COMMENTARY farmers of Punjab, the present study was Rural Healthcare and undertaken in 2008-09, with following objectives: (1) to estimate the level of Indebtedness in Punjab c­redit acquisition for healthcare purpos- es by marginal and small farmers in Pun- jab; (2) to assess the present scenario of Narinder Deep Singh public healthcare services in rural areas of Punjab. Despite many policy measures he agriculture sector in India is In the present study primary data was taken by the central and state presently facing a serious ecologi- collected using personal interview method governments, the indebtedness Tcal and economic crisis. Agricul- from 300 farmers (i e, 150 marginal and tural productivity has nearly stagnated 150 small farmers) spread over two dis- of farmers, especially marginal due to resource degradation (soil and water, tricts, namely, Amritsar and Gurdaspur for and small cultivators, keeps especially) leading to a consistent rise in estimating the income and expenditure of increasing. Some recent studies the cost of production or squeezing of marginal and small farmers, and purpose- on agrarian distress show the profit margins/income levels of farmers wise credit acquisition by these farmers. (GoI 2007). The worst-affected are mar- Secondary data was collected from govern- significant role of healthcare ginal farmers (having landholdings below ment reports/publications, journals, inter- expenditure in increasing one hectare) and small farmers (having net, etc, for evaluating the healthcare indebtedness. This article landholdings below two hectares) result- ­scenario in rural areas of Punjab. presents the result of a study ing in a high incidence of indebtedness and suicides among them. The most dis- Expenditure Exceeds Income conducted in selected villages concerting fact is that the largest number The annual/monthly income of marginal of Amritsar and Gurdaspur of farmer suicides was reported from and small farmers from all sources was districts of Punjab in 2008-09 states like Maharashtra, Andhra Pradesh, e­stimated to be less than their total to estimate the level of credit Karnataka, Kerala and Punjab, which are e­xpenditure. Table 1 (p 23) shows that considered to be agriculturally prosperous ­total annual income was estimated to taken for healthcare purposes by states. The government of Punjab in a re- be Rs 56,428 (marginal farmer) and marginal and small farmers. It port to central government has confirmed Rs 1,05,680 (small farmer), whereas their also analyses the present scenario 2,116 farmer suicides since 1988 due to average annual expenditure were esti­ of public health services in i­ndebtedness, but the actual figure accord- mated to be Rs 79,769 per marginal farm- ing to unofficial sources was more than er and Rs 1,46,378 per small farmer. The rural Punjab. 40,000 between 1988 and 2005 (Jaijee annual income of both categories of farm- 2005). Some of the reasons identified for ers fell short of their annual total expendi- indebtedness among marginal and small ture by 41.4% in the case of marginal farmers are low income level of farmers farmers and 38.5% in the case of small due to low production/productivity levels, farmers (Table 1). increased cost of production due to Consumption expenditure constituted a d­egradation and depletion of soil and wa- major part of the total annual expendi- ter, rising cost of living, inadequate institu- ture of marginal and small farmers. It was tional credit, unproductive expenditure on estimated to be Rs 44,760 (56.1%) and social ceremonies and i­ntoxicants, etc. Rs 65,892 (45%) of total annual expendi- In recent studies on agrarian distress, it ture per farm for marginal and small was found that health expenditure has farms, respectively. The annual agricul- been significant in causing or increasing tural production expenditure per farm the indebtedness of farmers, which has, in was only 28% and 35.2% of total annual turn, been a proximate cause of farmer’s expenditure of marginal and small farm- suicides (Economic Research Foundation ers. The annual expenditure on payment 