perspective

government claims have been taken to Public Health System in UP: a­ddress some of the problems identified in Section 1, drawing upon the National What Can Be Done? R­ural Health Mission (NRHM) funding and guidelines. It also highlights the specific problems that remain with the implemen- Santosh Mehrotra tation of the NRHM agenda of reforms in the government health system. The final This article offers a menu of t is common knowledge that social section concludes. options for reform of Uttar outcome indicators in the northern 1 Diagnosing the Malaise Pradesh’s public health system. Istates are far worse than those prevail­ ing in southern India. The outcomes are In this situation analysis of the health Though some actions have been closely linked to the quality of services i­ndicators of UP, we will focus on a com- taken after the introduction of provided by the otherwise widespread parison with only one other BIMARU state the National Rural Health Mission and pretty adequate public health infra- – with which most of the Indian intelli- in late 2005, a large number of structure. How effective the services are gentsia brackets UP – namely, Bihar. The depends on how serious is the political c­omparison will also be with the Indian very serious problems remain. commitment to improving the public average for the same indicator. Unless they are addressed, health delivery. This has been amply The NRHM lays down the standards or the monitorable targets of the demonstrated by the fact that Bihar, where norms that have to be achieved in the Eleventh Five-Year Plan in regard the public health infrastructure is on many country. Therefore, the NRHM is making counts much worse than in Uttar Pradesh an effort to strengthen the public health to health and nutrition in India (UP), has recently shown a remarkable system of: village level providers (at least will not be met, since UP has such turnaround in the effectiveness of services one accredited social health activist a large weight in the unmet needs and the utilisation of public health services (ASHA), anganwadi worker (AWW), v­illage of public health in the country. has improved considerably, as the govern- health drug day kit for 1,000 population); ment of Bihar has demonstrated a politi- sub-primary health centre for five to six cal commitment to improve services.1 villages (with maternal and child health Given the improvement in health and (MCH)/immunisation days) for population e­ducation indicators in Rajasthan and with a telephone link; primary health Madhya Pradesh also in recent years, it c­entre for 30-40 villages with round the appeared till recently that only UP and clock services; and a block level hospital Bihar may remain within the erstwhile for 100 villages or 100,000 population. Bihar, Madhya Pradesh, Rajasthan, Uttar Pradesh (BIMARU) category of states. Child Health: Table 1 (p 47) shows that However, provided there is political the indicators of child health in UP in commitment, there could be a similar 2005-06 (National Family Health Survey turnaround in UP’s health system as well, 3) are not only much worse than for India given that in terms of health infrastruc- on the whole, but actually worse than ture it is in most cases better endowed those in B­ihar. than Bihar. This paper diagnoses the Preventable deaths of children under problems with the government-provided five have been dramatically reduced by health infrastructure, and goes on to public health interventions in all high- s­uggest prescriptions for the medical achieving developing countries in the m­alaise in UP. world (Mehrotra and Jolly 1997) and also Section 1 examines the health outcome by high-achieving states in India. How-

The statistical assistance of Purnachandra Rao and output indicators for UP, apart from ever, in UP barely 23% of all children is gratefully acknowledged. Thanks are due to analysing the infrastructure and human b­elow two years of age have been fully Naresh Saxena, A K Singh and participants at a resource gaps that the state faces, which immunised, or half the Indian average, Observer Research Foundation Seminar on UP, are part of the malaise of the government and 50% less than in Bihar. May 2008, for comments on an earlier draft. health system in UP. Section 2 discusses a Santosh Mehrotra ([email protected]) menu of options that the government has Maternal Health: Institutional delivery is is consultant to the Planning Commission, in terms of policy prescriptions. Section 3 another good indicator of the demand for New Delhi. reviews briefly the actions that the UP the public health system. Table 2 (p 47)

46 december 6, 2008 EPW Economic & Political Weekly perspective shows that barely 22% of UP’s mothers are ministry of rural development (depart- reasonably close to the national average. d­elivering babies in an institutional ment of drinking water and sanitation), In other words, the problem is primarily s­etting, the same as in Bihar and again has its work cut out for itself in UP as does with government hospitals and with gov- roughly half of the Indian average. 2 Only the state government. What is remarkable ernment hospital beds. half of Indian women had at least three is that 92% of hospitalisation cases in The remarkable situation is that in UP antenatal care visits for their last birth, rural UP were on a­ccount of infectious the number of sub-centres stood at 20,153 but the share of UP women is only half of and parasitic diseases, especially for diar- at the end of the Seventh FYP (1990) (after the Indian average; Bihar was doing worse rhoea and gastroenteritis. This indicates having increased from 15,653 at the end of in this respect. clearly the widespread problem of poor the Sixth FYP in 1985); but the numbers After birth, the mother should ideally water quality and the absence of basic did not increase during the Eighth FYP r­eceive health check-ups and supplemen­ sanitation and h­ygiene (Jan S­wasthya (1992-97), nor in the Ninth FYP (1997- tary nutrition, and there are arrangements Abhiyan­ UP 2008). 