Urban crisis

A CAG report on health services in four major Delhi hospitals reveals the plight of the urban poor.

T.K. RAJALAKSHMI in New Delhi

JAIBUNNISSA is a full-time domestic worker and part-time masseuse in East Delhi. Last year, her husband Siraj, a barber, was diagnosed with diabetes and tuberculosis. Jaibunnissa became the main earner in a family of seven, including four school-going children. She managed to get her husband admitted to the local tuberculosis dispensary, using the influence of the local pradhan. Siraj remained in the hospital for close to two months. Could the family have afforded to treat Siraj in a private hospital for the same duration? Certainly not. The poor need public hospitals and the public health system even though their services are far from satisfactory.

The performance audit by the Comptroller and Auditor General (CAG) of India on health care in four leading public hospitals in Delhi has highlighted the abysmal state of public health services. The report reveals massive shortages of staff, beds, essential medicines and equipment and over-expenditure on electricity. Together, the hospitals have a bed strength of 3,227, which is 32 per cent of the total bed strength of public hospitals in Delhi. If findings from the national capital's hospitals are bad, the state of public hospitals and the public health system elsewhere in the country can only be imagined.

The hospitals reviewed were the Lok Nayak Hospital and the Deen Dayal Upadhyay Hospital (both under the administrative control of the Department of Health and Family Welfare of the Government of Delhi), the Hindu Rao Hospital (managed by the Municipal Corporation of Delhi) and the Charak Palika Hospital (managed by the New Delhi Municipal Council). The audit was conducted between March and July 2006 and it reviewed progress since the previous audit, in 2002.

The CAG report shows shortages of medical, paramedical and nursing staff in all four hospitals. Despite a continuous increase in patient load since 2001, no attempts were made to fill staff vacancies or review the adequacy of staff strength. Consequently, there were abnormal delays in conducting diagnostic tests and surgical procedures. In the Hindu Rao Hospital, a department of neurosurgery had not been established because the two sanctioned posts lay vacant. Nearly 147 head injury cases during 2003-05 had to be referred elsewhere. No specialist for the Burns and Plastic Surgery Department had been appointed since 2005 and the Psychiatry Department was run by two medical officers (one of whom had only a diploma in psychiatry) after the specialist left on an assignment abroad in 2004. As a result, the hospital stopped taking outpatients for these illnesses despite having seen 3,341 patients for burns treatment and plastic surgery and 25,417 patients for psychological treatment between 2001 and 2003. The Lok Nayak Hospital was the worst affected in terms of staff deficiency; it operated without a quarter of the medical staff, 37 per cent of the paramedical staff and half of the nurses necessary for proper treatment.

The report also shows that not enough was spent on essential equipment and medicines. Three of the four hospitals did not have essential drugs to treat diabetes, hypertension, typhoid, tuberculosis, blood clotting, Parkinson's disease, cancer and epilepsy for periods ranging from one month to five years during the time the audit covered. These drugs are on the Directorate of Health Services' 2002 list of 359 essential drugs, which all hospitals are supposed to keep in stock. But patients from all except the Deen Dayal Upadhyay Hospital had to purchase them from private chemists. There were delays in procuring, installing and commissioning nearly 72 per cent of medical equipment. Shockingly, two hospitals had accepted Rs.1.04 crore worth of medicines and vaccines with reduced shelf life.

The CAG found that emergency departments had not received adequate attention in terms of infrastructure, supplies and manpower and were therefore ill equipped to deal with the number of patients they received. More than 50 per cent of the ambulances were used for purposes other than patient care; in two of the hospitals selected for the review, the ambulances did not have essential equipment for basic life support. The average bed occupancy was also high. In Lok Nayak hospital, the average bed occupancy in its casualty and emergency services department was as high as 282 per cent, which meant that two or three patients were sharing a bed.