2006). Credit taken for healthcare facili- of old debts constituted 15.9% and 19.8% ties was identified as one of the major of total expenditure of marginal and components of total credit acquisition as small farmers, respectively. The marginal nearly 41.6% of total credit acquired by f­armers were incurring annual production marginal and small farmers was for expenditure of Rs 22,325 per farm or Narinder Deep Singh (ndsingh241074@yahoo. healthcare purposes (NSSO 2005). There- Rs 11,750 per acre (as the average farm com) is with the Faculty of Agriculture, Khalsa fore, to have a better insight into health- size of sample marginal farmers is 1.9 College, Amritsar. care credit availed by marginal and small acres), whereas the small farmers were

22 march 13, 2010 vol xlv no 11 EPW Economic & Political Weekly COMMENTARY Table 1: Annual Expenditure and Income of Marginal and Small Farmers in Punjab (in Rs /farm) (80,000 for hilly areas). But in rural areas A Annual Expenditure Marginal Farmers Small Farmers 1 Consumption expenditure (monthly/farm) of Punjab, there are only 2,858 SCs against (a) On food items 2,755 3,878 the requirement of 3,219 (according to (b) On non-food items 183 298 population estimates of 2001 Census, i e, (c) On education of children 376 535 (d) Miscellaneous 416 780 1,60,96,488 persons), 484 PHCs against Sub total (monthly) 3,730 5,491 the requirement of 537 and 126 CHCs, Sub total (annual) 44,760(56.1) 65,892(45) whereas 134 are required. More­over, the 2 Agricultural production expenditure (annual/farm) including labour charges 22,325 (28) 51,526(35.2) number of health institutions in rural are- Agriculture production expenditure/acre 11,750 12,268 as of the state has not increased and has 3 Payments of old debts (annual/farm) (a) Short-term credit 5,088 13,170 remained more or less stagnant over the (b) Medium/long-term 7,596 15,790 years, which highlights the poor commit- Sub total 12,684 (15.9) 28,960 (19.8) ment of state governments, whereas the Average annual total expenditure (1+2+3) (100) 79,769 (100) 1,46,378 (100) B Total average annual income/farm 56,428 1,05,680 population in rural Punjab which consti- Difference of expenditure and income 23,341 (41.4) 40,698 (38.5) tutes 63.3% of the total population, has C Agricultural production expenditure/acre increased significantly over the years. The (as per recommendation of PAU, Ludhiana) 15,500 actual requirement of medical institu- D Present annual agricultural production expenditure/acre 11,750 12,268 tions, on the basis of projected population E Difference 3,750 (24.2) 3,232 (19.6) * Figures in parenthesis are in percentage. PAU: Punjab Agriculture University. estimates of r­ural Punjab for the year Source: Field Survey. 2008, i e, 1,84,62,672 persons (calculated ­incurring an annual production expendi- credit acquired. Moreover, credit which on the basis of state’s average annual ture of Rs 51,526 or Rs 12,268 per acre (as was sought for agricultural production ­population growth rate of previous average farm size of sample small farmers purpose was diverted to other purposes ­decade, i e, 2.1% per annum) is much in 4.2 acres). which were mostly unproductive like higher – nearly 3,693 SCs, 615 PHCs, and c­onsumption of liquor, social/religious 154 CHCs are required which outstrips the Credit Acquisition ceremonies, etc, resulting in accumulation actual availability of these institutions Credit was acquired by marginal and of the debt burden on the farmers. The (Table 3, p 24). small farmers for various purposes/uses miscellaneous category includes credit Due to the existence of a smaller number from various sources. The maximum credit taken for purchase of two-wheelers, tele- of public health institutions than their was acquired for production by both mar- visions, mobile phones, etc. Under this a­ctual requirement, these institutions in ginal and small farmers, i e, nearly 46.4% category nearly 4.9% and 3.5% of total rural areas are overburdened in terms of and 40.9%, respectively of the total credit credit was acquired by marginal and small both