2002). Hence at the end of 2005, the n­umber of sub-centres stood pretty much Table 1: Child Health Indicators Indicators Uttar Pradesh Bihar India where it was at the beginning of the 1990s. Rural Area Urban Area Combined Rural Area Urban Area Combined Rural Area Urban Area Combined Something very similar happened in res­ Infant mortality rate 75.0 64.0 72.7 63.0 54.0 62.0 62.0 42.0 57.0 pect of PHCs in UP. Their numbers had Child mortality rate – – 25.6 – – 24.7 – – 18.4 doubled (from 9,115 at the end of the Sixth Total fertility rate 4.13 2.95 3.82 4.22 2.87 4.00 2.98 2.07 2.68 FYP to 18,671 at the end of the Seventh Children age 6-35 months who are anaemic (%) 85.7 82.5 85.1 89.0 75.8 87.6 81.2 72.7 79.2 FYP). Over the Eighth FYP the numbers Children 12-23 months fully increased by about 12%, but a­lmost not at immunised (%) 20.5 32.6 22.9 31.1 45.6 32.8 38.6 57.5 43.5 all during the Ninth and Tenth FYP peri- Percentage of children with a birth weight less than 2.5 kg – – 25.1 – – 27.6 – – 21.5 ods, so the total number ended up at only – not available. 23,236 by September 2005. Source: National Family Health Survey (NFHS-3), 2005-06. Two other indicators are very impor- tant to determine the effectiveness of the Table 2: Maternal Health Indicators (in %) Indicators Uttar Pradesh Bihar India public health system: the average rural Rural Area Urban Area Combined Rural Area Urban Area Combined Rural Area Urban Area Combined population served by the population Mothers who had at least three health i­nfrastructure and also the aver- antenatal care visits for their last birth 22.6 40.9 26.3 14.5 36.2 16.9 42.8 73.8 50.7 age rural area/radial distance covered by Trends in institutional it. Both the average area (in sq km) and deliveries 18.0 40.0 22.0 19.0 48.0 22.0 31.0 69.0 41.0 the radial distance (in km) in UP from Source: National Family Health Survey (NFHS-3), 2005-06. sub-centres (1.91 km radial distance), for this at the anganwadi centre (AWC). The Health Infrastructure: The popula- PHCs (4.51 km), and CHCs (13.9 km) is less How­ever, the AWCs in the entire country tion served in UP per government hospital, than the national average (2.61, 6.3 and have been n­otoriously ineffective in per- per government hospital bed, per d­octor, 17.22 km, respectively) and not signifi- forming this role (Table 2), but in UP they per primary healthcare sub-centre, per cantly different from that prevailing in have functioned even worse than in the primary health centre (PHC) and per com- Kerala. In other words, if the sub-centres, rest of the country. munity health centre (CHC) are all system- PHCs and CHCs were to function it would atically lower than the national average, not be that difficult for people to actually Health Inputs: Without clean water and but at the same time in all cases better seek medical care in them. However, part sanitary means of excreta disposal there than in Bihar (Table 4, p 48). That clearly of the difficulty is that the average rural is little possibility of a dramatic improve- s­uggests that there is a desperate need to population covered by the primary ment in health outcomes. The remarkable address the infrastructure disadvantage healthcare infrastructure is higher in UP phenomenon here is that even in urban that UP’s public health system suffers from than the national average (6,416 as areas where piped water is available to and which should be funded from NRHM against 5,085 for sub-centres, 35,972 three-fourths of the nation’s population, – which is already allocating some vis-a-vis 31,954 for PHCs, and 341,084 only 35% of urban UP residents have Rs 7,000 crore to UP (2006-07). vis-a-vis 221,904 for CHCs). The further a­ccess to piped water (Table 3, p 48). The population served per government difficulty is, of course, that doctor and The share of rural households that have hospital in India on average is 1.45 lakhs, paramedical staff absenteeism from a toilet is barely 16% in UP (same as in in UP it is 1.98 lakhs and in Bihar 8.7 lakhs. duty is endemic in UP, slightly more B­ihar), and way below the national a­verage Similarly, the population served per gov- so in UP than in other states of the (26%). Overall, a third of UP residents ernment hospital bed is 2,257 in India, but country (a­ccording to a World Bank have access to a toilet facility, while that 5,646 in UP and an astounding 28,959 in study of 2004). share is 45% in the c­ountry as a whole. Bihar. However, the situation is not so bad In addition to the primary healthcare Clearly, the Total Sani­tation Campaign, in respect of sub-centres and PHCs, in infrastructure discussed above, UP also the centrally-sponsored scheme of the which case the population served in UP is has one of the country’s most extensive

