The features common to this pattern: One, newborns formed the majority of those who died. Second, a culprit was found and publicly denounced. In Gorakhpur, it was Dr Kafeel Khan, a paediatrician; in Nanded, Dr Wakode, the dean of the hospital, was publicly humiliated and then booked for homicide. In Gorakhpur, a company was blamed for the failure of oxygen supply. In Nanded, the lack of supply of medicines is blamed. Even the scapegoats are predictable.

But the real cause — overcrowding — is yet to be addressed.

In Gorakhpur, very sick neonates admitted to the NICU were three times the number of available beds. Recently, three maternal deaths occurred in a week in the district-level women and children’s hospital in Gadchiroli. The reason? 300 women were admitted for delivery when the hospital had a capacity of 100 beds. Overcrowding causes a breakdown in hygiene, exhausts supplies, and leaves the doctors and nurses stretched to capacity. As a result, the quality of healthcare suffers.

Monetary issues

The red tape, corruption, political apathy, poor governance and vacancies worsen the situation. Maharashtra has nearly 18,000 unfilled posts in the health department, including 32 out of the 42 positions of directors, 1,600 positions of doctors and 14,000 class three and four positions. Healthcare is not produced by machines. Human resources is the most crucial ingredient. The state government recently decided to create 2,800 temporary positions on an urgent basis. Too little, too late.

There are three national policy decisions that can also be identified as central to these tragedies.

One, the number of patients seeking healthcare at government health centres and hospitals has increased. The financial allocation, however, hasn’t increased in tandem. For nearly three decades, the government health expenditure — Centre and states together — has stayed at around 1% to 1.4% of the national GDP. The Congress-led United Progressive Alliance (UPA) as well the Bharatiya Janata Party (BJP)-led National Democratic Alliance (NDA) governments made policy pronouncements of allocating money equal to 2.5% of the national GDP to the health sector. But that never happened. It remained 1.3% in 2015-16 and 1.4% from 2016-17 to 2019-20.

In the latest two national budgets (2022-23 and 23-24) the honourable finance minister played a clever trick by including the earlier ‘non-health’ allocations (water supply and nutrition) under health, inflating it to 2.1% of GDP. But the actual budget of the ministry of health has changed little — from ₹84,500 crore in 2021-22 to ₹89,200 crore in 2023-24.

Even at the claimed 2.1% of GDP, India would be at the lower end of the international ranking. The majority of the governments in developed countries spend 8 to 10% of their GDP on health—the financial gap between the need and the allocation results in breakdowns like Nanded and Gorakhpur.

Dependence on hospitals

The second policy decision, named the Janani Suraksha Yojana (JSY), was to incentivise women to deliver in healthcare institutions. Mothers and ASHA workers were paid money for that. Consequently, the proportion of institutional deliveries nationally increased from 40% to over 90%. Out of these, nearly 70% of the deliveries in rural areas occur in government hospitals. This has resulted in nearly 15 million additional deliveries each year in health facilities. Have we increased our institutional and human resource capacity? Only the gap has increased.

The third reason is the bad implementation of a good policy.

In 2011, the then Planning Commission and the health ministry decided to provide Home Based Newborn Care (HBNC) through ASHAs. This was due to the impossibility of providing facility-based care to 26 million neonates born annually in the country. Moreover, the scientific field trials (1995-98, 2002-05) conducted by our NGO in Gadchiroli, Society for Education, Action and Research in Community Health (SEARCH) and subsequently by the Indian Council of Medical Research (ICMR) (2006-2010), had proven that HBNC was eminently feasible, acceptable to people, effective in rapidly reducing infant mortality rate (from 72 to 30) and was most cost-effective (US$ 5 per life-year saved). Only 5% of newborns ended up needing hospitalisation. Nine lakh ASHAs were trained and equipped. They now make home visits to 1.42 crore newborns each year.

However, the strong hospital bias in the medical system and in the JSY policy resulted in ASHAs, Auxiliary Nurses and Midwives (ANMs), and Primary and Community Healthcare Centres referring most of the mothers and newborns to district hospitals and medical colleges. It is well-accepted that only 15% of deliveries need active medical intervention. Instead, the JSY has resulted in 90% of deliveries occurring in healthcare institutions. Neonatal ICUs (NICUs) were crowded to three times their capacity. In this situation, Nanded and Gorakhpur, Thane and Kota are bound to be repeated.

So, what is the way forward? Double the real healthcare allocation and human resources, strengthen and empower the peripheral institutions and delegate more roles to frontline workers, ASHAs and ANMs. That is the only way India can provide healthcare to 1.4 billion people living in its nearly million villages, hamlets and towns.

Padma Shri Dr Abhay Bang is a physician and public health researcher, and founded SEARCH with his wife, Dr Rani Bang. He was chairman of the Expert Committee on Tribal Health, Government of India