West Bengal has witnessed continuous protests for the last two months after the incident of rape and murder that took place in one of the city’s prominent medical college hospitals. Junior doctors under the West Bengal Junior Doctors’ Front have led the protests, but the spontaneous participation of the common masses from all walks of life has made the protest a movement of the people.
The mode of protest has also changed. Initially, the junior doctors went on a complete ‘cease work’; from there, they resorted to a partial ‘cease work’. At present, the junior doctors have returned to work. Some junior doctors also observed a hunger strike – they ended it on October 22 but their protest is still ongoing.
In a democracy, protest plays a significant role in the expression of dissent. It is also helpful in understanding the context and the reason behind an agitation. This article focuses on the demands of the junior doctors.
Three of their ten demands – that a central referral system be implemented in the state’s hospitals and medical colleges (demand 3 in the list that the doctors gave the state government), that every hospital and medical college have a digital bed vacancy monitor (demand 4) and that vacant positions for doctors, nurses and health workers in hospitals be filled immediately (demand 7) – directly concern the state’s health infrastructure.
There are two views regarding the junior doctors’ demands; they argue that some of their demands will favour the state’s common people, but others deny this claim.
This article attempts to understand demands 3 and 4 and if their fulfilment will serve society at large within the context of the existing medical facilities in the state.
Where does the majority of the population go for health services?
Public healthcare facilities are the primary source of healthcare in the state. According to the latest National Family Health Survey data, around 69.6% of total households – 73.2% in rural areas and 62.4% in urban areas – depend on public sector healthcare facilities. The remaining 25.5% of total households depend on the private sector, mainly private doctors or clinics. Only 3% of total households go to private hospitals.
Thus, any demands concerning the public healthcare system are, in fact, in favour of the majority of the population in the state. The heavy dependence on the public sector motivates us to understand the structure of the healthcare system in the state.
Also read: The R.G. Kar Protests Conquered Fear. But Have They Done Much Else?
Basic structure of the healthcare system in West Bengal
The healthcare system is divided into three tiers: primary, secondary and tertiary.
The primary healthcare system consists of sub-health centres, primary health centres and community health centres. The main aim of primary healthcare facilities is prevention, the promotion of health and addressing health problems. Primary healthcare facilities are found across the rural and urban areas of any state.
Secondary healthcare facilities include district hospitals, sub-divisional hospitals, state general hospitals, multi-specialty hospitals and rural hospitals. The basic aim of secondary healthcare facilities is to provide specialised treatment to patients referred to them from the primary tier.
The highest tier is tertiary care and consists of medical college hospitals. Tertiary healthcare facilities provide highly specialised treatment for a relatively prolonged period of time. In West Bengal, as per official data, there were 913 primary health centres, 75 block primary health centres, 273 rural hospitals, 24 state general hospitals, 36 sub-divisional hospitals, 42 multi super-specialist hospitals, 18 district hospitals and 18 medical colleges in 2018*.
In 2023, the scenario stood changed. The number of medical colleges increased to 24 and the number of district hospitals declined to 14. The number of sub-divisional hospitals, state general hospitals and primary healthcare facilities increased over the years.
The three-tier structure allows patients to be referred from the primary to the secondary to the tertiary sector. This existing structure can be better understood if we focus on the spatial distribution of some essential indicators as discussed below.
Figure 1: Structure of healthcare facilities in West Bengal in 2018. Source: Health on the March 2018.
Structure of healthcare facilities in West Bengal in 2023. Source: Health Dynamics of India 2022-23.
Spatial concentration of healthcare facilities
As per the data in the 2018 official publication Health on the March, West Bengal had a total of 18 medical college hospitals across all its 23 districts. Of the 18 medical college hospitals, five were in Kolkata. The remaining 13 medical college hospitals were in the following districts: Bankura, Murshidabad, Purba Bardhaman, Birbhum, Darjeeling, Cooch Behar, Malda, Nadia, North 24 Parganas, Paschim Medinipur, South 24 Parganas and Uttar Dinajpur.
Until 2017, there were only 13 medical colleges. However, in 2018, five more district hospitals were upgraded to medical college hospitals.
Between 2018 and 2023, the number of medical colleges increased to 24. Most districts now have at least one tertiary medical college facility, except a few like Alipurduar, Kalimpong, Dakshin Dinajpur and Paschim Bardhaman.
However, the major tertiary government medical facilities continued to be concentrated in and around Kolkata. Below is the spatial distribution of medical colleges in the state in 2018 and 2023 respectively.