Economic & Political Weekly EPW december 6, 2008 47 perspective publicly-funded ayurveda, unani, siddha, and 56% were without an all weather ap- S­upreme Court. But for AWCs to function, yoga, naturopathy, homeopathy (AYUSH) proach road (Table 5). Under such condi- they must have the AWWs and helpers; but hospital and dispensary systems in the tions, it is no surprise that the public over 15,000 AWWs and 17,000 helpers are in short supply, and have to be appointed Table 3: Water and Sanitation (in %) Indicators Uttar Pradesh Bihar India (funds for which are made available by Rural Area Urban Area Combined Rural Area Urban Area Combined Rural Area Urban Area Combined the central government). Households using piped Even if the shortfall in infrastructure drinking water 2.0 34.8 10.3 1.2 19.8 4.2 27.9 71.0 42.0 Households with access to a and staff were met, the real issue is toilet facility 16.0 83.7 33.1 16.2 73.0 25.2 25.9 83.1 44.5 whether the parents perceive the pro- Source: National Family Health Survey (NFHS-3), 2005-06. gramme to be effective. The evidence country. While India has 3,198 such hos- health infrastructure suffers from under- from both the FOCUS Survey in 2006 as pitals, UP alone had 1,973 of them, or utilisation of its facilities. well as the NFHS 3 in 2005-06 does not nearly two-thirds. In addition, it had 1,871 Even more shocking is the state of PHCs. seem to be encouraging. One reason is such dispensaries, of the over 21,000 in None of the UP PHCs had a labour room as that the government of UP has shown the country. In other words, quite clearly of September 2005; none had an opera- l­ittle interest in switching from centrally the primary health infrastructure in UP is tion theatre, only 50% had four to six beds procured panjiri, which is currently dis- not exactly poor. The real issue is the kind and information about a 24 hour delivery tributed to children and mothers by way of services provided by the personnel facility was not available. All these bare of supplementary nutrition, to hot cooked employed­ there. minimum facilities were available in most meals – which is the practice in at least 15 of the other states. states around the country but is also a Health Personnel and Their Facilities: r­equirement as per instructions of the The impact of the infrastructure shortfall Nutritional Outcomes: It should have S­upreme Court. has a corresponding shortfall in staff. shocked the nation that half of India’s A­lthough the ASHA is the community out- children are malnourished (2005-06) Public and Private Expenditure on reach worker as of 2005, the auxiliary and the situation has not improved at Health: The state of primary healthcare nurse midwife (ANM) or multi-purpose fe- all since 1998-99, the last time a compa­ in UP is partly reflected in the fact that male worker is the real front line health rable survey was done. UP is doing as compared to the rest of India, patients provider within the public health system, badly as India on average and have to spend more out of their pocket, located at the sub-centre. The number of not much worse, Table 4: Health Infrastructure as on March 2006 ANMs required in UP was over 20,000 (as though its child Particulars Uttar Pradesh Bihar India of September 2005), a number twice as rate of u nder weight Population served per government hospital 198,143 868,712 145,137 large as in the next highest state and the is lower than that Population served per government hospital bed 5,646 28,959 2,257 shortfall was of the order of 3,198, which of Bihar. However, Population served per doctor 23,986 NR 15,122 was greater than the shortfall (relative to it is unclear wheth- Population served per sub-centre 8,931 10,245 7,671 requirements determined by norms) in all er this is any con­ Population served per PHC 50,077 55,303 49,062 other states taken together. solation, since a Population served per CHC 4,74,824 12,96,457 2,84,446 Government hospitals include central government, state government and local government bodies. If staff is going to be found at the health h­igher proportion NR = information not received, NA = not available. facility, there is a higher likelihood that of UP’s children are Source: National Health Profile, 2006. patients will be attracted to them. One stunted compared to Bihari children, with private health expenditure as a pro- factor determining whether medical staff while Bihari children are doing worse in portion of total health expenditure being will arrive at work is if they have staff res- terms of wasting. 92%, way above the national average of idential quarters at the health facility. Of The most important intervention by the 79% (Table 6, p 51). This is partly a reflec- the 20,521 sub-centres (as of September government to address malnutrition has tion of the fact that the UP government’s 2005), 32% had ANM quarters and in most been the Integrated Child Development health expenditure per capita (Rs 84) is of them the ANM was actually l­iving in the Scheme (ICDS), with AWCs in each village. less than half the average of all states of quarter (5,183 of 6,494) (­Table 5, p 49). But The AWC is supposed to provide six services: India (Rs 207). At the same time, private given that two-thirds of the sub-centres (a) supplementary nutrition; (b) pre-school health expenditure per capita in UP is way did not have staff quarters, it would be education; (c) immunisation; (d) health above the national average, even though hardly surprising if the ANM rarely showed referrals; (e) growth monitoring; and it has one of the lowest per capita incomes up for work. (f) health check-ups. But for AWCs to pro- in the country. It is obvious that high pri- Even if staff show­ed up for work, they vide these services they have to be univer- vate e­xpenditure is not only inequitable can do their job only if minimal facilities sally available. UP has one-seventh of all (as it adversely impacts the poorest people are available: water supply, electricity and the AWCs operational in the country, and in one of the poorest state of India) but all weather a­pproach road. Of all sub-­ the number is likely to increase, since h­ighly inefficient, since UP has one of centres in UP, 59% did not have regular AWCs are to rise in number to universalise the poorest health outcome i­ndicators in water supply, 75% did not have electricity, ICDS, as per the i­nstructions of the the country.

