It is possible to nurse many govt hospitals back to good health. So, what is holding us back?

On August 15th ,  Shoba, a resident of Medak district near Hyderabad, reached out to Niloufer government hospital for mother and child health, with a newborn suffering from severe jaundice.

By E Kumar Sharma  
Tuesday, August 29, 2017

On August 15th,  Shoba, a resident of Medak district near Hyderabad, reached out to Niloufer government hospital for mother and child health, with a newborn suffering from severe jaundice. Its serum bilirubin level, a standard measure for the ailment, was at as high 40 milligram per deci-litre (normally much less than 10 mg per dL in a newborn).

During the course of the day, doctors took care of the baby and opted for a procedure called 'exchange transfusion' for the treatment. It is a process, wherein, the baby's  entire jaundiced blood is replaced by the fresh blood. The whole process was completed within three hours of hospitalization, which is critical we are told, to prevent brain damage. In addition, the baby was put through 'intense triple photo therapy' and he was cured and discharged in three days.

"I am happy on a day like August 15th, which was a public holiday and people were busy celebrating, our doctors worked tirelessly and helped save this child," says Dr Srinivas Kalyani, professor of paediatrics, who along with Dr Himabindu and a team of doctors attended the baby. He does not fail to remind that all of this was done free of cost. Procedures such as these cost anywhere around  Rs 10,000 in a private setting, he says.

The happy conclusion to this case only underlines the point that there is good medical talent available in these hospitals and it is not appropriate to think of government hospitals as a basket case.

But then, why do we, every now and then, hear stories of tragedies involving avoidable deaths - be it the recent deaths of children in Ghorakpur, UP or the sterilization deaths in Chhattisgarh in  2014, or in 2015 when rats killed an infant in a hospital in Guntur, Andhra?

In fact, the medical superintendent of the hospital, Dr Murali Krishna was initially sceptical of what we might report and was at pains to impress upon us that the state government has been "quite proactive" in its support and "a lot has been changed in the hospital over the last one year."

True, it has and grown from a 500 bed to the double of that today and there is new and neat atmosphere being provided to babies in the neo-natal intensive care units. But then, ask him about the high patient load (enter the hospital compound and it is teeming with patients, sick babies with parents and attendants sitting and lying in the grounds around the hospital), he says, "This will always be the case since we cannot deny admission to any patient. If we increase our bed strength to 2,000 even then we will have this situation as there will be even larger inflow of patients." The hospital today gets anywhere between 1200 to 1500 patients, depending on the season. Krishna sees Niloufer as a hospital in transition and he talks of some of the new systems and processes which have been put in place. But more on that later.

For the moment, step back and take a macro picture of public healthcare in India, specially the government hospitals, be it district level or specialised entities, all have some common concerns. Solutions to these are apparent but then there is little being done about it. When you visit hospitals, talk to doctors and health workers, the common elements across most government hospitals become all the more evident. And till these are dealt with comprehensively, nursing all the government hospitals to good health will remain a challenge. Consider some of the common pain points.

The first thing which strikes you about any government hospital is the over-crowding.

Second issue is the nature and profile of patients. Part of the reason the mortality rates are high in government hospitals is to do with the fact that a significant portion of patients admitted are terminally ill cases, usually shifted from a private/corporate hospital.

Third is the under-staffing and issues around infrastructure. Symptoms of these get reflected in the little time that physicians are able to spend with patients and the increased pressure on machines.

But most crucial and a fundamental shift is disinterest of doctors to work in government hospitals, and it has in many ways led to the rapid deterioration.

"With the advent of private hospitals (read corporate hospitals) the nature of private practice of doctors has undergone a major shift. It has moved from personal clinics (earlier just at their home in the evenings) to engagement with corporate hospitals, where many of the doctors also practice," says Professor K Srinath Reddy, president of the Public Health Foundation of India and former head, department of cardiology at the All India Institute of Medical Sciences (AIIMS). This, he feels, has "diminished the interest  of doctors (who are also linked to private hospitals) from maintaining good services in government hospitals."

There is yet another shift, he says, which affecting government hospitals adversely.

"There is a shift of attention for personal care of politicians, bureaucrats and other opinion makers of society to corporate hospitals and this has led to near complete neglect of government hospitals," he says. But then, Reddy is quick to remind that there is an inherent danger in this.

"Please remember that most doctors , even in many private hospitals, are those who were trained in government hospitals or in the hospitals attached to the government medical colleges." Therefore, if the quality of training goes down in government hospitals, it will sooner or later also get reflected in the clinical outcomes of private hospitals. "The government hospitals are the training grounds and a nursery and should be treated as precious education and training resource apart from ensuring that they be the responsible providers of medical care," adds the doctor.

Can these be attended to? It is after all no rocket science that is beyond the understanding of politicians, bureaucrats and hospital managers. Incidentally, government hospitals have doctors heading them and not managers. Though, they are trained also as managers, a medical superintendent is a doctor at the end of the day, and will know when a patient needs oxygen. Or even what can be done to keep staff motivated and ensure drug availability. The fact, that there was a time when a debate was on whether oxygen was in short supply or not, is itself a sad state. As a doctor very aptly asks:  "Do we ever have a debate on whether there was enough oxygen for the rockets on the Mars mission. How is ISRO (Indian Space Research Organisation) able to manage it?"

One example, which stands out in this whole gambit of public health, is that of the All India Institute of Medical Sciences (AIIMS) in Delhi. Here, despite the proliferation of private healthcare, patients continue to prefer its services and the crowds are only rising.  What could be the reasons?

The most apparent one is its lower cost. AIIMS is much cheaper than a corporate hospital with similar facilities in Delhi. Plus, it is generally perceived as one where unnecessary procedures may not be undertaken. Last but not the least, the sheer volume of patients and the training given to doctors ensures not just deep hands-on experience but also knowledge across a wide range of ailments. Annually, AIIMS-Delhi gets about 35 lakh outpatients, over 2 lakh admissions, 1.7 lakh surgical procedures (numbers that some of the leading corporate hospital chains can match only after adding up across several of their hospitals). AIIMS incidentally has a bed strength of around 2400. Per day, a doctor at AIIMS points out, typically you will see around 10,000 patients at AIIMS, Delhi.

Meanwhile at Niloufer, the key leadership team is motivated enough to take you around and ensure you see each and every new measure that has been put in place.  

Some of them are: "We have started a unique section called the Kangaroo Mother Care, where mothers are taught to wrap the newborns around their chest for warmth. It is cheapest health intervention you can think of. Or, we will be starting a human breast milk bank and create a pool of human breast milk. This will ensure supply of mother's milk for a newborn always. Or we also have "ventilator support, artificial surfactant for lung maturity apart from many life saving gadgets like radiant warmers to maintain normal temperature."   

But then, one of the doctors points to a grim reminder of the permanent challenge: About 5 per cent of children are brought dead, he says, and about 30 per cent admitted into the hospital tend to be terminally ill cases.

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