Government policies and interventions for development in various sectors and issues arising out of their design and implementation.
Issues relating to development and management of Social Sector/Services relating to Health
Gorakhpur Tragedy: Learning lessons
Over 30 children died within a span of 48 hours at the government-run Baba Raghav Das (BRD) Medical College hospital in Gorakhpur last week.
According to initial reports, many of the children died because their oxygen supply was cut off as the hospital hadn’t paid its dues to the supplier—the matter is under investigation.The incident is in equal parts tragic, shameful and outrageous.
Not first such incident:
A mass sterilisation camp in Bilaspur (Chhattisgarh) in 2014 ended in the death of many women. In fact, earlier this year it was reported that the doctor accused in this case was acquitted by the court.
In 2015, reports emerged from a Badwani district hospital in Madhya Pradesh of a cataract camp that resulted in some people losing vision in one eye.
The same year, people died in a Chennai hospital due to power outage during the floods.
Hospitals in New Delhi witnessed the shocking incident of a child dying from dengue and his distraught parents committing suicide.
Encephalitis has been a scourge in Gorakhpur for nearly 40 years — and it has not been addressed by successive governments with the urgency it deserves. According to conservative estimates, 25,000 people have succumbed to it since the disease was first reported in the area in 1978 — more than 50 of them this year, before last week’s incident.
The BRD hospital said the deaths took place due to various illnesses. Of the 60, 12 died of acute encephalitis syndrome.
What is Encephalitis?
Encephalitis is a viral disease that mosquitoes transmit to humans from pigs. In most cases, it causes a mild fever and headache that recede within a few days. But one in 250 people develop high fever, severe headache and neck stiffness that exacerbates into seizures, paralysis and coma. At times, survivors are left with serious disabilities, mental and physical.
Why Gorakhpur is prone to Encephalitis?
In 2006, a study in the journal, Emerging Infectious Diseases, pointed out why Gorakhpur is prone to the virulent form of the disease.
An abundance of rice fields and a bowl-shaped landscape that allows water to collect in pools create ideal breeding grounds for mosquitoes.
Poor sanitation facilities, open defecation and encephalitis in eastern UP where Gorakhpur is located is also one of the aggravating factor. Yet uncovered drains, clogged sewers and garbage-strewn streets remain a common sight in the region. Gonda, which sends a large number of encephalitis patients to the Baba Raghav Das Medical College Hospital every year, has been named the worst performing district in the Swachh Bharat Survey this year.
Encephalitis is correlated with expansion of irrigation and construction of dams four decades ago, resulting in an increase in disease-transmitting mosquitoes. Proximity to pigs and birds created viral transmission pathways.
What has happened in Gorakhpur isn’t merely about oxygen cylinders and unpaid bills—it is a symptom of many deeper problems.
India’s abysmally low public spending on healthcare. That at least partly explains why the country’s healthcare system is in shambles. Public spending has increased but only marginally over the past two decades—from 1.1% of gross domestic product in 1995 to 1.4% in 2014. The National Health Policy 2017 promises to up this spending to 2.5 per cent by 2025. And though this may sound like good news, it isn’t because this has been a long-pending promise of successive governments, their political ideologies notwithstanding.
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.
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. India’s 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. India’s inability to find a workable model for itself has left its poor particularly vulnerable.
Even for those who can afford better, the choices are limited. Most state-run facilities are so poorly managed that they aren’t 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.
Poor governance– Weak enforcement of rules on quality and governance.
Poor social determinants– In the case of U.P., the epidemics have their roots in weak social determinants such as housing and sanitation, coupled with ecological changes.
The infant mortality rate in India in 2015 was 38, according to the World Bank—far 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.
The Medical Council of India (MCI) will have to reform the entire medical education system if the man power gap has to be filled.
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.
Last year, Prime Minister Narendra Modi laid the foundation stone of an AIIMS at Gorakhpur. While the setting up of such an institution is welcome, encephalitis can be best combated by strengthening primary healthcare facilities. Epidemiological studies have shown that lives of encephalitis patients can be saved if they receive immediate treatment from trained doctors and are not forced to travel long distances to access medical care.
By 2025, the population will increase, hospital infrastructure is woefully inadequate even today. For a country with 26 million births a year, an increased spending by 2025 is not good enough. It needs to be at least 5 per cent or more because India is a country that is simultaneously home to malnutrition and lifestyle problems like obesity and diabetes; a thousand people die of tuberculosis a day and numbers dying of cancers and heart-related ailments are only increasing.
Health is a state subject, but it is high time the Centre set the bar high by putting its money on health and prioritising it on the Government’s to-do list.
It is also an appropriate moment for the Centre and the States to consider their poor record. They trail even other developing economies, such as neighbouring Thailand and some African countries, in moving to universal health care.
A universal healthcare system is required and such a system should be non-commercial and regulated to contain costs, giving everyone affordable access to doctors, diagnostics and treatment.
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 children’s death galvanize the people to demand that their leaders fix the country’s broken healthcare system? Will it force the politicians to make healthcare a serious campaign platform?
Connecting the dots:
The Gorakhpur tragedy is a national shame. The problems highlighted but the incident is not new but lack of political means crises like Gorakhpur will continue to happen. Critically analyze.
