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Uttar Pradesh’s child death crisis

LiveMint logoLiveMint 29-08-2017 Ramanan Laxminarayan

The recent tragedy of more than 85 children and newborns who died in Gorakhpur has, not for the first time, put the spotlight starkly on the country’s ailing public health system. The lack of all things important to human settlements—sanitation, disease surveillance, primary healthcare, tertiary hospitals, resources, life-saving equipment, political will and public health response—was so dramatic, if someone were to document the state of affairs of a crumbling health system, one couldn’t have described it better.

Yet it is imperative to see the Gorakhpur incident against a larger backdrop of child deaths in Uttar Pradesh. The state’s neonatal mortality rate stands at 49 deaths per 1,000 live births. Each day, 1,043 children under the age of 1 (including 751 newborns) die in Uttar Pradesh, mostly from entirely preventable causes. And Uttar Pradesh is not one single monolith. Infant mortality rates are especially high in the eastern part of the state, where neonatal deaths rates rise to as high as 97 per 1,000 live births in districts like Shravasti. For comparison, the infant mortality rate in Sierra Leone, one of the poorest countries in Africa, is only 89 per 1,000 live births. Gorakhpur is in the middling category of neonatal mortality—certainly not the worst performer in Uttar Pradesh but not the best either.

Gorakhpur’s Baba Raghav Das (BRD) Medical College witnessed more than 85 of these tragic deaths but the larger question remains for the rest, who are dying of various illnesses, including malnutrition, pneumonia and diarrhoea.

We don’t have to look to developed countries for solutions. If the 5.6 million children born in Uttar Pradesh every year had been born in another state with better health systems, like Kerala or Tamil Nadu, for example, 90% of the babies who die in that state in their first year of life would still be alive. While the authorities in Gorakhpur are still trying to investigate and solve the more immediate problems of oxygen cylinder supply, it is time we acknowledge and address the backlog of long-standing health indicators, without which we would only be treating the symptoms rather than addressing the root cause.

In Gorakhpur, the issue has been perennial, with some reports claiming more than 25,000 encephalitis deaths among children in the last 40 years. Despite that, one is left wondering how a system could be caught so off-guard in an endemic region that faces the same issues year after year.

To begin with, a lack of preventive measures is at the heart of the problem. Consider this: The available vaccine for Japanese Encephalitis (JE) helps only a small percentage of children who are affected by the disease. Yet, not enough measures are being taken to address the larger problems of lack of clean drinking water and poor sanitation.

Other measures that could have given these children a standing chance to fight disease, disability and death are also at a disappointing low, with only one in two children fully immunized in the state.

The failure of primary healthcare is yet another glaring gap: A little more than 3,600 primary health centres (PHCs) serve more than 97,000 villages. And the existing PHCs are not adequately staffed. Uttar Pradesh has among the lowest health worker densities among states.

Poor disease prevention and weak infrastructure at the primary level continually lead to the overburdening of tertiary care hospitals. Tertiary hospitals like Gorakhpur’s BRD Medical College, despite having a special ward for encephalitis, crumble under patient load as the outbreak peaks each year. Well-equipped intensive care units (ICUs) with enough beds, doctors, staff, medicines and other critical resources are a fact of life in most countries at India’s level of prosperity. One cannot expect healthcare systems to work without these. The number of patients that pour in each year also have to be taken into account—shared ICU beds should not be considered normal or even tolerable.

If we are to save our children, these recurrent issues must be addressed. This would require scaling up health spending. Uttar Pradesh is India’s most populous state with a population of 200 million, yet it spends only Rs452 per capita on health, 70% less than the national average. If we don’t act now, next year, the doctors working round the clock in Gorakhpur will be able to do little to stop this from recurring.

We also need to build in accountability in our public health systems—not just hospitals but, starting, in fact, with government-funding mechanisms. Departments that are responsible for sanitation, clean drinking water, last-mile connectivity to our villages, safe working conditions in remote areas, awareness programmes, all fall under the purview of public health and need to be brought into the accountability framework for delivering healthcare.

Healthcare management is not just a doctor’s responsibility in most countries—it is time we handed over the system to a trained cadre of professionals who understand finance, logistics, procurement and supply chains.

And we need to make more noise for the sake of the 350,000 infants who will die in Uttar Pradesh this year but will remain statistics buried in government reports rather than 350,000 tragedies deeply etched in our minds.

This article is the second in a series on public health in India.

Ramanan Laxminarayan is director of the Center for Disease Dynamics, Economics & Policy, and senior research scholar at Princeton University.

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