48 december 6, 2008 EPW Economic & Political Weekly perspective 2 prescriptions r­ural areas for at least three years. The UP to meet the needs of the population. The government should initiate such a course NRHM funds are already available under A Menu of Prescriptive Options in medical colleges at the earliest. the flexi-pool of funds from the central The situation analysis of outcomes in UP (2) There is a large body of “registered government for hiring consultants at the demonstrates in no uncertain terms that medical practitioners” (RMP) of highly un- SIHFW in Lucknow, to strengthen the the public health system is not delivering; even quality in UP, who claim to provide f­aculty to conduct such training. this implies that public health is not prior- medical services. There are essentially (4) Training of rural practitioners itised by policy. Moreover, there is a clear two types of such providers (even though should be to promote and actively support impression from the government of UP both may be lacking in verifiable qualifi- public health measures, including immu- (GOUP) policies that the focus of the gov- cations and credible training) – complete nisation, oral rehydration therapy for ernment health system still remains cura- quacks and those who have some medical d­iarrhoea, diagnosis and treatment of tive and clinical care, rather than preven- experience. There is no alternative to to- pneumonia, support of family planning and tive and primary health services – when tally eliminating the first category – and the regular provision of oral contraceptive it is entirely un- pills, condoms and other spacing methods. Table 5: Facilities Available at Sub-Centres (as on September 2005) clear what ac- They should, at the same time, recognise States No of Existing No of Sub- No of Sub- Witout Without Without Sub-Centres Centres with Centres with Regular Water Electric Supply All-weather tion the UP and refer the more severe and chronic ANM Quarter ANM Living Supply Motarable in Sub-Centre Approach g­overnment is health conditions, especially t­uberculosis Quarter Road contemplating to (TB), leprosy, kala-azar, J­apanese encepha- Uttar Pradesh 20,521 6,494 (32) 5,183 12,083 (59) 15,332 (75) 11,572 (56) achieving this litis, malnutrition, human immuno defi- Karnataka 8,143 4,493 (55) 4,493 na na na task. The point ciency virus (HIV), etc, to the PHC. Kerala 5,094 2,528 (50) 1,659 1,292 (25) 913 (18) 351 (7) Figures in bracket give the corresponding percentage. is not to enforce (5) The GOUP needs to encourage the na-not available. a ban that al- attachment of rural practitioners to quali- Source: Rural Health Statistics in India 2006. ready exists, but fied doctors that would result in a continu- in fact, the focus should be exactly rather to weed out the system of illegal ing relationship of guidance and upgraded r­eversed, with the latter taking primary registration of such “RMPs” that has flour- knowledge. priority over the clinical care services. ished. At the same time, the public would (6) Now that the GOUP has finally de- Given that UP has among the worst need to be educated that without a legal cided, following the very successful expe- health indicators in the country, UP needs registration, a RMP is a quack, and should rience of the Tamil Nadu Drug Procure- to be at the forefront of the efforts to im- not be approached. The second category, ment Corporation, to create a drug pro- prove health outcomes. This is especially however, needs to be incorporated into curement corporation of its own, drugs important since UP is one of the only six the health provision s­ystem, through a should be made available with RMPs, PHCs states in the country where the number of process of professional­isation focused on and sub-centres. An audit mechanism has poor has not declined for over 30 years their training – which could serve as a to be created that also monitors PHC (1973-74 to 2004-05, according to NSS sur- means of incentivising and thus legitimis- d­octors’ prescriptions behaviour, since veys), and in fact, it is one of the six states ing them. The Rajasthan Registered Medi- doctors tend to prescribe drugs that are where the number of poor has actually in- cal Practitioners Association has adopted not available in the PHC pharmacy – since creased to 54 million in 2004-05. It is also a criteria to identify such providers who there is collusion between outside private well-known that poor health o­utcomes could be “professionalised” through pharmacies and those of the PHC. The PHC are highly correlated to poverty. r­egular training. This requires that the UP doctors’ prescriptions should naturally be health department prepare a checklist to based on a list of generic essential drugs. Preventive/Promotive Measures facilitate identification of such providers, Use of such drugs would increase the The following public health measures who would then be provided training e­ffectiveness of the treatments prescribed need to be addressed. at existing training schools for ANMs by RMPs and PHCs and sub-centres, and (1) There is a need for doctors in rural and ASHAs. discourage the use of injections; together areas, since qualified MBBS doctors have (3) There is need for greater synergy in such actions would enhance the credibili- shown unwillingness to live and work in the training efforts of the National ty of RMPs in the eyes of the public, and rural areas. To address the need for doc- I­nstitute for Health and Family Welfare thus increase their practice. tors in rural areas, both the UP govern- (New Delhi) and UP’s State Institute of (7) Research evidence over the years ment and the Planning Commission’s Health and Family Welfare (SIHFW, Luc- and across the country shows that the best Eleventh FYP make a case for starting a know). The State Institute needs to lead doctor is the government doctor who is three-year as opposed to the current five- the training of the second category of engaged in private practice. The govern- year MBBS course. There is an urgent need RMPs. However, it is likely that the SIHFW ment doctor’s salary should, therefore, to initiate such a course in UP, with the would itself be understaffed, and would have two components: a base salary in the o­bjective of part meeting the needs for therefore need additional trainers in form of a retainer; a second component, r­ural doctors; once appointed these o­rder to undertake the large-scale training based on performance measured entirely d­octors would be required to serve in of potential RMPs that would be required on the number of patients seen.

