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India spends next to nothing on public health, and its new prime minister is cutting even deeper. Can the rural clinics that serve the country's poorest survive?


GANIYARI, India — It was 8 p.m. on January 12 at the Jan Swasthya Sahyog (Health Care for the People) clinic, and Dr. Yogesh Jain was examining one of the last patients of the day: a strikingly gaunt man stricken by malnutrition and diabetes. The patient, Jawaal Singh Gondh, is a construction laborer in Ganiyari, a rural town in Chhattisgarh, one of India’s poorest states, and one of the dozens of acutely sick people whom Jain sees every day at the charitable clinic. As Jain tended to Gondh, his knees jutted through too-large pant legs, like a child in his father’s clothes.

Jain, a plainly dressed middle-aged man with salt-and-pepper hair, is a pediatrician trained at the All India Institute of Medical Sciences in New Delhi, one of the top medical research centers in the country. He now works as a community doctor and activist at the rural clinic in Chhattisgarh, a mostly agricultural state of about 24 million people in the hills of central India.

In the absence of clinics like Jan Swasthya Sahyog, thousands of mothers deliver children in poorly equipped, dirty operating rooms. Patients often shuttle between private and public clinics in a Sisyphean quest to diagnose serious diseases. Over half of children under age 3 are underweight or malnourished, and the state has one of India’s highest infant mortality rates, with 48 of every 1,000 babies dying before their first birthday, according to a 2014 report published by the Bangalore-based research organization SciBiolMed.

Most of the clinic’s patients travel hours by bus or on crowded jeeps from the tribal areas, India’s government-reserved regions for indigenous communities and tribes, who account for a little over 8 percent of the country’s 1.25 billion people. These are the poorest of India’s poor, the people who struggle most to receive health care. And with no safety net, they are extremely vulnerable to diseases like malaria, anemia, and malnutrition.

Chhattisgarh is a disturbing sign that India’s government health-care system desperately needs more money. But in India’s annual budget, released on Feb. 28, the government once again failed to prioritize health care — allocating only roughly $5.3 billion for public health. India spends roughly 1 percent of its GDP on health care — less than half of that spent by the comparably sized economies of Brazil and Russia. And not only is $5.3 billion a drop from 2014’s budget of $6 billion, but it is not nearly enough to implement the National Health Policy — Prime Minister Narendra Modi’s ambitious plan, released in December, to expand health insurance and facilities.

The government health-care system, a tiered network of primary-health clinics and specialized hospitals, is notoriously understaffed and poorly maintained. India has only one doctor per every 1,400 people — lower than its impoverished and chaotic neighbor Pakistan.

On a chilly day in early January, Brajesh Singh Kashyap was the sole doctor on duty at the Navanagar Primary Health Clinic, a public health-care center amid the hills of northeastern Chhattisgarh. The rusty, two-room clinic serves 25,000 people across 25 villages. That day, Kashyap said the clinic ran out of malaria medication due to delivery delays from the state, which is supposed to provide the drugs for free under a national malaria program. The staff was asking patients, most of them barefoot, to purchase cough and fever medicines — also meant to be provided by the government — from the local pharmacy. That’s often a tactic to help doctors line their own pockets by selling the free government drugs to dispensaries, said Sulakshana Nandi, a researcher and activist with the People’s Health Movement, an advocacy and research organization. (Kashyap denied his staff was doing this.)

Sitting in his spacious office in the state capital Raipur on Jan. 14, Chhattisgarh’s health minister, Amar Agarwal, refused to accept that his state’s health system is underfunded. In fact, he said, they couldn’t even spend all the money New Delhi distributed — about $118 million from 2013 to 2014. Chhattisgarh, he continued, is one of the only states in India with some type of universal health insurance for families of all income levels. That in itself, he argued, gives people more power over their health. “They have faith in that purchasing power,” Agarwal said.

The idea that Chhattisgarh has more than enough funding for health care is laughable, said Sakhtivel Selvaraj, a senior public-health economist with the Public Health Foundation of India, a public-private research and policy organization. If funds aren’t being used, he added, it’s because officials don’t have the authority or flexibility to use them when and where they are actually needed.

And pinning hope on universal health insurance in Chhattisgarh seems unrealistic, especially since those who do have coverage under government insurance often have a difficult time when they try to get treatment.

Twenty-five-year-old Mala Yadav, a housewife, was eight months pregnant in early January when she felt a sudden, sharp pain tear through her body at her home in Lamgaon, a village in a small tribal community in northeastern Chhattisgarh. Her family called an ambulance to take her to Parida Nursing Home, a low-cost private hospital in the nearby city of Ambikapur, where she said she had been going for her checkups. But when they arrived at Parida, Yadav said, there was no doctor on duty. They rushed to Holy Cross Hospital, a missionary hospital known for treating low-income rural families. But Yadav said the nurses turned her away after seeing scarring on her face from a recent bout of chickenpox, for fear she was contagious. (Holy Cross officials did not respond to multiple requests for comment.)

Finally, Yadav checked into Sankalp Hospital, a new private hospital in Ambikapur. Lying on a clean cot in the maternity ward after her Caesarean section on Jan. 10, the new mother could barely concentrate on the baby boy tucked under a blanket at her chest. Instead, she was fretting about the $300 hospital bill she would have to pay, since the hospital didn’t accept her government insurance. “We’ll have to borrow money and pay later,” Yadav said, lines of worry etched across her forehead.

For patients like Yadav, the combination of a skimpier budget with continued poor implementation most likely means more struggling to see doctors, buy medicines, and pay bills.

And doctors like Yogesh Jain at Jan Swasthya Sahyog will continue to treat the lines of patients sleeping in their corridors. Standing at the center of a treatment room after the starving, diabetic man had left the room, Jain shook his head. “Sometimes I think we’re just standing at the end of the drain,” said Jain, cupping his hands together, “trying to catch whatever the system doesn’t destroy.”

Photo credit: SANJAY KANOJIA / Stringer

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