfilled doctor vacancies. In the case of Uttar Pradesh, the CAG found that about 50% of the PHCs it audited did not have a doctor, while 13 States had significant levels of vacancies. Basic facilities in the form of health sub-centres, PHCs and CHCs met only half the need in Bihar, Jharkhand, Sikkim, Uttarakhand and West Bengal, putting pressure on a handful of referral institutions such as the Gorakhpur hospital.
Templates for an upgraded rural health system have long been finalised and the Indian Public Health Standards were issued in 2007 and 2012, covering facilities from health sub-centres upwards. The Centre has set ambitious health goals for 2020 and is in the process of deciding the financial outlay for various targets under the National Health Mission, including reduction of the infant mortality rate to 30 per 1,000 live births, from the recent estimate of 40. This will require sustained investment and monitoring, and ensuring that the prescribed standard of access to a health facility with the requisite medical and nursing resources within a 3-km radius is achieved on priority. Such a commitment is vital for scaling up reproductive and child health care to achieve a sharp reduction in India’s deplorable infant and maternal mortality levels, besides preventing the spread of infectious diseases across States. It is imperative for the government to recognise the limitations of a market-led mechanism, as the NITI Aayog has pointed out in its action agenda for 2020, in providing for a pure public good such as health. We need to move to a single- payer system with cost controls that make efficient strategic purchase of health care from private and public facilities possible. Bringing equity in access to doctors, diagnostics and medicines for the rural population has to be a priority for the National Health Mission.