Economic & Political Weekly EPW december 6, 2008 49 perspective Population-Based areas on an urgent basis, since these The GOUP has made a request to the Public Health Measures are low-hanging fruit which can be central government that as part of a pack- plucked by the GOUP to bring about quick age for Bundelkhand and Poorvanchal Sanitation: There is little likelihood of a results: (1) Data shows that reducing or r­egions of UP, three new requirements decline in child malnutrition rates or IMR eliminating births that occur less than 24 should be met. First, Jhansi needs an All- unless coverage of safe sanitation im- months apart could attain the greatest re- India Institute of Medical Sciences (AIIMSS). proves. The Total Sanitation Campaign duction in child mortality. However, The ministry of health of the union govern- (TSC) requires the states to compete in u­nfortunately the entire health and family ment has already decided, meanwhile, e­ngineering behavioural changes; the lat- welfare programme is oriented towards that of the six new AIIMSs being created in ter requires that villages are declared sterilisation, when it should be focused on the country during the Eleventh FYP, one open-defecation free (ODF) zones. increasing birth spacing through condom should be set up in Varanasi. Of the 70 districts in UP, only 30 have use. Also, child bearing in the age group Second, the GOUP would like to see a more than 33% sanitation coverage. The of below 20 is five times more as compared National Institute of Virology (NIV) in GOUP cannot expect much improvement to the 35 plus age group, and these Gorakhpur, to help UP address the prob- in addressing malnutrition and r­eduction births are at short birth intervals (Second lem of Japanese encephalitis, a disease in communicable diseases in the absence H­uman Development Report of UP 2007). which is endemic in the north-east of UP of a serious effort to implement the The mean age at marriage in UP remains (UP accounts for 60% of India’s c­ases of TSC programme, and without advancing around 16. Thus campaigns are needed to Japanese encephalitis). The NIV in Pune the date (2012) for coverage of the discourage child bearing among women already has an outpost in Gorakhpur. e­ntire state. less than 20, to raise the age of marriage, However, it is not entirely clear what pur- and encourage birth spacing. (2) By far pose will be served by a new national in- Malnutrition: The National Family the largest differential between female stitute, when one already exists; nor was Health Survey III (2005-06) shows that and male child mortality is in the age it made clear how a national institute of UP’s child malnutrition rate is 47%, while group 1-5 (i e, not in the first year after v­irology will resolve the problems of sani- the national rate is 46%. The ICDS cover- birth), with female child mortality being tation, water quality and hygiene, which age is low, even though the Supreme much higher. Females under one year may are the underlying and proximate reasons Court has for several years been instruct- be less disadvantaged relative to males for the high incidence of Japanese ing state governments to universalise b­ecause children of both sexes are breast- encephalitis­ in the sub-region. Nevertheless, ICDS, and to end contractor-driven sup- fed. After breast-feeding stops, the poten- a NIV has already been sanctioned for plementary nutrition. However, UP risks tial for differential treatment of boys and Gorakhpur by the central government. being now in contempt of the S­upreme girls increases. Clearly, a campaign is Third, medical colleges in UP are Court if it continues with the contractor- needed informing people all the facts, and s­everely short of staff; so the GOUP wants driven supplementary nutrition. Second- advising corrective action within the the union government’s to provide finan- ly, the allocation for ICDS is being signifi- household. cial support to create new medical colleges cantly increased d­uring the Eleventh FYP to train such staff. However, it is not clear for ICDS; the programme must be rapidly System-Wide Needs of Infrastructure: how the latter is a solution to the problem universalised, with a f­ocus on scheduled First, the shortage of ANMs arises because of staff shortage in medical colleges. caste com­munities, since it is their ham- the training centres have not been con- A­pparently, the real problem is that while the lets which are currently u­nder-provided ducting training since 1992 – encouraging existing UP medical colleges do get enough in UP with AWCs. a de facto privatisation of the healthcare good applications for staff for clinical system in the state of UP. During 1992- f­aculty positions (e g, medicine, surgery), Immunisation: The immunisation pro- 2004 pre-service training of ANMs did not they do not for para-clinical (social and gramme has been overtaken by the focus take place; training was restarted only in preventive medicine, pharmacology, etc) on the “polio plus” campaign, to the detri- 2004. There are 40 ANM training centres and for pre-clinical (e g, biochemistry, ment of the entire immunisation effort. in the state, each with a training capacity physiology, anatomy). This is because not Not surprisingly, the increase in the immu- of 