New Delhi: An overstretched health facility, weak multi-level management and referral system, under-performance of official health insurance schemes, and a seasonal rise in patients. These have been identified as key reasons behind the deaths at Dr Shankarrao Chavan Government Medical College (DSCGMC) in Maharashtra’s Nanded in late September.
Less than a month after 24 patients died at the hospital in 24 hours between 30 September and 1 October, a six-member fact-finding team from Jan Swasthya Abhiyan (JSA) — the Indian chapter of the global health network People’s Health Movement — flagged these issues in a detailed report.
ThePrint has a copy of the report, which is likely to be sent to the government in a few days, Dr. Abhay Shukla, national co-convener of JSA who provided technical input for the report, said.
According to JSA, of the 24 deaths, 11 were of neonates (1-4 days old babies) with diagnoses of respiratory distress syndrome, pre-term, birth asphyxia, or septicemia. Nine were senior citizens over 65 years old. Seventeen of those who died were referred to GMC by other hospitals.
Besides these, seven more deaths were reported on 3 October, according to media reports.
“The recent excessive deaths appear to be only the tip of the iceberg, which reflects a much deeper multidimensional health system crisis, extending far beyond the medical college (and) hospital,” JSA said in its 10-page report.
According to it, a large number of sick neonates not only from Nanded but also from other districts are referred to the hospital as the “court of last resort”, putting a strain on the hospital’s capacity and resources.
But DSCGMC isn’t the only hospital that was flagged — according to the report, the fault lies with the specialised healthcare in the public health system not only in Nanded but across the state.
“The excess deaths in Nanded are not an isolated phenomenon, rather they are more visible and extreme manifestations of a deepening, state-wide public health system crisis, reflecting a heavily over-stretched and under-resourced system which is now moving close to breaking point,” the report said.
Dr. Abhay Shukla said that the network decided to investigate deaths as media reports on the issue were “largely superficial”.
“Often, what is cooked in the kitchen is not decided in the kitchen,” he said. “If there are a large number of deaths happening in a medical college, it does not mean that there is a problem only with that one medical college but points out a larger systemic issue that needs to be seen in the right context.”
ThePrint reached Maharashtra’s Principal Secretary (Health) Milind Mhaiskar and GMC’s medical superintendent Dr Ganesh S. Manoorkar for comment via calls and text messages. This report will be updated if and when their responses are received.
‘2-3 babies in one bed’
The six-member team from JSA visited not only the DSCGMC but also a number of other government-run community healthcare centers and hospitals in the district. According to its report, DSCGMC has 500 beds but deals with over 1,100 in-patients, including neonates and sick infants.
It also has 20 Neonatal Intensive Care Unit (NICU) beds as against the sanctioned strength of five.
“However, we were informed that actual admissions in the NICU are often 60 to 70 neonates. We observed that two to three babies were being treated on the same cradle, this is reported to be a common situation,” said the report.
It found the hospital’s paediatric intensive care unit lacking, with only 20 beds against the actual admission capacity of 35. This is against “a total of 613 admissions reported in last month, which means that there were often 2-3 times more children than available beds”, the report noted.
According to the report, its higher in-patient admission also results in a skewed patient-nurse ratio — there are currently only 2-3 nurses every shift in the NICU as against the 1:2 per shift ratio mandated in both the Indian Public Health Standards and the National Board for Accreditation of Hospitals and Healthcare Providers.
“Hence, for an NICU, even with 20 beds at least 10 nurses would be required in each shift, meaning at least 4-5 higher number of nurses are required in the NICU compared to the present number,” said the report.
The situation, according to the team, is even more dire in Nanded’s 12 rural hospitals where there are only seven paediatricians. This means that nearly half of the rural hospitals have no paediatricians, which means no specialised care is provided for sick newborns, the report said, adding that such lack of resources was the reason for Nanded’s 19 public hospitals — including one civil hospital and 12 rural hospitals — to refer sick newborns to DSCGMC and stretching it to capacity.
‘Inadequacy’ of Ayushman Bharat-PM Jan Arogya Yojana
The report also points out inadequacies in government schemes such as the Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (PMJAY). Significantly, Ayushman Bharat PMJAY — a central scheme that promises cashless hospitalisation of up to Rs 5 lakh for beneficiaries — also encompasses the Mahatma Jyotirao Phule Jan Arogya Yojana (MJPJAY), Maharashtra’s state-level health insurance scheme.
According to the report, while these schemes are aimed at closing gaps in the public healthcare system, they “appear to be complete failures”, at least in the case of Nanded.
Despite the fact that Nanded city has at least 21 private hospitals providing market-based care on payment of fees, only two private hospitals in the district are enrolled under PMJAY (including MJPJAY) for providing neonatal care, the report said.
“This is yet another evidence that health schemes cannot be a substitute for health systems,” the report notes. “Over-reliance on such schemes which have patchy performance at best, can draw away precious resources and political attention from the public health system, which continues to provide much-needed services to the most vulnerable and deprived sections of the population, despite so many imposed constraints.”
As a medical college, the primary role of DSCGMC Nanded is teaching while the hospital is an associated role. However, according to the report, certain faculty members expressed the concern that due to massive gaps in secondary and tertiary care in Nanded and some nearby districts, there is a disproportionate flow of patients at the hospital.
“This overwhelms the capacity of the medical college hospital (expected to have only 500 beds and related staff as per NMC norms, but dealing with over 1100 indoor patients),” the report said. “At the same time, regarding the clinical departments, the preoccupation of their residents with providing clinical care leaves minimal space for clinical teaching activities, which affects the basic functioning of the medical college.”
Short-term factors
The JSA team also found that there had been an overall rise in the number of patients in the hospital between August and September due to seasonal illnesses such as dengue and upper respiratory infections.
According to the report, the average number of monthly admitted patients at the hospital from January to July 2023 was 5,963. This was against the in-patient admission of 7,475 in August and 7,192 in September — a 23 percent increase compared to the first seven months, according to the report.
Similarly, the average death a day in GMC Nanded had gone up to 12 in August and 13 in September from 8-10 deaths between January and July 2023. “This rising trend of in-patient admissions and deaths reflects the further overstretching of the already strained treatment capacity of this referral hospital,” it said.
Recommendations
Based on the findings, the fact-finding team has suggested an independent public audit of the September deaths with “broad-based social participation” of the civil society.
The report also highlights the state of the healthcare system in Maharashtra — it quotes a Reserve Bank of India report for 2022-23 on state finances to highlight how Maharashtra is placed at the bottom of a list of 28 Indian states when it comes to the percentage of their budgets spent on public health and medical education.
The team has suggested that there is an urgent need to double the state’s public health and medical education budget from the current Rs. 1,800/ year to around Rs 4,000.
Also, “a Tamil Nadu–type autonomous, transparent, and technically empowered medicine procurement and distribution system” should be adopted to ensure an uninterrupted, adequate supply of all essential medicines to public health facilities, it said.
(Edited by Uttara Ramaswamy)
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