Discussion on the recent tragic deaths of children in the BRD Medical College Hospital at Gorakhpur has, so far, been focussed on the apparent immediate cause — the interruption of oxygen supply to the hospital, linked with continued default in payments to the oxygen supplier. While the death count in BRD continues to rise alarmingly, reaching nearly 300 in the last month, the state and Central governments have failed to even express an intention of addressing the real oxygen supply of the system - adequate and timely budgetary inflows to the hospital, which are essential for enabling the hospital to deal with the continued influx of critically ill children. The shortfall of payments to the oxygen supplier needs to be understood as the final link in a cascading chain of severe budget cuts, which has choked the flow of critical resources to the hospital, and the programme for treating children with encephalitis, leading to catastrophic outcomes.

The Gorakhpur hospital tragedy was not just due to a local aberration, though local factors did play a role. If we ignore this deeper chain of causation and fail to seek systemic solutions, there is a risk of remaining confined to knee-jerk answers, which may be at the cost of many more innocent lives.

No hospital or health system can function without adequate financial resources, which translate into sufficient doctors and staff, medicines and supplies, infrastructure and other essential inputs. Adequate budgets are essential to keep health services properly functioning. And the converse is obvious — if the system is chronically and severely deprived of such resources, it might manage to cope for some time, but then a breaking point is bound to be reached. The interruption of oxygen supply following major, continued default of payments to the oxygen supplier for the Gorakhpur hospital represent such a breaking point in a system which was already under tremendous strain, due to severe and long-standing constriction of finances at all levels.

The first link in this chain of choked budgets becomes clear when we examine the allocations for Acute Encephalitis Syndrome (AES) and Japanese Encephalitis (JE) for UP over the last few years. This is the main government programme which supports facilities and services for children suffering from these illnesses, for which Gorakhpur is the epicentre. The number of children dying from these illnesses over the last few years remains persistently high — 661 deaths in 2014, 521 in 2015 and 694 in 2016. The deaths increased in 2016 by a massive 33 per cent over the previous year.

In this situation, we would expect a substantial hike in resources for the current year, to take care of expected patients, as well as preventive efforts. The reality is exactly opposite — proposed funds, as well as actual allocations provided by the Union health ministry to the state government under the National Health Mission, have been significantly reduced. The budget demand by UP for AES/JE for 2016-17 was Rs 30.40 crore, of which only Rs 10.19 crore was approved by the Centre. However, in the current year (2017-18), the budget demand was reduced to Rs 20.01 crore, while the amount approved by the Centre was further slashed to just Rs 5.78 crore — barely 29 per cent of the proposed amount.

The further link in the chain is equally worrisome. After grossly inadequate allocations from the national level, at the state level, there is a further holding back of fund disbursement. Out of the amount committed for the AE/JE programme in UP for 2016-17, the actual expenditure of funds over the entire year was only 33 per cent. Parallel to this choking of funds for the encephalitis programme, the funds available for running the 808-bed Nehru hospital associated with the BRD medical college, have also been inadequate. A teaching hospital of comparable size — Nair Hospital in Mumbai — spends Rs 30 lakh per bed annually, while Nehru hospital spends a mere Rs 11.5 lakh.

Similarly, UP’s overall health budget is one of the lowest in the country at Rs 790 per capita, in sharp contrast to the national average of Rs 1,538 per capita. With over 16 per cent of the country’s population, UP accounts for only 9 per cent of India’s public health spending, which gets reflected in the most adverse health outcomes. Some other states like neighbouring Bihar have recently significantly stepped up their health sector funding, by using flexibilities allowed by the 14th Finance Commission’s recommendations. However, the UP government seems to be unwilling to use a larger part of the additional revenues now available to it for increasing its abysmally low health spending which should at least be brought to levels of the national average per capita spending.

Given the context of a constricted flow of resources from various levels, it is not surprising that within the hospital, allocations and fund flow for important supplies like oxygen have been woefully inadequate. The total budget for medicines, materials and supplies (which would include medical oxygen) for the BRD medical college associated hospital in 2015-16 was Rs 8.85 crore. Despite an increase in the number of patients and an increase in prices, this has been reduced to Rs. 7.92 crore in the current year. Further, the flow of funds from the state to hospital level is reported to have been chronically erratic and delayed. The doctors in the encephalitis ward (who are engaged on a contractual basis) reportedly had not been paid for over four months, when the tragedy struck. The non-functioning of ventilators and baby warmers in the wards due to a lack of funds for maintenance has also reportedly been common.

In this larger setting, it is not surprising that since November 2016, payments were not being released to the company supplying liquid oxygen, and by March 2017 the unpaid amount owed to the company had reached Rs 72 lakh. It should be no surprise that the company stopped supplying oxygen to the institution — not an isolated incident, but rather likely to have been the final link in a lethal chain of budgetary blockages, the last straw which broke the proverbial camel’s back.

The Centre and state government seem to be busy blaming the deaths on encephalitis, pneumonia, infections etc., thus deflecting attention from the underlying man-made cause — major strangulation of the “oxygen supply” of the public health system, namely budgetary provisions for healthcare. Grossly inadequate, downsized health budgets are by no means unique to UP; public health facilities across the country are today finding it increasingly difficult to breathe. This is not just about Gorakhpur, but about Lucknow, Jamshedpur, Ranchi etc.

The loss of innocent lives must not be brushed aside with facile excuses, or by making scapegoats of a few low-level officials; the real responsibility lies higher up in the system, where governance is led, and budgetary allocations are decided. These unfortunate deaths of scores of children, who breathed their last before they could have their chance at life, should serve as a resounding wake-up call. The message is clear — there is urgent need to massively increase financing of public health services, along with making major improvements in governance, including systems for social accountability. Otherwise, many more Gorakhpurs will happen.