60 per batch. Of these 30 have been enough students wish to register for post- nisation rate in UP between 1998-99 made partially funcitional. There is a graduate training in the latter two sets of (NFHS 2) and 2005-06 (NFHS 3) was barely problem as regards the availability of disciplines as they prefer only clinical dis- 3 percentage points, from 20% to 23%. It is t­utors, which should be resolved, by h­iring ciplines. If existing medical colleges can- obvious that polio might be a special pro­ them on a consultancy basis for temporary not adequately staff faculty positions for blem besetting UP in particular,­ but it can- periods, against funds to be drawn from para- and pre-clinical positions, it is totally­ not be addressed at the expense of the NRHM. In addition, there are 30 district unclear how creating new medical colleges­ r­emaining preventable diseases. training centres which are non-functional will solve the problem. at present, and should be reactivated, and Fourth, to fill vacant positions for doc- Campaigns: There is a special need to if necessary, funds utilised from NRHM for tors in rural PHCs, GOUP is making the adopt a campaign approach in the following the purpose. l­egitimate case for creating a new course

50 december 6, 2008 EPW Economic & Political Weekly perspective which will require fewer number of years central government. A pilot project (with b­ehaviour change, home-based care of than the current five years for a medical a GOUP allocation of Rs 10 lakh) has been the new borns and integrated manage- (MBBS) degree. initia­ted. Urgent action is needed to ment of neonatal and childhood illness Fifth, the GOUP also made a case for q­uickly put in place the project, so that the has been combined for best results. In the budget support from the central govern- learning from the project could be used to first phase 17 districts have been selected ment to create new medical colleges, with universalise health insurance for BPL (one from each administrative division of total capital costs being shared equally f­amilies in UP. the state) with highest IMR and availabili- between the state and central govern- ty of minimum required infrastructure. ments. Based on the norm of one medical 3 changes under NRHM All the medical officers, staff nurses,ANM s college for every 50 lakh population, there It should be recognised that within the and ASHAs are being trained under the is indeed a deficit of 24 medical colleges in last year, some changes have indeed project. Fixed day, fixed time, fixed place UP. There are 11 medical colleges in UP – o­ccurred in UP’s public health system – schedule is being followed for village level seven in the public sector and four in the thanks to the NRHM. It should be noted, of monthly immunisation days. private sector. By contrast, the southern course, that health is a concurrent subject As regards malnutrition, a bi-annual states more than meet the norm. Naturally, in the Constitution, and state govern- Bal Poshan Swastha strategy is being im- the southern states produce more doctors ments are dominantly responsible for plemented in all the districts with the help than UP, although UP’s population is much health p­rovisioning. The GOUP has of UNICEF and ICDS. Iron administration larger. However, the southern states have claimed that the following actions have has been included for pre-school children a larger number of private medical been taken and improvements in services under NRHM, and also compulsory IFA to c­olleges than public ones. UP, on the other have occurred. all pregnant women. Iodine deficiency hand, has failed to attract private invest- Janani Suraksha Yojana has already in- control programme has been expanded ment in medical education. creased the number of institutional deliv- under NRHM umbrella. Sixth, even if new medical colleges eries by more than twofold. It is proposed As regards, the poor health infra­ were to come up in UP, without putting in to operationalise one district women’s structure sub-centre and PHC construc- place a mechanism to ensure that the doc- hospital and at least two CHCs per district tion is under way in a phased manner tors produced by medical colleges will Table 6: Public and Private Expenditure on Health, 2001-02 a­ctually be willing to serve in rural areas, States Health Expenditure (in Rs 000s) Public Exp Private Exp Per Capita Expenditure (in Rs) it is unclear how the larger supply of phy- as a % of as a % of Total Total sicians and surgeons will solve the prob- Public Private Total Expenditure Expenditure Public Private Total lems with the health delivery system. Uttar Pradesh 1,40,88,564 17,40,25,330 18,81,13,894 7.5 92.5 84 1,040 1,124 Bihar 77,08,790 5,74,55,419 6,51,64,209 11.8 88.1 92 687 779 Tamil Nadu has an effective system to India 21,43,91,018 81,81,04,032 1,03,24,95,050 20.8 79.2 207 790 997 e­nsure that doctors employed by the gov- All India public expenditure including expenditure by the MOHFW, central ministries and local bodies, while private expenditure ernment actually serve in rural areas, includes health expenditure by NGOs, firms and households. Source: National Health Profile 2006, National Health Accounts and M/o.Health and Family Welfare, GOI. which the GOUP has signally failed in en- suring. B­esides, there