area and the number of persons de- taken (Table 2). farmers (Table 2). pendent on them. On an average, one PHC Short-term production credit which is covers nearly 100 sq km, whereas one CHC 68.4% and 62.7% for marginal and small Healthcare Credit caters to 383 sq km of area. One doctor is, farmers was acquired for purchase of agri- Healthcare credit had a major share in the therefore, available for 26 villages (on an cultural inputs such as seeds, fertilisers total borrowing by marginal and small average basis), as one PHC is available for and agrochemicals, whereas medium- farmers as cheap medical facilities 26 villages. And one CHC is available for long-term credit was acquired for pur- through government health services were every 101 villages, which sounds unbeliev- chase of farm machinery, implements, inadequate, and not available at times. able. Some of the basic facilities in these farm buildings, livestocks, irrigation There are fewer subcentres (SCs), primary government health institutions are not structures, etc, and it was estimated to be health centres 38.9% and 31.3% for marginal and small (PHCs) and commu- Table 2: Credit Acquisition by Marginal and Small Farmers for Different Purposes (in Rs /farm) farmers, respectively. The second impor- nity health centres Short-Term Credit Medium/Long-Term Credit Total Credit Use of credit Marginal Small Marginal Small Marginal Small tant purpose for which credit was acquired (CHCs) than their Production purpose 7,794 13,547 12,930 1,75,304 20,724 28,851 by marginal and small farmers was for actual requirement (68.4) (62.7) (38.9) (31.3) (46.4) (40.9) health reasons, i e, nearly 20% and 23.2%, in the rural areas of Consumption purpose 536 691 2,859 3569 3,395 4,260 respectively. The third important purpose Punjab. A­ccording (4.7) (3.2) (3.6) (7.3) (7.6) (6.0) for which credit was acquired by marginal to the Indian public Health purpose 1,379 2,938 7,546 13,398 8,925 16,336 (12.10) (9.6) (22.7) (27.4) (20) (23.2) and small farmers was social/religious health norms, there Social/religious 592 1,621 4,467 8,801 5,079 10,422 ceremonies which include expenses should be one SC for (5.2) (7.5) (13.5) (18.0) (11.4) (14.8) i­ncurred on birth, death, marriages and 5,000 people (3,000 Payments of old debts 832 1,923 3,490 6,259 4,322 8,182 other social events, not only in their own in hilly areas), one (7.3) (8.9) (10.5) (12.8) (9.7) (11.6) family, but also in functions of relatives. PHC for 30,000 peo- Miscellaneous 262 886 1,928 1,565 2,190 2,451 (2.3) (4.1) (5.8) (3.2) (4.9) (3.5) Similarly, for payment of old debts, ple (20,000 for hilly Total 11,395 21,606 33,240 48,896 44,635 70,502 m­arginal and small farmers had taken areas) and one CHC (100) (100) (100) (100) (100) (100) fresh loans, i e, 10.9% and 13.1% of total for 1,20,000 people Figures in parentheses are percentages.

Economic & Political Weekly EPW march 13, 2010 vol xlv no 11 23 COMMENTARY Table 3: The Availability and Requirement of Medical In Punjab, households have undertaken states, the progress of NRHM has been very Institutions in Punjab (in numbers) nearly 76.1% of the total healthcare spend- tardy (Garg and Nath 2007). A government- Particulars SCs PHCs CHCs 1 Availability ing from their own sources, whereas pub- funded review of the NRHM reveals its slow (a) Sixth Plan (1981-85) 2,602 130 10 lic spending is only 18%, and all other progress due to problems in the implemen- (b) Seventh Plan (1985-90) 2,852 460 70 sour­ces like non-governmental organisa- tation of the NRHM such as a­dministrative (c) Eighth Plan (1992-97) 2,852 484 105 tions, charitable trusts, etc, contribute constraints, governance i­ssues, inadequa- (d) Ninth Plan (1997-2002) 2,852 484 105 (e) Tenth Plan (2002-2007) 2,858 484 126 only 5.9% of total health expenditure. The cies in human resources as well as the poor (f) Eleventh Plan (up to March 2008) 2,858 484 126 ratio of 1:4 for public to private health ex- investment in public health services in the 2 Requirement penditure reflects the inadequate quantity recent past (Shrivastava 2008). (a) As per 2001 population 3,219 537 134 and quality of public health services in ru- Similarly, the Punjab government had (b) As per 2008 population estimates 3,693 615 154 ral areas of Punjab (Rural Health Statistics introduced two reforms in health policy. Source: Rural Health Statistics, 2009. 