From Bilaspur incident in 2014 to Gorakhpur incident this year, the healthcare system of India hasn’t improved. Discuss the issues and challenges in providing an effective health care to all.
TOPIC: General Studies 2
Issues relating to development and management of Social sector or Services relating to Health, Education, Human Resources.
Government policies and interventions for development in various sectors and issues arising out of their design and implementation.
Welfare schemes for vulnerable sections of the population by the Centre and States and the performance of these schemes; mechanisms, laws, institutions and bodies constituted for the protection and betterment of these vulnerable sections.
Investing in the earliest years of a child’s life
The government recently reviewed the section of the Right of Children to Free and Compulsory Education (RTE) Act which stipulated that “no child admitted in a school shall be held back in any class or expelled from school till the completion of elementary education”, which covers Classes 1 to 8.
This decision, which now permits states to impose examinations which can detain, and presumably expel, children during elementary education, has been welcomed by many teachers because the automatic promotion of students was leading to large numbers of students landing up in Class 9 without basic learning abilities. This, in turn, doomed them to failing the Class 9 examinations and ultimately triggering drop-out.
The latest report of the Annual Survey of Education, published last year, and based on assessments of basic abilities of reading, writing and arithmetic of over five lakh rural children, offered a glimpse into the scale of the challenge confronting India.
While 95 per cent of children aged 6 to 11 years were enrolled in schools, a large proportion of children were simply not learning. Nationally, less than half the children in Class 3 were able to read a Class I level text, a figure which had shown virtually no improvement since 2011.
One of every four children enrolled in Class 8 could not read at Class 2 levels. Just over a quarter of Class 3 children could do a two-digit subtraction and a similar proportion of Class 5 children could do simple division.
Too late and too little:
It is presumed that detection of learning under-achievement during elementary education will trigger efforts by students ultimately improving educational outcomes.
But besides the obvious pedagogical reasons such as large class sizes and the focus on rote learning, there is one major reason why this sudden change of policy is unlikely to reap the dividends the government and educational community hopes for: It is happening far too late in the life of the child.
Economic survey 2016:
Tomorrow’s worker is today’s child or foetus and events which occur while a child is in the womb i.e inside pregnant mother or very young (<2 yrs) affect cognitive development and health status even in adulthood i.e. if today’s child is weak, chances are tomorrow’s worker would be less productive.
Why does health of new born affects outcome much beyond the childhood?
The most rapid period of physical and cognitive development in a person’s life occurs in the womb.
Research has shown that low birth-weight children benefit less from early-life cognitive stimulus programs i.e. early we intervene the better i.e. investment in mother and fetus. very young children
Success of subsequent interventions—schooling and training—are influenced by early-life development
World Bank report:
A few years ago, the World Bank referred to the development of young children as “one of the best investments that countries can make” because a child’s earliest years presented “a unique window of opportunity to address inequality, break the cycle of poverty, and improve a wide range of outcomes later in life”. A key philosophy was that children should be intellectually “ready” for primary school.
Limited success of ICDS:
While India was amongst the earliest countries to acknowledge the importance of this investment through the Integrated Child Development Scheme launched in 1975, the observations on learning abilities are testimony to the limited success of this scheme.
Further, the scheme is almost entirely facility based, missing the enormous opportunity to provide nurturing environments in the homes of young children.
Deprivations in early years of life:
A huge proportion of India’s children, exceeding 50 million in a recent estimate, experiences fundamental limitations of learning abilities which have their roots well before they even enter primary school.
In short, their intellectual capabilities, a direct outcome of the level of cognitive development of the brain, have been blighted by enormous deprivations in the early years of their lives.
These deprivations are mostly the direct result of poverty, from the lack of adequate nutrition which leads to bodies, and minds, being stunted, to the lack of a responsive parenting environment due to the enormous economic and social barriers experienced by their parents, in particular their mothers.
Lack of essential nutrients to the lack of essential stimulation, adversely impact the architecture and function of the developing brain.
A vast proportion of India’s children who are failing to learn in school were already condemned to this fate before they entered school.
Giving attention to physical health especially the essential nutrients for the newborn as well as young children. Exclusive breast-feeding for first six months of a child should be taken seriously.
We must act on the need that young children have for intellectually and emotionally nurturing environments, through providing adequate support and information to the care-givers of young children to stimulate them through play, building parent skills to be responsive and non-punitive, and providing affordable and appropriate pre-school child education and high quality engaging primary education.
Providing with a nurturing alternative, one where both the primary emotional and physical needs are met. Some of these are finally being addressed on a war-footing, for example through improvements in sanitation and hygiene by the eradication of open defecation.
Programs targeting younger children also appear relatively cheap in comparison to investments made in older children. For instance, iodine supplementation is way cheaper compared to improving teacher quality or re-designing institutions to raise school accountability.
As we celebrate the fact that India’s children now survive in unprecedented numbers, we must turn our attention to giving every child the opportunity to thrive so that they ultimately become capable adults who not only attain their own dreams, but also contribute to the development agenda of the nation. For this to happen, we will need a massive and renewed national commitment to investing in the earliest years of a child’s life.
Connecting the dots:
Indian children’s poor performance in schools and colleges is often presumed to be so because of poor elementary education. However as pointed by World Bank recently and by Economic Survey 2016 we need to invest in earliest years of child’s life. Discuss.