is a provision in the as first referral units during 2008-09. This under NRHM. CHC upgradation and Eleventh FYP for converting some district unit will be well equipped to perform cae- strengthening of district hospitals as per hospitals into medical colleges, through sarean operation and intensive neonatal IPHS is also underway in phased manner the public-private partnership mode. care. Dai training is being implemented in under NRHM. Seventh, in addition to the measures big way so that at least one to two trained The UP government’s self-assessment of proposed to revive the government health dais are available for every 1,000 popula- its achievements after NRHM needs to be system in UP, there is a nation-wide pro- tion who will help the community to itself evaluated. We will rely upon two posal to introduce health insurance for d­eliver in hygienic conditions at home, if sources for such an evaluation: the NRHM’s the below poverty line (BPL) families. i­nstitutional delivery is not possible. own Common Review Mission ((hereafter There are one crore BPL families in UP Presently, 300 out of 823 PHCs are func- NRHM Mission Review) by a combination (BPL population is 5.4 crore). With a pre- tional round the clock (24×7). All PHCs of independent and government special- mium of Rs 500 to provide coverage of will be functional as 24×7 during 2008-09. ists and experts in November 2007)3 and Rs 30,000 per BPL family of five, the GOUP Three staff nurses are being contracted at also an evaluation by the Jan Swasthya will need Rs 500 crore to cover the cost of each PHC and six at each CHC under NRHM. Abhiyan (hereafter JSA report) an inde- health insurance premium to cover all BPL Contractual lady doctors of the Indian sys- pendent NGO that has been surveying families. The GOUP is willing to contribute tem of medicine at PHC level in phased states where the NRHM has been imple- Rs 100 crore of the Rs 500 crore required; manner are being appointed. The pilot was mented over 2006-08. What emerges is it also believes that families could be re- initiated in 10 districts at two block PHCs the following: quired to contribute Rs 100 per family to- each and is being expanded now. Throughout the country the ASHA pro- wards the premium (or Rs 100 crore for all The comprehensive child survival pro- gramme is a major component of the BPL families per annum). The remaining gramme has specially been designed for NRHM strategy. The Janani Suraksha Rs 300 crore would need to come from the UP, where communication strategy for Y­ojana is another visible and welcome

Economic & Political Weekly EPW december 6, 2008 51 perspective component. Untied funds have been an- ...(there is an) increase in block PHC OPDs all the villagers. She should be a married/ other successful component at all levels, [out-patient department examination of divorced woman residing in the village. provided to the sub-centre, PHC and dis- patients] from 39 per month two years At least three-four consultations should trict hospital.4 Hospital development soci- ago to over 2,500 per month now for many be done with the villagers and a final list eties (Rogi Kalyan Samitis) have also been months, and from 7,000 institutional should be approved in the gram sabha. formed in most states, and along with the d­eliveries in government institutions in The JSA Report for UP finds that 56% provision of untied funds to them are act- October 2006 to over 100,000 deliveries of the ASHAs were selected in a meeting, ing as enablers of facility development. in October 2007…Given the low utilisa- the remainder were recommended with- The Indian Public Health Standards (IPHS) tion of public services in Bihar as reported out such procedures. There could be an have been introduced, and widely circu- by NSSO 60th Round 2004-05 (5% out-­ opportunity for auto-correction since lated; they are acting as a valuable bench- patient and 11% in-patient treatment in poorly selected ASHAs, who were expect- mark for facilitating states to reach desir- government institutions), this is indeed ing regular remuneration or a government able levels of both infrastructure and outstanding. There is a confidence that job, tend to drop out and replacements h­uman personnel. the public system shall deliver quality could be done better. Of the 13 states visited by the NRHM healthcare services and people are flock- Drug kits are supposed to be given to R­eview Mission almost all have reported ing to the public system to utilise services each ASHA. The review mission report increased performance in terms of abso- even on holidays and over weekends. notes that while drug kits have been lute attendance and to a lesser extent in We turn our attention now to UP’s given to all Mitanins (ASHAs by another terms of quality of care. Since we started p­erformance under NRHM, by key subject. name) in Chhattisgarh, and about 50% our analysis in Section 1 by comparing of ASHAs in Rajasthan and Assam, they UP’s performance with that of Bihar, it ASHAs are not yet distributed in UP, since drug is worth quoting the NRHM Review The guidelines state that the selection of procurement is not complete. This deprives Mission’s summary finding on Bihar: ASHAs should be done in consultation with the p­rogramme of much effectiveness.

