On a chilly November morning, 54-year-old Arsheeda Akhtar lay under a thick blanket at Srinagar’s Khyber Hospital, waiting patiently for her dialysis session to end. She has been under dialysis for the last five years. Her family, most of whom are labourers, have already spent a lot of money on the treatment.

Under the Ayushman Bharat programme, a government health assurance scheme for low income groups, Akhtar was entitled to free dialysis at the hospital. But since March 2020, her Ayushman Bharat golden card stands cancelled due to “fraud”. The family is now struggling to find the money.

“Each session of dialysis costs Rs 3,500, we are spending about Rs 30-32,000 on her treatment every month,” said Akhtar’s son, Suhail, who had accompanied her from their home in Pulwama district. The family of nine sold land to raise funds. “Recently, we again borrowed Rs. 90,000 from a money lender,” said Suhail.

Fifty-three-year old Abdul Ghani, also at the Khyber Hospital for dialysis, had a similar story. He had got an Ayushman Bharat card in 2019, which helped him get dialysis. In March, his card was cancelled.

“My father worked as a driver but cannot work now because of his health issues,” said his daughter, Waqas Ghani. “We are spending Rs 30,000 per month but it is only my brother who is currently working, earning about Rs 7,000 per month.” Her father had a heart attack in March, she said, and they were taking loans just to keep him alive.

Healthcare in Kashmir has received a double blow over the past year and a half. First, after August 5, 2019, when the Centre stripped Jammu and Kashmir of special status and split it into two Union Territories. Healthcare suffered as the Valley saw restrictions on movement and months of communication blockade. Just as internet services were being restored – the Valley still does not have 4G internet – Kashmir was hit by the pandemic and a new lockdown.

The twin crises have choked off access to healthcare – especially for non-Covid patients – in a number of ways. Treatment under the Ayushman Bharat scheme had already run into trouble because of the internet ban post August 5, 2019. More glitches followed in March, when officials undertook a record-cleaning exercise just as the pandemic lockdown was being imposed. Second, with hospitals requisitioned for Covid care, there is limited capacity to tackle non-Covid cases. Third, even when facilities are available, patients are afraid to show up for fear of Covid.

Doctors in the Valley are afraid that patients are missing out on treatment. Many would have delayed going to the hospital, they say, some might even have died waiting for circumstances to go back to normal.

Arsheeda Akhtar waits for her dialysis session at Khyber Hospital to end. Picture credit: Swagata Yadavar

The Ayushman Bharat mystery

Chronic kidney patients in Kashmir who relied on the Ayushman Bharat scheme are among the worst sufferers. According to authorities at the Khyber Hospital, their cards were cancelled because they had been made fraudulently so either the right beneficiaries had not received them or they carried errors.

“We do not understand how they call these cards fraudulent, we got the cards from the khidmat centres in the local eidgah,” said Waqas Ghani. Khidmat centres, or common service centres, were a joint initiative by the Jammu and Kashmir government’s information technology department and the Jammu and Kashmir Bank. They were meant to provide banking or single-window online services to rural areas.

The erstwhile state of Jammu and Kashmir had among the highest number of golden cardholders under the Ayushman Bharat scheme. About 60% of the population owned a card within 90 days of its launch.

State health officials claim the cancellation of the cards was a routine part of anti-fraud drives undertaken during the Covid-19 lockdown. “Earlier, our focus was to ensure every needy person got a card,” said Qurshid Ahmad Khan, the medical officer in charge of the scheme in Jammu and Kashmir. “Later we detected many cases where the wrong beneficiaries were added.”

Khan added that 12 lakh beneficiaries had received the cards in Jammu and Kashmir, almost double of the six lakh beneficiaries eligible for it. According to him, most of the irregularities occurred at the local khidmat centres, where ineligible beneficiaries had managed to get cards. In some cases, he said, the hospitals had wrongly claimed money. Cards issued under the scheme would now be linked to Aadhaar, a 12-digit unique identification number, he said.

Since March, Khan’s team has cancelled about 10,000 cards, many of them held by dialysis patients who were among the first to enroll for the scheme. Khan said that these beneficiaries would be added in the universal health insurance scheme to be launched by the Jammu and Kashmir government soon.

Bursting non-Covid hospitals, empty Covid wards

Meanwhile, the few hospitals reserved for non-Covid patients are struggling to cope. Past lunchtime on a November day, the outpatient department of Srinagar’s Gousia hospital was brimming with people. Physical distancing was out of the question as more than 30 patients, young and old, huddled in the narrow corridor on the second floor of the hospital.

The Gousia Hospital, which was originally a primary healthcare centre, is now the only hospital reserved for non-Covid patients in Srinagar. “This hospital is used to seeing only 300 patients but now we see about 1000 patients on a daily basis – you tell us how we will cope,” said a member of the hospital staff who did not want to be named.

Sixty-five-year old Abdul Hamid, waiting with his wife for an eye appointment, was losing patience. “Please tell them to open the services in Rainawari,” he said. “I have come here since 11:30 am in the morning and it’s been three hours and we do not know when we will get a chance to see the doctor.”

He was referring to the 200-bedded Jawaharlal Nehru Memorial Hospital in Rainawari which usually caters to the entire Srinagar district. It was the first hospital in the city to be designated a Covid care centre.

While the Gousia Hospital struggles to handle the flood of patients, the Jawaharlal Nehru Memorial Hospital is relatively empty on most days. On November 3, for instance, it only had 20 Covid patients. “Now that the covid burden is less, we are hoping to open it for non-Covid patients,” said Bilkis Shah, deputy Medical Superintendent at the hospital.

