India Together: Testing healthcare reforms in U.P. – 01 December 2003

01 December 2003 –

October is usually a month of festivals, and a major holiday season. First there is
Dussera and then Diwali and Bhaiya Duj. This year the festivities were spoiled by the
resurgence of an old disease everyone – at least in Lucknow – had forgotten. Dengue,
(pronounced den-ge) achieved notoriety a few years ago in Delhi when stagnant
water in
air-coolers was thought to be the main reason for the sudden breeding of the tiger
mosquito. To me, a person who had not had the misfortune of being in Delhi during that
time, dengue was a comparatively unknown phenomenon. I remembered it as one of those
short questions in the final MBBS examinations when we memorized a mnemonic for
diagnosing different kinds of fevers which were accompanied by rashes. My few years in
medical college and in the paediatrics department in a Kolkata hospital did not acquaint
me with the disease either. In Lucknow, in twenty first century India, I found myself
face to face with the disease.

First there were the many newspaper reports, which like most newspaper
reports (be they of riots or wars) I initially treated with a distant cynicism. From the
newspapers it would appear that dengue is something like the plague and anyone who gets
it is sure to perish. Political parties organized demonstrations as many controversies
surfaced. Even the state high court had stepped in with advice for the health
department. All this would have been hilarious, when suddenly my daughter first got high
fever and then the characteristic rash appeared all over her abdomen. Luckily most of
the 50 million or so dengue cases every year recover, and so did my daughter. But when
all the din was over, more than 200 persons in Lucknow alone had lost their lives.

The health care systems in Uttar Pradesh are currently undergoing
reforms through a US $110 million loan from the World Bank towards the implementation of
the Uttar Pradesh Health Systems Development Project. One of the two objectives of this
project is to improve the performance of the health system through improvements in the
quality and effectiveness of health services at the primary and referral levels, and
increase access to health services in selected areas that have the greatest needs. The
project aims to increase the access to health care by 2 million persons each year. The 5
year project was approved in April 2000. The project closes on December 31, 2005.
Against this background, the outbreak of dengue – an old infectious disease making a
comeback – provided an opportune moment to study the effectiveness of the health care
system.

As mentioned earlier dengue is spread by a mosquito, which interestingly
bites during the day. Most cases of dengue remain limited to being a viral fever with
severe body ache, pain behind the eye, and rashes. In a few cases there is internal
bleeding; this is known as dengue hemorrhagic fever. The platelet count (a component of
blood which assists in coagulation) gets severely depleted, and the only treatment is to
provide platelet infusion. In very few cases of dengue hemorrhagic fever death may
occur.

What one heard, read and saw in Lucknow did little to raise the confidence of average
citizen in the health system. While the health department brought out newspaper inserts
and large public hoardings listing the preventive measures to take – wear full-sleeved
clothes, avoid the pooling of water, etc. – there was little effort to explain to the
public that not all dengue was necessarily dengue hemorrhagic fever. The newspapers were
full of the conflict between the doctors of the cities’ two premier medical institutions
– the King George Medical University (KGMU) and the Sanjay Gandhi Post Graduate
Institute (SGPGI). The KGMU did not possess the required equipment to make platelet
infusions, while the SGPGI felt that its services were required for more serious
illnesses.

Primary Health Centres, Community Health Centres and District Hospitals from
neighbouring areas referred cases to Lucknow at the slightest suspicion. Some doctors
prescribed expensive tests which could confirm diagnosis but were of no value where
treatment is concerned. We sent two suspected cases to the city civil hospital and the
doctors here referred them to a private laboratory to determine the blood platelet
count.

All this while the newspapers carried reports of people dying of the
disease in different places. We also learned that the fogging machines (for spraying
insecticides) belonging to the municipality were not working and a political party tried
to get some quick popularity by conducting fogging operations. The high court stepped in
and ordered the city authorities to start spraying insecticide. In the middle of this
chaos we learned that a machine for platelet separation had arrived at the KGMU, but it
would not work for the next month or two because that much time would be required to get
a certificate from the Central drug authorities. Predictably, the epidemic ended before
the certificate was received.

These events bring into sharp focus the inefficiency of the health
system of the state. It is especially galling to note that this inefficiency is despite
the fact that the state has taken a huge loan to improve the health system, – and
especially the curative system – both at the primary and referral levels. Responding to
dengue required coordination between the curative and the preventive systems, between
the private and the public health care systems, and last but not the least between the
primary and the secondary/tertiary care systems. The experiences in Lucknow proved that
none of these linkages are working.

Also, they raise some very pertinent questions about the way health care reforms are
ongoing throughout the country. In this era of increasing privatization what is the
clear role of the government system? The private sector will surely not take up the
responsibility for dealing with epidemics. As the focus in health care is increasingly
moving towards curative medical care, who will remain responsible for public health?
And even if managers of the Uttar Pradesh Health Systems Development Project have
learned an important lesson, are they accountable for their failures?

A new festival season has arrived with Eid, and temperatures have dropped sharply across
the northern plains. The mosquitos have slowly gone away, and the spectre of dengue has
lifted. But the real epidemic – the unconcern of the health department – continues
without respite.