Public healthcare alone can't avert calamities like Gorakhpur child deaths
Children in a Gorakhpur hospital slipped off delinquent arms as India embraced yet another year of Independence. What stiffened overnight into corpses were little bodies ready and restless to grow. The tragedy triggered mundane outrage that subsides like routine sunset.
The hunt for individual culprits began so that the nation could cleanse itself of collective culpability. The sinners appeared in many disguises - Rajeev Mishra, Kafeel Khan, Pushpa Sales, Japanese Encephalitis, Siddhartnath Singh and Yogi Adityanath .
Public discourse has pursued these characters in all instances of health tragedies that seven decades of freedom have offered to India. The villains come and go but the plot remains unchanged. The health system in India needs a revolutionary script. It must de-territorialise and welcome motivated hearts with skilled hands to serve the poor. Perhaps in that vein, the NITI Aayog has announced Draft Guidelines for Discussion about a public-private partnership (PPP) model to treat non-communicable disease.
The advantage of PPP in healthcare is efficiency. But the disadvantage is loss of public control over the very objective of such model - life for all humans. Greed is very good. Profit maximisation is essential and achievement must be incentivised to honour talent.
But India has to decide if greed should lead even in matters of what must be basic guarantees. Healthcare is surely one of them. A redesigned PPP model is a potential route. The concept of PPP in healthcare must be altered to minimise profit and maximise efficiency.
India is the carrier of aeons-long traditions of "seva" and service. There is no dearth of noble institutions and individuals here that tend to the sick. If the current government does not want to continue turning ailing citizens into "medical tourists"; then it should tap indigenous resources including culturally-specific motivational aspects.
"Make like India" must complement "Make in India". For instance; what stops the state to identify selfless and inspired private entities, provide them with public funds and monitor their performance by a specially raised bureaucracy headed by retired judges of the higher judiciary? This would privatise organisation of healthcare but not the political economy of it.
There are excellent private hospitals that neither profit nor advertise. God forbid but you will have to know them if you cannot afford profit-oriented healthcare and are weary of efficiency (not expertise) in public hospitals. The killer Gorakhpur hospital is not the only example. In short-lived public memory this is merely the most recent. Just a year ago, Dana Majhi in Orissa carried his dead wife on his shoulders for 12 kilometres because he could not pay for a vehicle at the public hospital. Their daughter walked alongside and cried.
But why would private entities consider the PPP model if there is no meat in it for them? The answer is simple. Not all private entities see moolah as meat. Many institutions in India render top-notch and basic healthcare at cost price or lower and even for free. They also provide affordable medical training in a country where there is a shortage of 5,00,000 doctors. Take the cases of Christian Medical College (Vellore), Ramakrishna Mission Seva Pratisthan (Kolkata), Mother Teresa's Missionaries of Charity or Bharat Sevasram Sangha. The state can explore tie-ups with them and limit itself to funding and monitoring. In these institutions there is the will to serve - an ethical pool with a unique history in India. In fact, contributions of business entities such as Tata Memorial Centre (Mumbai) - a pioneer in cancer treatment and Narayana Hrudayalaya must be mentioned as well.
Some may be uncomfortable at the "religious" names of the institutions. They may dwell upon the "whatever works" and "horses for courses" arguments in a sector as important as healthcare. Moreover, it will do well to remind them what Hannah Arendt said about "The Perplexities of the Rights of Man" in a "modern" world: "...in the new secularised and emancipated society, men were no longer sure of these social and human rights which until then had been outside the political order and guaranteed not by government and constitution but by social, spiritual and religious forces."
She asserts, "...the moment human beings lacked their own government [or had a Gorakhpur-like inefficient one] and had to fall back upon their minimum rights, no authority was left to protect them and no institution was willing to guarantee them."
The problem in poor and overpopulated polities like India is that the state is either absent or have unaccountable presence in large parts of the country. Profit-oriented privatisation is inapplicable here because of unaffordability. Selfless service motivated by spiritual ethics is a probable solution.
Religion, unless reduced to faith, is fertile ground for such discourse - a matter exemplified by none other than MK Gandhi. "Seva" and service flourish on ethical grounds; not on grounds that breed the otherwise necessary greed.
However, no amount of "seva" and service in India can make up for the shamelessly low budget allocation to health that successive governments have penned in states and at the Centre. Despite expectations, health expenditure saw only a nominal increase in budgets this year. Finance ministers and their electorates should note that when they decided those paltry figures in the health budget they did not deny the Gorakhpur children toffees like tough parents; they denied them life like filicidal ones.
Besides mobilising political will to fund public health, the state must raise funds via health insurance. For instance, the number of bank account holders in India is on the rise thanks to the Jan-Dhan Yojna. The state could use them and guarantee primary and secondary healthcare in return for mandatory monthly payment of a single digit sum or more by every employed adult in the country. Citizens are unlikely to grudge such duty provided the state extends healthcare as a right.
Finally, have you ever wondered why Good Samaritan doctors who provide affordable healthcare die as idols in school notebooks? It is likely that the money economy kills them. A doctor, the lifesaver, has no material incentive other than money. The state can counter this and make them distinguished in the status economy. Why not housing projects, free ration, "laal battis" and more for doctors?
This way, dedication required to save poor lives will be compensated financially and status-wise. The state must give to them generously who give lives. Equally, the state must take from them ruthlessly when they derelict.
We must push for adequate funding and par excellence human resource as pillars of affordable healthcare. Add to that the enduring ethics of "seva" and service to steer it and a change may unfold. If there is life of some sort after death, the Gorakhpur victims may then consider an iota of forgiveness for you and I.
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