As India celebrated 70 years of independence last week, a tragedy in a remote corner of India’s largest state, Uttar Pradesh, highlighted how far the world’s largest democracy still is from being able to provide a healthy life for most of its citizens. For all its talk of smart cities and industrial corridors, this is the government’s greatest failing — and one where it could make a big difference quickly. The town of Gorakhpur dominates the far northeast of Uttar Pradesh. UP is a vast province, home to more than 200 million residents -– including some of the poorest people in the world, living in conditions that Prime Minister Narendra Modi has compared to parts of sub-Saharan Africa. Gorakhpur lies close to the Nepal border, in a muggy, densely populated strip of land famous as much for the size and stamina of its mosquitoes as anything else. It is not a small town, but it’s rarely the center of attention in India.
It is now, for a tragic set of reasons. Earlier this month, over 60 very young children died in the local government-run hospital in just five days, dozens of them on one particular night. That itself might sadly not have been sufficient to attract national attention. But on this occasion, many of the deaths had reportedly occurred because oxygen supplies had run out. The hospital hadn’t paid its bills — and the contractor had cut off the supply.
The case has drawn particular attention because Gorakhpur is the home of the new chief minister of Uttar Pradesh, a pugnacious monk-turned politician named Yogi Adityanath. He represented the town in India’s parliament for decades — running it like a personal fiefdom — and he’d actually visited the hospital on one of the days in question, unaware of the unfolding crisis.
Adityanath’s response has left much to be desired. He seemed to accept denials by state bureaucrats that they’d sat on the authorization to pay the oxygen supplier; instead, the hospital’s head was held accountable. More surprisingly, so was a doctor who’d been the hero of the initial reports because he had wandered the town commandeering extra oxygen cylinders when the piped supply had run out. (This attracted particular attention because the doctor happened to be Muslim, and Adityanath does not have a reputation for religious tolerance.) And, finally, the small company that had been granted the oxygen contract — which had not been paid an outstanding bill of millions of rupees for months — found itself the subject of a police investigation.
This seems a near-perfect example of all that is wrong with India’s public health care system and with state administrations in general. Local strongmen prioritize control and capturing rents over governance and welfare. Bureaucrats run the offices of the state callously and with an eye to self-preservation. And any companies or professionals who step out of line are made scapegoats if anything goes wrong.
Nor is this an isolated tragedy. As Adityanath himself pointed out, ostensibly in his defense, children in his home city have long fallen victim to a mysterious disease known as Japanese encephalitis, which — spread by those terrifying mosquitoes — carries off hundreds in northeastern Uttar Pradesh every year. Yet there is little indication that local health services have received the investment needed to deal with the epidemic.
For India’s federal government in New Delhi, this tragedy comes at a particularly awkward time. Its election manifesto promised healthcare for all. But it seems to think that its finances are too straitened for the kind of expansion of public healthcare that Indians expect. Currently, India spends barely one percent of GDP on public healthcare — one of the lowest proportions in the world.
The government has promised to increase that amount. But a recently leaked draft healthcare bill for India’s towns revealed the government was planning to further privatize the system. As with other such systems worldwide, this will be difficult to manage and costs might explode. Worse, the Indian state simply doesn’t have the capacity to monitor or regulate private hospitals properly. In health, regulation doesn’t come cheap.
Instead, the government should recognize that root-and-branch reform of public healthcare is necessary. It will have to happen nationwide and it will have to happen quickly. As elsewhere, the final structure of Indian healthcare will need to include some kind of pooled payment and an overall managing agency. This is far from impossible, even for a developing country; the government should study the lessons of Thailand’s rollout, in the early part of this century, of universal healthcare. Thailand spends 4.4 percent of its GDP on health, compared to 4.1 percent in India (when private spending is included) and has far better outcomes. As economist Amartya Sen has pointed out, no country can become rich — or even middle-class — with an unhealthy workforce. And every year reform is postponed risks more tragedies like Gorakhpur.