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52 december 6, 2008 EPW Economic & Political Weekly perspective The JSA finds that since there is no pro- c­reated. Block PHCs could have asked for policymakers. However, the preventive/ vision of salary to ASHAs, the work done nine nurses and as an intermediate stage promotive public health measures and the by ASHAs clearly reflects the attitude that could have asked for three nurses or ANMs population-wide health measures that she does only that work where incentives but in fact they have none or at best one u­nderpin a medical, clinical care delivery are paid (like Rs 300 for SIFA survey, ANM. This constrains both quality and system, which are the sine qua non of seri- Rs 600 for every delivery case though JSY, quantity of s­ervices provided. Second ous improvements in both health outputs Rs 150 per immunisation session, and ANMs are not in place. and health outcomes, so far do not seem Rs 50 per day for pulse polio campaign). to be forthcoming, except in the case of a At least for the pulse polio, the incentive Training and Need for Multi-skilling: slight increase in institutional deliveries. should be eliminated as part of a larger The NRHM Mission Review notes that none strategy to de-emphasise the polio campaign of the new skill based trainings – like Notes since, as we noted earlier, it is under-­ Skilled Birth Attendant training, IMNCI, 1 Note that the figures in this paper on Bihar are for mining the larger immunisation effort.5 2005-06 at best, i e, for a period before the new multi-skilling for specialist skills, etc, state government came to power two years ago in have reached these districts. Even on in- Bihar. Untied Funds and the Rogi Kalyan S­amiti: stitutional delivery or new born care, the 2 Bihar’s principal secretary for health claimed in the Planning Commission in January 2008 that The NRHM provides a major part of its fund- skill levels of the nurses and ANMs who institutional deliveries have gone up in Bihar ing through untied funds: The UP segment are a­ctually conducting them needs con- from 22% to 70% of all deliveries. Whether or not the 70% figure is correct, there must have been a of the NRHM Review notes the activation of siderable strengthening to achieve a qual- significant increase for the government to make sub-centres through untied grants and the ity that would have an impact on indica- such a claim. 3 The NRHM team visited facilities in two districts presence of ASHAs having connected house- tors. There could be much progress made and Jan Swastha Abhiyan visited eight districts holds with health facilities. in reaching the levels of IPHS specified of UP. 4 The JSY offers the following incentives: women The Rogi Kalyan Samitis have also been s­ervice pro­vision through closing skill delivering in rural areas Rs 1,400; for women set up and beginning to use the resources. gaps in existing staff. Training activity is d­elivering in urban areas Rs 1,000; for the rural motivator Rs 250 for transport, Rs 150 for other The RKS is a vehicle that can ensure the almost invisible at the district level. expenses, and Rs 200 as incentive (for urban proper utilisation of untied funds and One hope of the reform process through motivator­ Rs 200 in all). JSY scheme benefits are also given to recognised institutions for BPL, SC forms a framework of both accountability NRHM was that vertical programmes and ST women. Home delivery in rural areas and outcomes for it. In UP, the state would get integrated with functional pub- fetches BPL women Rs 500 each for the first two c ­h i l d r e n . a­lready had a system of user charges that lic health services at every level. However, 5 In private conversations, provincial medical has been modified after the RKSs came the NRHM Mission Review for UP finds ser­vices doctors in UP said to us that polio into existence. The earlier system of will never die in UP, for the reason that there that integration of vertical programmes is “too much money to be made by a sustaining d­epositing 50% of user charges c­ollected still remains a challenge. the incidence of polio, and since excessive into the treasury account is b­eing dis­ government funds are allocated to the Pulse Polio campaign”. continued, and should clearly be done as Drug Availability: Drug availability has a priority. The international e­vidence improved, but prescriptions for buying References is overwhelming: user fees for health from outside pharmacies are still high. Giri Institute of Development Studies (2007): UP: s­ervices only work if the revenues gener- The procurement and disbursement H­uman Development Report, Lucknow. Jan Swasthya Abhiyan UP (2008): People’s Rural ated are used to improve services at the s­ystem needs to be rationalised to prevent Health Watch Survey Report (on National Rural site where they are collected, not if they delays from procurement by the central Health Mission in UP from 2006-08), Lucknow, April. flow into the treasury account of the store and make distribution responsive Mehrotra, Santosh (2006): “Caste and Well-being in g­overnment. In this context, the RKS – a demands. Uttar Pradesh: Why UP Is Not Like Tamil Nadu?” Economic & Political Weekly, October. kind of hospital management committee National Rural Health Mission (2007): NRHM C­ommon – can become the instrument to improve 4 Final Remarks Review Mission – Draft, Ministry of Health and Family Welfare, Government of India, New Delhi. quality and accounta­bility of services, Clearly the previous section reveals that PM’s Task Force on UP (2008): The Social Sector and in addition facilitate effective use of in addition to the policy issues that were Strategy­ Paper, Planning Commission, Gov­ern­ u­ntied funds. highlighted in Section 2, with the NRHM ment of India, New Delhi. implementation a whole series of p­roblems Functionality of CHCs, the 24 Hour PHC that were highlighted there are coming and Appointment of Staff: There can be out further into the open. NRHM, if imple- no 24 hour PHC without the appointment mented successfully, might address available at of additional staff at para-medical level. some of the infrastructure and human Nagaraja Enterprises There continues to be a shortage of nurs- r­esource gaps that have long vitiated the 18(94), Mahakavi Kuvempu Road, es. The NRHM Mission Review for UP notes emergence of an effective government 5th Cross, Malleswaram, that there is a lack of nurses at almost health system. Bangalore - 560 003, e­very level of public health facility. “No Focusing attention on the immediate Karnataka. f­acility has anywhere near the nurses i­ssues arising out of the implementation Ph: 23368551 needed”. Even posts have not been of NRHM is clearly one priority of

Economic & Political Weekly EPW december 6, 2008 53