2009). The rural peo- First was the opening of healthcare serv- Table 4: Facilities in Public Health Institutions in Rural Punjab (as on March 2008) ple, who are more ices to the private corporate sector. Private Particulars SCs PHCs CHCs prone to diseases like sector hospitals were given land and facili- (1) Total no of institutions 2,858 484 126 (2) Population covered by one 6,460 38,146 1,46,529 tuberculosis, cancer, ties at concessional rates, and were ex- (3) Population to be covered as per IPHN 5,000 20,000 120,000 liver dysfunction, etc, pected in return to provide free treatment (4) Average rural area covered (sq km) by one 16.89 99.76 383.20 due to nutritional im- to yellow card holders (people below the (5) Average no of villages covered by one 4 26 101 balance, lack of pro­ poverty line) up to 10% of outpatients and (6) Institutions without buildings or to be constructed 1,025 82 10 per sanitation facili- 5% of inpatients. The second policy deci- (7) Institutions without electricity 404 5 _ ties and residual effect sion was the setting up of the Punjab (8) Institutions without regular water supply 389 24 _ of agro-chemicals, are Health Systems Corporation (PHSC) in (9) Without all-weather motorable road 134 10 _ forced to avail of the O­ctober 1995 by the state government, Source: Rural Health Statistics, 2009. services of private u­nder the World Bank-sponsored State available, such as electricity (404 SCs and medical treatment, which are quite costly. Health Systems Development Project II, in five PHCs), water (389 SCs and 24 PHCs) The poor rural people pay from their own which more than 150 healthcare institu- and all-weather motorable roads (134 SCs sources which are many times inade- tions run by the government were trans- and 10 PHCs) do not exist (Table 4). quate, forcing them to acquire credit ferred to PHSC. In these hospitals doctors Similarly, acute manpower shortages sometimes at an exorbitant rate of inter- were contractually appointed on an hono- also exist in these institutions. For exam- est, thereby increasing the debt burden rarium of Rs 30,000 per month and with ple, a shortage of 283 and 294 doctors in on them. Therefore, it was found during this money they were supposed to keep PHCs and CHCs (i e, nearly 60% shortage), the study that although nearly 11% mar- temporary staff of one nurse, one health 1,380 health workers, 650 health assist- ginal and 9.4% small farmers were suf- worker and one safai karamchari. Nearly ants/auxiliary nurse midwives (67.2% fering from serious ailments requiring 1,200 doctors were appointed out of which shortage), 340 laboratory technicians and immediate medical assistance, due to 800 doctors left their jobs within one year

342 nurses/staff nurses exists in these lack of funds they were unable to avail of Table 5: Manpower Availability in Rural Health i­nstitutions (Table 5). these services. Institutions of Punjab (as on March 2008) Furthermore, the absenteeism of m­edical Particulars Required Available Shortage Mission Failed Health workers (SCs) staff, poor/outdated/non-working medi- (male + female) 5,716 4,336 1,380 (24.1) cal equipment and lack of basic infrastruc- Although the government of India has Health asst/ANMs (PHCs) ture are some of the other problems which launched a new massive health policy (male + female) 968 318 650 (67.2) rural inhabitants face. One of the major known as the National Rural Health Mis- Nurse/staff nurse (PHCs+ CHCs) 1,366 1,024 342 (25) reasons for this pathetic state of rural sion (NRHM), with the objective to improve Lab technicians (PHCs+ CHCs) 610 270 340 (55.7) healthcare in Punjab, is the ever-­decreasing the availability of and access of quality Radiographers (CHCs) 126 61 65 (51.6) state government expenditure on health. healthcare to people, especially