More than 100 patients, including infants and newborns, died across government and civic hospitals in four districts in Maharashtra in under a week. Never before has the state seen patient deaths on this scale.
In Thane―Chief Minister Eknath Shinde's constituency―at least 25 people died in 24 hours. In Nanded, which is former chief minister Ashok Chavan's turf, 35 patients, including 16 infants, died in under 30 hours. In Aurangabad, which is represented by MP Imtiaz Jaleel, the Government Medical College, Chhatrapati Sambhajinagar, saw 14 deaths in 24 hours. Nagpur, home turf of Deputy Chief Minister Devendra Fadnavis and the Lok Sabha constituency of Union Minister Nitin Gadkari, reported at least 25 deaths in 24 hours at the government-run Mayo Hospital.
The dean and the paediatrician at the Nanded hospital have been booked for culpable homicide not amounting to murder. But, the root of the problem, not just at Nanded, but at all the public hospitals across the state is that there is not enough money, says.
Swati Rane, health activist, Jan Swasthya Abhiyaan, and visiting faculty at the Tata Institute of Social Sciences. “Every year, since 2019, there have been deaths inside NICUs (neonatal intensive care units) of state-run facilities,” she says. “In the NICU at the Nanded hospital, where the infant deaths occurred, the sanctioned bed capacity is only five, but at present there are 60 to 70 babies there. At any given time, on an average, there is just one staff to cater to 30 to 45 patients.”
Rane says such facilities do not even have drinking water and, given that Maharashtra does not have a Clinical Establishment Act, there is no regulation. “This is neglected in this state,” she says. “There is lacuna in every department across hospitals, from the lack of qualified personnel to infrastructure, medicines and permanent doctors.”
In 2014, associate professor Aswar Nandkeshav, medical officer Rewatkar Mangesh, and postgraduate student Akanksha Jain, all from the preventive and social medicine department at Dr Shankarrao Chavan Government Medical College and Hospital in Nanded, where the tragedy has now occurred, published a paper concluding that each patient waited 75.5 minutes to avail of outpatient services. According to the report, factors contributing to the delay included: registration clerk not coming to work on time; doctors coming late; doctors and pharmacists talking on their phones; difficulty in locating rooms; rush and VIP patients jumping the queue.
Experts question the state government's approach to public health saying that the area does not feature in its priorities. The budget allocation for public health and medical education in the state for 2023-2024 dropped by 7 per cent, year on year. This means it was less than 4 per cent of the overall budget, despite the inadequacies in the public health system highlighted by Covid-19.
In a research paper titled Health Infrastructure in Maharashtra, Prof P.S. Kamble of the department of economics at Shivaji University, Kolhapur, studied the facilities in rural Maharashtra. According to the study, “beds in government hospitals are often unavailable, not only in rural areas, but also in urban areas”.
Another problem is the number of vacancies in the state health department―around 18,000. “Of 42 posts for directors in various departments, 32 are vacant,” says Dr Abhay Bang, activist and community health researcher working in Gadchiroli district. He says 1,600 doctors' posts and 16,000 other key positions are vacant. “With such huge vacancies and overload, it is no wonder that the system is breaking down,” he says.
In Mumbai, which is reputed to have a far better public health care system compared with rural areas, there is a 27 per cent shortage of medical staff in five Brihanmumbai Municipal Corporation-run hospitals―439 out of 1,606 positions are vacant. The lack of assistant professors, who play a crucial role in academic work and patient care, is particularly high.
In August, the KEM Hospital had 180 vacancies. The Lokmanya Tilak hospital, Sion, and the BYL Nair Hospital, Mumbai Central, had 142 and 88 vacancies, respectively. And, doctors on contract had carried out a protest to highlight the shortage. Records at the Nanded hospital reportedly indicate that 42 per cent of medical positions across departments, including paediatrics and general medicine, remain vacant. Also, more than 60 per cent of the positions for senior resident doctors are vacant at the medical college.
The hospital serves patients from across the district and from neighbouring states like Telangana and has an annual footfall of 6.21 lakh. This leads to contractual hiring and that in turn means there are no timely promotions. Moreover, recruitment also takes a back seat. “We desperately need to recruit permanent staff,” says Bang. “Everyone is on contract.”
However, Bang also adds a word of caution with regard to the outrage sparked by the deaths, saying that we need to be sure that the number of deaths are excessive. “Not justifying the deaths, [but, at] any tertiary care hospital, where only serious patients are referred, there is a proportion of deaths which is unavoidable,” he says. “[So,] 24 deaths in a day is an accidental possibility in medicine. If this is perpetually the case, then it is problematic.”