Source: Health on the March 2016-17 & 2017-18 & Health Dynamics of India 2022-23.
To fully grasp the challenges and bottlenecks faced by patients in accessing inpatient services, it’s essential to also analyse the infrastructure of lower-level hospitals.
There has been a notable spatial concentration of in-patient infrastructure as measured by the population served per bed in public facilities across districts, with Kolkata and the nearby districts, along with a few northern districts, having better infrastructure (less than 1,000 served per bed).
However, infrastructure scarcity in some districts can force patients to resort to costly and often subpar private care or travel to better-equipped districts and facilities.
Due to the absence of recent data, the number of beds, the bed occupancy ratio, and the percentage of discharged patients who were referred out are given for 2016. This data is taken from Health on the March 2018, which is available on the government’s website.
Source: Health on the March 2016-17 & 2017-18.
Bed occupancy rate
A crucial indicator for assessing in-patient service utilisation is the bed occupancy rate (BOR), representing the percentage of hospital beds occupied during a certain period. A high BOR suggests significant strain on hospital resources, while a BOR exceeding 100% indicates a shortage of beds relative to demand. Elevated BORs also highlight substantial pressure on the healthcare system, potentially jeopardising patient safety.
Official data suggests a shortage of beds in district and medical college hospitals.
Source: Health on the March, 2016-17 & 2017-18.
The significant strain on hospital resources highlights the need to examine referral statistics.
The image below shows the percentage of discharged patients who were referred out in 2016. It reveals that the highest referral rates have been from sub-divisional and state general hospitals, followed by rural hospitals and block-level primary health centres.
Notably, over 18% of discharged patients in sub-divisional or state general hospitals are referred to district and medical college hospitals, which already experience bed shortages.
Source: Health on the March 2016-17 & 2017-18.
Social researcher Kumar Rana also notes that healthcare facilities in West Bengal are largely reliant on the tertiary sector, highlighting the vulnerable state of primary healthcare services.
A reasonable demand
This official data merely skims the surface of the complex issues currently confronting the healthcare system in West Bengal. Nevertheless, the healthcare metrics discussed here highlight the uneven distribution of healthcare infrastructure within the state, shortages, and frequent referrals to higher-level facilities located in specific regions and urban areas, necessitating travel for necessary care.
This situation often leaves patients and their families dealing with high costs, delays and significant uncertainty and confusion. The result is not only a threat to patient health, but also a potential erosion of trust between patients and healthcare professionals.
The healthcare system in West Bengal and India as a whole grapples with significant resource constraints and a shortage of medical professionals. Meeting the diverse needs of a vast population with limited means often compromises patient safety and healthcare providers’ working conditions, exacerbating potential patient-provider conflicts.
A practical and effective step to help patients and their families navigate the healthcare system for appropriate care would be to establish a central referral system and digital bed vacancy monitoring – demands 3 and 4 of the junior doctors.
A central referral system would streamline patient flow towards appropriate hospitals and specialists, while a digital bed vacancy monitoring system would provide real-time information about the availability of beds in facilities. These systems could efficiently narrow the gap between demand and supply, enhance service delivery, prevent life-threatening delays and foster trust between providers and patients.
The recent launch of the pilot project for the central referral system by the West Bengal government in the South 24 Parganas marks a positive first step.
Debolina Biswas is an assistant professor of economics at a college affiliated with the University of Calcutta. Soumava Basu earned his PhD in economics from the University of Utah and is now a researcher in the US. The views of the authors do not represent the position of their affiliated institutions.
*This data is accessed from Health on the March, a report published annually by the West Bengal health department that offers detailed data and insight into the state’s health system. It covers health outcomes, financing, infrastructure utilisation and policy developments. However, the last published report is for 2018. Even though it may not reflect the exact present scenario, we use it to get a broad idea of the state of healthcare in West Bengal.
On the other hand, the recent trend is available in Health Dynamics of India 2022-23, a publication by the Union government. However, this report focuses heavily on primary healthcare facilities and does not give an idea of crucial indicators such as the population per bed, the referral percentage, etc. In the absence of current data, this article takes data from the last available publication, i.e. Health on the March 2018.
However, data related to the population per bed, the bed occupancy ratio and the referred percentage are taken for 2016, as in the 2017 data, the bed occupancy ratio appeared to be zero for the SSKM hospital, which seems to be erroneous. All other indicators are chosen from 2016 data for parity purposes.
