A recent dengue outbreak in Delhi has once again revealed the shortcomings of the massively underfunded Indian public health system, alongside the unacceptable and illegal exclusion of poor patients by the city’s private hospitals. This blog steals the excellent analysis by my colleague Oommen Kurian from Oxfam India, recently published in the British Medical Journal, as well as the post-dengue prognosis of well known commentators, Reddy and Murphy.
Oommen Kurian’s BMJ blog outlined how the current dengue outbreak in Delhi came to international prominence following the unfortunate incident of a young couple who committed suicide after their son was rejected treatment by many prominent private sector hospitals in Delhi. Treatment was denied despite the government saying on 28 August that patients should not be denied admission to hospital on account of a lack of beds. Responding to such cases, the Government of Delhi has issued show-cause notices to five private hospitals asking them to explain why they refused to admit the boy and why their registration should not be cancelled.
Kurian’s blog focussed primarily on two major problems: the shamefully inaccurate ‘official’ data on incidence and deaths from dengue fever, and inappropriate profiteering by Delhi’s private health sector during the Dengue outbreak. Reddy and Murthy, two prominent commentators, also argue in their post-dengue prognosis that once the media hype and finger pointing of the current dengue fever crisis passes, citizens of India are left with the same long-term problem of a chronically underfunded public health system that causes unreported tragedy on a daily basis.
Kurian’s quick comparison of different sources of data on deaths from dengue fever show that only 29 of the 1221 deaths from dengue registered in Delhi between 2010 and 2014 entered the official system (see graph below). Official estimates of the annual incidence of dengue fever nationwide are a staggering 282 times lower than the actual number.
Dengue fever affects most of the metropolitan cities and towns in India, where the healthcare delivery systems are better than the rural areas. However, the preparedness of the system against it may be impacted by the level of massive under-reporting of cases and deaths.
Profiteering or serving?
Delhi has a large number of private hospitals, which have received free land and other subsidies from the government to provide a set percentage of their services free to poor patients. Over time, these charitable hospitals have become purely commercial entities, dishonouring the commitments made to the government.
A high level committee assigned by the Government of Delhi, headed by Justice AS Qureshi, took a bleak view of the nature of such hospitals which claim to be charitable just to lap up subsidies and have become “selfish, greedy, and exploitative” moneymaking machines. Data from 2014 show that the average total medical expenditure for treatment per case of hospitalisation is higher in Delhi than any other state in India, at Rs 34,658. The India average is Rs 18,268.
Profiteering in times of distress is nothing new to Delhi’s private health sector: even those which claim to be private “charitable” hospitals are notorious. For these very reasons, midway through the dengue outbreak, the Union Health Ministry decided to ask the Delhi government to take action against any overcharging by the private hospitals. On 16 September, Delhi’s Directorate of Health Services issued an order against private hospitals and laboratories overcharging, and implemented ceiling prices for dengue testing. Another advisory on the same day allowed the private hospitals and nursing homes to increase their bed strength by up to 20 per cent on a temporary basis for two months.
As of 21 September this year, the press has reported that while the death toll has “risen” to 22 this season, the deputy chief minister announced that the health situation is now better and the government is winning the battle against dengue. Activists do not take these numbers seriously. Advocate Ashok Agarwal, a member of a Delhi high court-appointed panel to oversee the implementation of the EWS scheme (beds reserved for patients from “economically weaker sections”) in private hospitals announced on social media that the Delhi Government’s dengue death figures are incorrect and that 23 dengue deaths have happened in one hospital alone. The director of another hospital in Delhi is on record saying that at least seven dengue deaths had taken place in his hospital alone, as of 17 September.
A look at civil registration data reveals that dengue strikes Delhi at regular intervals. With more money already put into health, the current Delhi government—only in its first year of rule—may be better placed to fight any dengue outbreak in the future. However, any effort towards containing contagion should begin with having correct numbers—of cases and deaths—and a long term plan to align the private sector in the state with the broader public health goals of society.
Once the current media hype has passed….
In their post-dengue prognosis Reddy and Murphy write that there is ‘justified outrage at the tragic deaths of children from dengue under deplorable conditions of apathy and neglect in the capital of India. But say the underlying causes of the crisis, namely chronic and long-term underfunding, poor co-ordination and planning, remain unaddressed and the daily tragedies facing citizens in the rest of the country, especially in rural areas, go unreported. They give the heartrending example of a tribal in Odisha who allegedly felt forced to sell his two-month-old son for Rs 700 to buy medicines for his sick wife. Reddy and Murphy conclude that:
Public health systems cannot function as a motley crowd of disconnected actors ad libbing their way through an unscripted play in chaotic fashion. The different actors involved require a script, coordination, direction, and need to work as a team. It is time India got its act together to create strong, well-resourced, responsive and responsible health systems. Or else, terrible things will continue to happen to innocent children, expectant mothers, poor tribals, disabled persons — and to your family and ours. We will all be responsible when such terrible wrongs happen.
Oommen C. Kurian is research coordinator, Oxfam India.
K Srinath Reddy is president and N R Narayana Murthy is chairman of Public Health Foundation of India