What happened at Shishubhawan is symptomatic of how deep the rot is in India’s crumbling public health infrastructure.
It has been two months since news and reports of the deaths of 40 infants at Shishubhawan, the largest paediatric care centre in eastern India, broke. The facility is for critically-ill children from Jharkhand, Chhattisgarh and Odisha. By the end of September, 56 deaths were reported in a span on 12 days.
Even for a State known for poor health indicators, the numbers were alarming. As TV channels picked up the news, the Health Ministry sent a team in from New Delhi to assess and fix the situation. Doctors were hired ad-hoc by the Odisha government, standard protocols fixed and the situation “addressed”.
Two months later, The Hindu went to the hospital to understand why there was the sudden spike in infant mortality rates at the centre.
The bad news first: it is not the hospital’s fault. It was not medical negligence. Nor was it due to a sudden outbreak of infection. What happened at the hospital is symptomatic of how deep the rot is in India’s crumbling public health infrastructure.
This was a worst case scenario at an ill-equipped hospital with overworked doctors making a bad case a bit worse. And everyone agrees. Yes, the hospital needs more hands. Yes, the laboratory closed too soon. Yes, the children were brought in too late. Yes, the media parachuted in, misread the situation and began screaming cold-blooded murder.
Now, at the hospital, it is business as usual. It is by and large clean. Since the reports of the deaths in August, the management has hired 15 new doctors and additional paramedical staff on an ad-hoc contract and keeps the laboratory open till 9 p.m.
“They were closing it around 4 p.m. earlier. So test results would sometimes come the next day and the baby’s situation would have significantly worsened by then,” said Arun Panda, Additional Secretary, Health Ministry, who was sent in to Odisha to “fix” the crisis.
Doctors and nurses are trying their best keep their patients alive. Most parents outside the ward are glad they got to the hospital in time. “My son has an infection in the bloodstream. There was no hospital near our village so we were advised to come to Cuttack by the local doctor,” said the mother of a week-old baby born in Mayurbhanj district, which borders West Bengal. The child was suffering from sepsis, a leading cause of mortality at the hospital together with premature birth and birth asphyxia (weak or no breathing at birth).
In April this year, 46 of the 86 infant deaths reported at the hospital occurred within 24 hours of admission. That’s 53 per cent of admissions, dead within hours. “It means that the babies reached us too late. We could do nothing,” said Dr. Saroj Satpathy, the hospital’s medical superintendent.
Now for the really bad news: the numbers don’t lie. In fact, the situation is worse than what the headlines from August let on — that’s how many babies die in any given two-week period at the hospital.
When this correspondent visited the hospital, the medical superintendent was watching over the wards and intensive care units from a television in his room.
Amiable Dr. Satpathy looks exhausted though as a result of explaining to everyone that Shishubhawan, officially known as the Sardar Vallabhbhai Patel Post Graduate Institute of Paediatrics, does not deserve the bad press. The centre is an extramural hospital, which means that every baby admitted was born elsewhere but referred there after complications.
“We get dying babies. We are the biggest hospital for paediatrics here. Naturally, when you get sicker patients, [the] mortality is higher compared to other centres. Unlike private hospitals that refer dying patients to government hospitals and keep their mortality rates clean, we cannot refer our patients anywhere,” he told me.
So, if the rates of mortality are always this bad, why did it become news this time?
“I cannot understand what happened,” said Arti Ahuja, the State’s Health Secretary. It now seems that two parents lost their babies on the same day and wanted a First Information Report registered against the hospital for medical negligence. “Distressed parents were agitating. In this sensitive situation, suddenly we found that after the first day, OB [outside broadcasting] vans landed up at our doors. For the next seven days and nights, journalists were counting each death. Even when we had patients ‘brought dead’, the journalists were chalking those deaths up to us. The deaths were never high even during that period,” Dr. Satpathy said. “Fifty-four babies dying in a 2-week period. We have similar numbers for the last 3 to 4 years.”
He is right.
Data for the corresponding period in the last four years shows: 1,154 admissions and 94 deaths in August 2012; 1,048 admissions and 71 deaths in 2013; 1,735 admissions and 167 deaths in 2014 and 1,470 admissions and 138 deaths in 2015.
“The mortality rate has been hovering around 8 per cent,” he said, almost to suggest that it is bad.
This brings us to the core of the crisis facing India’s government-funded public health system; we are out of doctors and without money.
“These are systemic issues. This is the legacy (of public health) we [have] inherited,” said Ms. Ahuja, who, only a few days ago had issued an order sacking 408 doctors in the State’s government hospitals.
As things stand, Odisha has one doctor per 9,729 population as against the national average which by itself is bad. With a population of 4,17,97,000, the State has only 19,188 registered doctors, allopathic and AYUSH [Ayurveda, Yoga & Naturopathy, Unani, Siddha and Homeopathy] practitioners included. It is a sign of desperation that a State struggling to find doctors, has fired such a large number of doctors en-masse. The “cleansing”, as she termed it, was necessary to make way for dilligent doctors.
“Things are pretty dire,” Ms. Ahuja said. “The shortage of anaesthesiologists in Odisha is so severe that the State is giving our general practitioners a crash course to allow caesarean section operations. And yet, these 408 doctors had to be fired. All these doctors were on leave for years and were within the system, so we could not hire more doctors for these posts, as they were technically not vacant.”
What is even more startling is that the State government is now counselling doctors to stay within the system. “We are counselling doctors to join and serve in underserved areas. The incentives are huge. If they agree to go to rural areas, we are willing to give them up to Rs.80,000 per month. They also have an advantage in post-graduate admissions,” she said.
“Will it be enough?” I ask her.
“We don’t know. We have given them incentives and 124 doctors have agreed to join government hospitals. We will have to wait and see if they join at all. Sometimes, these ad-hoc doctors agree but are no-shows,” she said.
That’s not all. If the State government manages to cross all the hurdles, there is one last stumbling block — New Delhi.
Under the National Health Mission (NHM) (earlier known as the National Rural Health Mission) most health interventions were funded by the Central government. “As a result, State governments started putting money in other areas instead of pooling the resources. So, money was spent on drug procurement and construction which are also necessary. The problem is in the way funds have been devolved. The understanding was the Odisha would get a larger share but we ended up getting a much smaller share,” Ms. Ahuja added.
It was only this week that Odisha was informed about the Centre-State division. “We only got to know yesterday when the year is ending. All of last year and this year we had no clarity on how much the State share on health will be.”
Meanwhile, inside Shishubhawan, a neonate is battling for life in the adequately managed Sick Newborn Care Unit. With her low birth weight and pneumonia, her parents have no clue of the outcome.
These parents do not understand the policy gaps leading to a shortage of doctors; the lack of clarity of funding patterns between the Centre and State or the academic debate around health system strengthening. But they do understand the injustice of going up against a system designed to fail them.