Since the attack on resident doctor Rohan Mhamunkar in Dhule on March 12, there has been a spate of attacks on frontline doctors working in public hospitals across the state of Maharashtra. The government has treated this purely as a law and order problem and even doctors associations have focussed mostly on providing security to doctors, some even floating extreme demands such as asking that doctors be permitted to bear firearms. What has not been highlighted sufficiently in the public debate so far, is the correlation between understaffed and inadequately resourced public hospitals, and the growing discontent among patients seeking care in these hospitals.

Maharashtra is considered a developed state with among the highest per capita income in the country. The state has a large Gross State Domestic Product per person of Rs 1,48,000. In this context its neglect of public health services in last few decades is surprising.

Maharashtra has among the lowest expenditures per capita on public health, spending just just Rs. 776 per person in 2016-’17 – an amount lower than the expenditure of smaller administrations like Delhi and of less-developed states like Chhattisgarh, Rajasthan, Odisha, Uttar Pradesh and Bihar.

Until the 1980s, public health services in Maharashtra were considered better than many other states, but subsequently public health spending has stagnated in comparison to economic development. The state’s expenditure on public health as a proportion of the Gross State Domestic Product has been halved from an already poor one percent in 1985-’86 to 0.49% for 2017-’18. With major advances in medical technology, a rise in non-communicable and chronic diseases, and rising expectations of the population, these levels of public resources are now grossly inadequate.

Chronically low levels of public health resources and a virtual freeze on regular appointments of medical staff have debilitated the system. Massive, unregulated expansion of private hospitals has further pulled specialists away from public medical service. Currently 60% of posts for surgeons, gynaecologists, paediatricians and other specialists in rural hospitals across the state are vacant. There are practically no specialists in district hospitals such as those of Akola, Nanded and Parbhani. It is unsurprising then, that the trigger for the assault in Dhule was the non-availability of a neurosurgeon to treat a patient with a head injury.

Given this backdrop, it is worrying that the state government has cut Maharashtra’s health budget further for the coming year by Rs 559 crore. Accounting for inflation and population increase, this is a cut of about 10% in real terms.

(2016-'17: Revised estimates)
(2016-'17: Revised estimates)

Moreover, large proportions of these inadequate health budgets remain unspent every year due to delays in sanctioning fund releases at various levels, procedural bottlenecks, and with centre-state financial dynamics.

For example, at the end of the financial year on March 31, only 74% of Maharashtra’s public health budget has been spent. This serious constriction of release of funds amounts to a second, undeclared massive budget cut.

Inadequate staffing and poor resources lead to situations where junior doctors are often overworked. Long working hours and multiple responsibilities limit their ability to spend adequate time with patients. Sometimes there is only one doctor handling more than a hundred patients in an out-patient department. When patients are faced with overworked doctors and inadequate facilities, sometimes violence erupts and these frontline doctors, the most visible face of the system, are made targets.

Large public hospitals that deal with hundreds of patients, many from rural areas and with limited education, have hardly any patient-friendly guidance and grievance redressal systems. This lack of information and dialogue mechanisms adds to the gap between users and the system.

Hospitals need a patient help desk and an accessible, effective grievance redressal cell that might be run a local NGO or citizens’ group.

The Universal Health Coverage system in Thailand has mechanisms such as Independent Complaint Centres run by NGOs to process complaints by patients, and a fund offering “No fault compensation’ to patients who have suffered negative consequences during treatment. These might be adapted to India.

On March 22, the civil society coalition Jan Swasthya Abhiyan in Maharashtra organised a unique public dialogue in Mumbai involving representatives of the health movement, the Mumbai citizen-doctor forum and the nurses union. An organiser of the state’s resident doctors association and the Indian Medical Association’s youth wing also participated. While the need to protect doctors was acknowledged, a strong consensus also emerged on the need to overhaul the system with substantial increases in health budget and better staffing to ensure essential services in public hospitals. The problem can no longer be framed as a doctor against patient conflict, but as a failure of the system. The movement has, therefore, adopted the call “Don’t target the doctors, target the system”.

The writer is a public health physician and health activist associated with Jan Swasthya Abhiyan and Alliance of Doctors for Ethical Healthcare. Ravi Duggal and Richa Chintan helped with budget-related information for this article.