Yet, what is stark and abnormal is the proportion of newborn deaths―out of the first 24 deaths at the Nanded hospital, 12 were of newborns. Sudden newborn deaths have been reported in public hospitals in Maharashtra earlier, too. In 2017, for example, 55 infants died in the NICU of the Nasik Civil Hospital. “One reason is that the tertiary care hospitals cater to the cases referred from the surrounding five to six districts and because the peripheral institutions are not well developed and mismanaged, everyone passes the buck by referring serious patients to district hospitals and further on to the medical college,” says Bang. “Usually, in NICUs there is one nurse for three to four sick neonates. But the situation is such that even for five times more neonates, there is just one nurse. So, there is overloading at these apex hospitals.” The government recently announced the creation of 2,800 temporary posts in the health department. But this is too less and too late, say experts.
Bang says the Centre's Janani Suraksha Yojana, launched in 2006, in which women are incentivised to come to hospitals for delivery, is an issue. In the scheme, women who give birth and the ASHA worker who brings her to the hospital are both paid an incentive. The percentage of institutional deliveries in India has gradually increased from 40 per cent to 90 per cent. “This means that nearly 1.5 crore more women have started delivering in hospitals,” says Bang. “The government has brought this load on to tertiary hospitals, and, [incentivises] it. If 90 per cent of women in nearby villages deliver in hospitals, it is natural that their newborns are admitted, thereby overloading the NICUs. Newborn care is breaking down because of this perverse incentive. It is important for the state government to develop the capacities of peripheral institutions, sub centres, PHCs and CHCs.”
Moreover, there is no nursing directorate in the state's healthy ministry, which means there is nobody to regulate the nursing staff. The Maharashtra Nursing Council was dissolved a few months back, for the fourth time in around 10 years, because of the irregularities in appointments and the functioning of the autonomous body. “The state is only catering to private sector interests,” says Rane. “In 2001-2002, there was Rs31 crore of foreign investment in the hospitals sector in the state. Now, that has grown to more than Rs4,000 crore. This shows the government is only interested in privatising health care.”
Dr Himmatrao Bawaskar | Amey Mansabdar
The breakdown that begins right at the primary health centres have a massive impact on the state's tribal population. Back in 2000, eminent medical scientist and Padma Shri awardee Prof S.L. Kate had highlighted the issue of sickle cell anaemia (SCA) among children; “in every village, there are at least one or two suffering from sickle cell disease”. He found the prevalence to be high among the Bhil and Pawara tribes from the Nandurbar district and Madia, Pardhan, Otkar and Gond from Gadchiroli. He estimated that there were more than 10,000 sickle cell patients in Nandurbar and an equal number in Gadchiroli. The information has not led to an improvement in the situation. Even today, Nandurbar, which has a predominantly tribal population, has the most number of SCA patients in the state.
The situation on the ground has remain unchanged even in the case of malnutrition and anaemia. Sapna Rokade, a researcher from the department of social work at the Tata Institute of Social Sciences, studied the nutritional status among 4,000 tribal women in Maharashtra and found that more than half, especially in the northwest districts, were anaemic. Severe anaemia was found in almost all districts in western Maharashtra. The study was published in Clinical Epidemiology and Global Health.
Dr Amol Annadate, a paediatrician and activist based in Aurangabad, says the recent deaths are a result of administrative failure, not medical failure. “This issue has been a long standing one and there is no guarantee that this will not repeat,” he says. “It is not the fault of health workers. They are extremely overburdened. There are only five to six doctors for every 100 patients there, which is shocking, to say the least. Health is a state subject and the joint responsibility of the medical education department and the health department and, unfortunately, both are corrupt.” He adds that “so much corruption” was on top of meagre budget allocations.
“What we need is an audit of the number of deaths occurring daily at these hospitals, the magnitude of human errors and infrastructure shortage and more,” says Annadate. “There is an absence of accountability and any system of audits at these hospitals.”
Meanwhile, the state government is announcing new hospitals in a bid to improve health care infrastructure and address the shortage of doctors. It has approved the establishment of new government medical colleges in nine districts at a budget of Rs4,366 crore. “What is the point?” asks Rane. “They should focus on providing doctors in the existing facilities instead of constructing more buildings.”
Padma Shri awardee Dr Himmatrao Bawaskar says: “The most crucial aspect which is often ignored is that medical officers must carry out regular OPDs and one medical officer must be available 24x7 in periphery care centers and PHC/CHCs, especially at night, when most urgencies happen and patients are sent to higher institutions.” This may seem a minor thing, he says, but it will bring significant change.