The Lok Nayak Hospital and the Deen Dayal Upadhyay Hospital made an excess payment to the tune of Rs.6.23 crore by way of energy charges and demand charges for the July 2002-May 2005 period. This, the audit report stated, meant that the hospitals were unable to exercise effective controls relating to payments and monitoring of hospital expenditure.

The working class population of any city depends on public health services, and this is particularly true of New Delhi where the urban population grew by 31.2 per cent, or 68 million, between 1991 and 2001, almost double the population growth in rural areas. Sixty million people, 21 per cent of the total urban population, live in slums. According to data on slum populations released by the Census office, the percentage of people living in slums in 21 municipal corporations that have a population of over a million ranged from 8.7 per cent in Bhopal (Madhya Pradesh) to 46.5 per cent in Faridabad (Haryana). In Maharashtra alone, there were seven municipal corporations where the percentage of people living in slums ranged from 2.9 per cent (Kalyan-Dombivli) to 54.1 per cent (Greater Mumbai).

The Urban Health Resource Centre (UHRC), a non-governmental organisation (NGO) working on health issues amongst the urban poor, estimates that the urban poor have very limited access to health services. Its analysis of National Family Health Survey II data shows that less than half (47.7 per cent) of mothers from urban poor families received the recommended three antenatal visits during pregnancy. Over half of the child births (56.1 per cent) in urban poor families took place at home without the presence of a trained birth attendant. Children faced an increased burden of diseases such as measles, diarrhoea, diphtheria, whooping cough and tetanus. Only two out of five children received all the recommended vaccinations. The malnutrition rates in the under-five category were as high as 56.8 per cent. This meant that despite geographical access to private and public health services, the state of health of the urban poor was far from satisfactory. In fact, urban health infrastructure was inadequate. A task force was constituted by the Ministry of Health and Family Welfare to advise the National Rural Health Mission on strategies to handle the problem of urban health.

Dr. Siddharth Agarwal, Executive Director of the UHRC, told Frontline that the belief that urban residents were better off than their rural counterparts had led to the neglect of the urban poor. Currently there is only one urban health centre for every 230,000 persons, where as there should be one for every 50,000. The Integrated Child Development Services (ICDS) covers only a sixth of the urban poor. Often, services are not provided at all in urban slums for fear of "legitimising" their existence. And several sections of society who are not part of the urban slum or urban poor list, such as brick kiln workers or construction workers, are inevitably left out of any form of health care.

In 2004, the Union Health Ministry prepared a set of guidelines for State governments for health projects in slums and other vulnerable areas. The Ministry admitted in a statement on the guidelines that at the time no systematic efforts were made to provide primary health care services in most urban areas and that health indicators in urban areas were worse than those in rural areas. The stated goal of the urban health programme was to "improve the health status of the urban poor community by provision of quality primary health care services with focus on reproductive and child health services to achieve population stabilisation".

In a covering letter addressed to the State Secretaries of Health, Union Health Secretary P.K. Hota stated that "since population stabilisation was the main mandate of the department", the project formulators needed to ensure that at least 50 per cent of activities related to family planning and immunisation services. He also wrote that as urban areas and cities had a large number of private health providers and NGOs and as the private sector had "considerable capacity and potential", which had not been tapped, public-private partnerships should be explored, especially for family planning and immunisation.

Aggarwal said that in a highly privatised health care system such as the one in India, investment in both private and public health care was low at the primary level and high at the super-speciality levels. He said that initial data from the National Family Health Survey III did not show any great improvements as far as immunisation, maternal mortality and child malnutrition were concerned. He said that the need to earn affected caring practices at home, thus increasing the vulnerability of women and children.

With more agrarian distress and fewer employment opportunities in rural areas, the population of the urban poor will only grow. Almost every city has its slum and working population. Only a strong public health system, with the primary health centre as the nodal point, backed up by universal ICDS, and a working public distribution system will stem the tide of morbidity and mortality among the urban poor.

The government will also need to realise that "population stabilisation" will not lead to health for all; proper health care and education will reduce birthrates and curb population growth. Perhaps it should change its priorities accordingly.