The crowded outpatient department at Gousia Hospital. Picture credit: Athar Parvaiz

Going public

The city’s biggest hospitals – the Sher-e-Kashmir Institute of Medical Sciences and the Sri Maharaja Hari Singh Hospital – are catering to both Covid and non-Covid patients. The fear of contracting Covid-19 was keeping patients away, said doctors at the hospitals.

The outpatient department at Sher-e-Kashmir-Institute of Medical Sciences had been open throughout the Covid period, said its medical superintendent, Farooq A Jan. However, services were downsized and consulting time reduced from six hours to three. All routine surgeries were postponed. “OPD patients, during the last six months, were reduced by 60%,” he said.

Departments like emergency medicine and oncology remained open during this period, albeit recording much lower numbers.

Jammu and Kashmir received its first confirmed cases of Covid-19 in March 2020. As of December 16, the Union Territory has recorded 1.16 lakh cases and 1,812 deaths. Srinagar and Jammu recorded the highest number of Covid-19 cases. But the Covid burden has eased considerably over the past couple of months – November saw a 21% dip in fresh cases and a 26% fall in deaths compared to October. Daily cases have fallen from over 1,000 in early September to 300-400 in December. Meanwhile, the burden of non-Covid cases is building up.

The structure of the Valley’s healthcare system has made it particularly sensitive to shocks from the Covid outbreak. The best public healthcare facilities were converted to Covid-care centres, yet 99% of people in Jammu and Kashmir rely on treatment in the public healthcare system.

There are few private hospitals in the Union Territory. Srinagar – one of the hotspots for the virus – hosts most of the private hospitals and nursing centres. “Since the 1990s, J&K has been in a state of conflict, not many major private hospital chains wanted to invest here,” said Farooq A Jan, medical superintendent of Sher-e-Kashmir Institute Medical Sciences and professor of hospital administration. But this had one advantage, he added – the best doctors remained in the public sector.

In March 2019, the former state of Jammu and Kashmir had approved a State Healthcare Investment Policy to attract global investment to the tune of Rs 1000-2000 crore for new health infrastructure. This process was stalled due to Covid-19 but has now begun again, said a report in the Kashmir Observer in October 2020.

Where are the tuberculosis patients?

Outside Srinagar, hospitals in smaller towns and rural districts also see a strange mix of activity and emptiness. Take Bandipora district in North Kashmir, where the district hospital has seen a rise in non-Covid cases since August, when the lockdown eased, but half its staff have been put on Covid duty.

The district hospital was meant to shift to new quarters in a five-storeyed building. But the pandemic delayed the move. As of November 10, it was still functioning from the old premises, now earmarked for a sub-district hospital. The old building cannot hold the additional load. Over 10 patients, including the elderly, were crammed together in the first floor waiting area.

A patient who had been waiting for hours demanded, “There is only one orthopedic doctor for the entire district, how are we to get treated?”

Yet other departments and chambers are relatively deserted. In the tuberculosis control department, senior treatment supervisor Munir Ahmad sat making notes. Usually, he has his hands full. But in the last couple of months, the number of new cases detected has dropped significantly. “From detecting 20 new cases a month, we are down to detecting only five,” he said. “Villagers are so scared of being detected with Covid-19 that they refuse to give their samples for TB screening.”

At the back of the main hospital building, there was a long queue of patients, including paramilitary personnel, outside Parvaiz Sajad Shah’s chamber. But these numbers are nothing to Shah, who has been a general physician in Bandipora for over 17 years and is used to checking patients from 10 am to 4 pm, sometimes without even pausing for a meal.

“The number of patients has dropped since the beginning of COVID as the patients are scared to come,” he said. “Every day, we used to detect patients with diabetes, tuberculosis, these have reduced in the last few months. This does not mean the incidence has gone down.”

This may be the lull before the storm and doctors and hospitals should brace themselves, he warned. “As people get used to Covid, there will be a flood of patients in the hospitals,” he predicted.

Reaching hospital

The pandemic added to the problems of a healthcare system that was already stressed. Doctors at the Sher-e-Kashmir Institute for Medical Sciences said their troubles had begun in August 2019, when all communication was snapped and movement was restricted. For months, the hospital used to send an ambulance to fetch doctors or contact the nearest police station to get in touch with doctors in case of emergencies.

“I lost a patient who would have easily lived for another few years had I been there to take care of the complication,” said a senior oncosurgeon at the institute, speaking off the record. “However the senior resident on call could not deal with the post-operative bleeding and the ambulance could not reach me. The patient died within a few days and I still live with the regret.”

The institute had a system of shortlisting the patients who needed surgery and calling them when a slot opened. With no communication possible during those months, they lost contact with many patients. Some are now untraceable as they changed their prepaid numbers to postpaid, which were subject to fewer restrictions.

At Khyber Hospital, too, the flow of patients thinned to a trickle. “First, abrogation with no communication,” explained hospital administrator Shahnawaz Amin. “Then, as the numbers were coming back to normal, Covid-19 hit and now Ayushman Bharat services are hit.”

Cardiologist Jahangir Beig said patients have also been delaying treatment because they cannot afford the treatment due to the fall in incomes post August 5, 2019 – months of lockdown have ravaged the local economy. “By the time many of the patients reach us there are complications,” he said. “There is heart failure along with kidney failure and the patient’s chances of recovery fall.”

This reporting was supported by a grant from the Thakur Family Foundation. Thakur Family Foundation has not exercised any editorial control over the contents of this reportage.

Swagata Yadavar is an independent health journalist based in Delhi and Athar Parvaiz is an independent journalist based in Srinagar.