Under Pressure

In numbers: Maharashtra’s under-funded health services keep its junior doctors in the line of fire

Violence against doctors is not about doctor-patient conflict as much as it is about lack of funds and personnel to attend to the sick.

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.

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Removing the layers of complexity that weigh down mental health in rural India

Patients in rural areas of the country face several obstacles to get to treatment.

Two individuals, with sombre faces, are immersed in conversation in a sunlit classroom. This image is the theme across WHO’s 2017 campaign ‘Depression: let’s talk’ that aims to encourage people suffering from depression or anxiety to seek help and get assistance. The fact that depression is the theme of World Health Day 2017 indicates the growing global awareness of mental health. This intensification of the discourse on mental health unfortunately coincides with the global rise in mental illness. According to the latest estimates from WHO, more than 300 million people across the globe are suffering from depression, an increase of 18% between 2005 and 2015.

In India, the National Mental Health Survey of India, 2015-16, conducted by the National Institute of Mental Health and Neurosciences (NIMHANS) revealed the prevalence of mental disorders in 13.7% of the surveyed population. The survey also highlighted that common mental disorders including depression, anxiety disorders and substance use disorders affect nearly 10% of the population, with 1 in 20 people in India suffering from depression. Perhaps the most crucial finding from this survey is the disclosure of a huge treatment gap that remains very high in our country and even worse in rural areas.

According to the National Mental Health Programme, basic psychiatric care is mandated to be provided in every primary health centre – the state run rural healthcare clinics that are the most basic units of India’s public health system. The government provides basic training for all primary health centre doctors, and pays for psychiatric medication to be stocked and available to patients. Despite this mandate, the implementation of mental health services in rural parts of the country continues to be riddled with difficulties:

Attitudinal barriers

In some rural parts of the country, a heavy social stigma exists against mental illness – this has been documented in many studies including the NIMHANS study mentioned earlier. Mental illness is considered to be the “possession of an evil spirit in an individual”. To rid the individual of this evil spirit, patients or family members rely on traditional healers or religious practitioners. Lack of awareness on mental disorders has led to further strengthening of this stigma. Most families refuse to acknowledge the presence of a mental disorder to save themselves from the discrimination in the community.

Lack of healthcare services

The average national deficit of trained psychiatrists in India is estimated to be 77% (0.2 psychiatrists per 1,00,000 population) – this shows the scale of the problem across rural and urban India. The absence of mental healthcare infrastructure compounds the public health problem as many individuals living with mental disorders remain untreated.

Economic burden

The scarcity of healthcare services also means that poor families have to travel great distances to get good mental healthcare. They are often unable to afford the cost of transportation to medical centres that provide treatment.

After focussed efforts towards awareness building on mental health in India, The Live Love Laugh Foundation (TLLLF), founded by Deepika Padukone, is steering its cause towards understanding mental health of rural India. TLLLF has joined forces with The Association of People with Disability (APD), a non-governmental organisation working in the field of disability for the last 57 years to work towards ensuring quality treatment for the rural population living with mental disorders.

APD’s intervention strategy starts with surveys to identify individuals suffering from mental illnesses. The identified individuals and families are then directed to the local Primary Healthcare Centres. In the background, APD capacity building programs work simultaneously to create awareness about mental illnesses amongst community workers (ASHA workers, Village Rehabilitation Workers and General Physicians) in the area. The whole complex process involves creating the social acceptance of mental health conditions and motivating them to approach healthcare specialists.

Participants of the program.
Participants of the program.

When mental health patients are finally free of social barriers and seeking help, APD also mobilises its network to make treatments accessible and affordable. The organisation coordinates psychiatrists’ visits to camps and local healthcare centres and ensures that the necessary medicines are well stocked and free medicines are available to the patients.

We spent a lot of money for treatment and travel. We visited Shivamogha Manasa and Dharwad Hospital for getting treatment. We were not able to continue the treatment for long as we are poor. We suffered economic burden because of the long- distance travel required for the treatment. Now we are getting quality psychiatric service near our village. We are getting free medication in taluk and Primary Healthcare Centres resulting in less economic stress.

— A parent's experience at an APD treatment camp.

In the two years TLLLF has partnered with APD, 892 and individuals with mental health concerns have been treated in the districts of Kolar, Davangere, Chikkaballapur and Bijapur in Karnataka. Over 4620 students participated in awareness building sessions. TLLLF and APD have also secured the participation of 810 community health workers including ASHA workers in the mental health awareness projects - a crucial victory as these workers play an important role in spreading awareness about health. Post treatment, 155 patients have resumed their previous occupations.

To mark World Mental Health Day, 2017, a team from TLLLF lead by Deepika Padukone visited program participants in the Davengere district.

Sessions on World Mental Health Day, 2017.
Sessions on World Mental Health Day, 2017.

In the face of a mental health crisis, it is essential to overcome the treatment gap present across the country, rural and urban. While awareness campaigns attempt to destigmatise mental disorders, policymakers need to make treatment accessible and cost effective. Until then, organisations like TLLLF and APD are doing what they can to create an environment that acknowledges and supports people who live with mental disorders. To know more, see here.

This article was produced by the Scroll marketing team on behalf of The Live Love Laugh Foundation and not by the Scroll editorial team.