No care for those born poor

Saroja, 11, complains of weakness and lies down on the floor. Her mother Gudiya nervously murmurs that the fever is getting worse for the frail child.

It was a wrong decision to bring their daughter to the “sarkari” hospital, she tells her husband. “I didn’t think twice till the tests had to be conducted. But how will I afford her treatment at a private clinic,” Mohan Lal asks his wife.

Doctors at a private clinic in Anand Parbat recommended “immediate admission” of the child. When Mohan Lal expressed his inability to do that, the clinic referred them to a government hospital.
 
At Kalawati Saran Hospital, doctors told the family it is not an emergency case and suggested another set of tests and a visit to the afternoon OPD.

The family is now confused whether Saroja needs “immediate attention” or can wait:  the child mumbles she is feeling extremely unwell.

Saroja’s tale is common across government hospitals where patients are randomly referred from private hospitals when they are unable to afford treatment there. And they remain clueless when they arrive at the government hospital.

Last Monday, a one-day-old infant died after being turned away from two government hospitals. The baby, born in a private hospital, Muskaan, needed ventilator support. When the family said they couldn’t afford the Rs 10,000 per day for the ventilator, doctors referred them to a government hospital, according to the baby’s grandfather Shanti Swarup.

Both Kalawati Saran Hospital and Ram Manohar Lohia Hospital turned away the baby due to “lack of beds and ventilator”. On arrival at Lok Nayak Hospital, the family lost time trying to figure out which department to take the child to. Doctors there declared the infant dead on arrival.

Coordination needed
There is currently no referral system in place. In most cases, families are sent away from one hospital to the other with the assurance that there is better infrastructure in the next one. Hospitals do not coordinate with each other if the facilities at the other hospital are in “working condition”.

“There is a need for government hospitals to coordinate among themselves when referring a patient to another hospital in the public sector. In critical cases, hospitals should send one trained paramedic in the vehicle transporting the child so that the child can be stabilised on the way,” says Dr Siddharth Ramji, Director & Professor, Neonatology Department, Maulana Azad Medical College (MAMC).

“The onus of coordinating with the other hospital should be on the administration and not on the patient who has no clue where to go to,” says Dr Ramji.

Neelam, who came for a check-up of her son at LNJP from Loni, Ghaziabad, says she was among the “lucky few” whose critical child was transferred from Chacha Nehru Bal Hospital a few months back. “In our case, the hospital was prompt.”

Most of the newborn deaths are due to lack of timely treatment. Coordination among all hospitals in the public sector is required as laymen have little knowledge of the difference among civic-body-run, Centre-run and state-run hospitals, according to medical experts.

Transporting patients from one hospital to the other in a vehicle is not adequate. Ambulances need to be well equipped to take care of the critical patients.

“Ambulances need to have incubators for the newborn and other support system in order to stabilise critical patients,” says Dr Ramji. Otherwise even trained paramedics accompanying the child may not be able to help.

CATS, the Delhi government’s ambulance service, is likely to roll out its first few high-end ambulances soon. Though private hospitals have these ambulances, the government sector is still lagging.

With government hospitals stretched to capacity, it is not possible to “not refuse” newborns coming from other hospitals, according to doctors.

“The burden of number of deliveries in the hospital is so big that it is not possible to cater to newborns from outside. We are catering not only to patients in Delhi but sharing the load of deliveries from Haryana and Uttar Pradesh. This constitutes at least 40 per cent of the total number of deliveries at the hospital,” says a senior doctor at Lal Bahadur Shastri Hospital.

Also, hospitals are wary of admitting newborns from other hospitals as they fear infection. “This puts infants in the nursery at a higher risk of infection. There is no mechanism in smaller hospitals to screen for infection,” adds the doctor.

However, some doctors differ. Even if there are no incubators or ventilators at the hospital where an infant is referred to, patients can be extended the basic care instead of being turned away. “It may not be possible to offer the optimum care, but it is better than turning away the patient,” says a doctor.

Doctors point out there will be little change in the situation if even patients suffering from common ailments continue ending up at the super specialty government hospitals like Lok Nayak or RML.

Basic ailments should be handled at the level of government dispensaries. Else, quality treatment for the critically ill will suffer at the bigger ones.

“There should be a referral system cutting across states without which patients cannot come to the tertiary hospital. There will be no improvement in the services till this open door policy for even basic ailments continues. The availability of medicines will also improve and the queues will be cut short,” says a doctor at LNJP.

Afaq from Begusarai in Bihar, whose son is being treated for respiratory distress in Kalawati Saran Hospital, pointing to the drugs bought, tells Deccan Herald, “In the one-month-long treatment, we have got only one strip of tablets – which costs Rs 20 – from the hospital. I just paid the chemist outside Rs 1,200 for the medicines prescribed.”

Waits with a newborn or older children for hours for their turn is normal for parents here. Even in the emergency department, the waiting time goes up to two hours, which patients feel is only “normal”.

“One cannot complain of waiting in queues for long when one comes to a government hospital,” says Pooja who brought her two-month-old infant from Hapur in Uttar Pradesh.

How can deaths be avoided?
Currently, poor patients can be treated for free at identified private hospitals. But there is need for a policy under which beds in the private sector are well utilised for critical patients.

Overburdened government hospitals need to refer more patients to these private hospitals. “This system should be developed in a way that the reserved beds under this quota are completely utilised through intensive referrals from the government hospitals. With the private sector equipped with better facilities, the load of critical patients can be transferred here. Even though the number of referrals have considerably increased, a lot more needs to be done,” says a senior doctor at Sanjay Gandhi Memorial Hospital.

Hospitals in the city’s periphery, with just makeshift OPDs for children, are the worst hit. “There has been no expansion in the infrastructure in the past few years. Even though the population load is on the rise, the hospitals in the periphery are ignored,” says a doctor at Rao Tula Ram Hospital.

Interventions are required at the policymaking level, point out experts. “It was suggested a few years back that the public sector enters into an agreement with the private sector where private hospitals treat emergency patients and the reimbursements would be given by the government. There was not much enthusiasm from the private sector then. The government should reconsider this suggestion,” says Dr Ramji.