for those Doctors (PHCs) 484 201 283 (58.5) Doctors (CHCs) 504 210 294 (58.3) The share of health sector in the overall residing in rural areas – the poor, women (a) Physicians 126 56 70 (55.6) budget as the state expenditure on health and children (NRHM 2005), the pace of im- (b) Obst and gynaecologists 126 46 80 (63.5) sector which was 7.19% of the total budget plementation of this scheme is very slow. (c) Paediatricians 126 39 87 (69.5) in 1985-86 subsequently d­ecreased over The Accredited Social Health Activists (d) Surgeons 126 69 57 (45.2) the years to 3.45% in 2007-08 (GoP 2008). (ASHAs), who are the key players, to work Figures in parentheses are percentages. Source: Rural Health Statistics, 2009. Low public sector spending on health serv- as an interface between the community ices results in an overdepen­dence on pri- and the public health system are few in for permanent jobs in neighbouring states vate sector for getting health services. In number and the state has not made any like Haryana and Himachal Pradesh. other words, out-of-pocket expenditure arrangement for their training. In India, Therefore, both these measures failed comprises a major share of expenditure as a whole, out of the total 2,28,327 ASHAs miserably. Hospitals no longer provide on healthcare in Punjab, especially in proposed to be selected only 1,45,546 free services, and instead, charge all pa- rural areas. ASHAs were selected, and in most of the tients a user fee, including people below

24 march 13, 2010 vol xlv no 11 EPW Economic & Political Weekly COMMENTARY the poverty line. Moreover, the complex ­underprivileged sections of society. ­Community Medicine, 32(3): 171-12. GoI (2007): “Towards Faster and More Inclusive and cumbersome procedures in these in- Therefore, policy measures like increasing Growth: An Approach to the 11th Five-Year Plan stitutions were constraining the access of the share of state’s expenditure on health- (2007-2012)”, Government of India, Planning Commission, New Delhi, 9. the poor to healthcare services. care, especially in rural areas, improving GoP (2008): “Economic Indicators of Various Sectors”, the existing healthcare facilities, filling up A Report of Economic Advisor, Statistical Abstract of Punjab, Government of Punjab, Chandigarh. Conclusions of vacant posts in these institutions, fre- Jaijee, I J (2005): “Farmers Suicides Being Under Commercialisation and privatisation of quent surprise visits by higher officials to Played: Report”, The Pioneer, 10 August. NRHM (2005): National Rural Health Mission, Minis- health services have excluded a sizeable check absenteeism, compulsory rural try of Health and Family Welfare, Government of India, New Delhi. retrieved, 5 December 2008, proportion of the population, particularly postings of staff and fixing accountability from NRHM web site: http://mohfw.nic.in/nrhm. those belonging to socially disadvantaged of employees are necessary to improve the htm. NSSO (2005): National Sample Survey Organisation, groups like landless labourers, marginal rural health scenario in the state. Income, Expenditure and Productive Assets of and small farmers, and poor from the cov- Farmers, 59th Round, Report No 497 (59/33/5). Rural Health Statistics (2009): Final Tables, Bulletin, erage of health services provided by References from NRHM web site: http://mohfw.nic.in/nrhm. o­rganised sector in rural areas. The subse- Economic Research Foundation (2006): “Government htm. Health Expenditure in India: A Benchmark Shrivastava, B (2008): “Rural Health Mission: Slow to quent financial burden of private health- Study”, undertaken for the MacArthur Founda- Take Off, Hit by Manpower Crunch”, retrieved care services is responsible for a large tion, India: 8-11. 5 December from livemint.com web site: http:// Garg, S and A Nath (2007): “Current Status of Nation- www.livemint.com/2008/05/15233313/Rural- ­proportion of total borrowing by these al Rural Health Mission”, Indian Journal of health-Mission-slow-to.html.

main motive is money, most would not un- Remembering Shahid Azmi derstand his moral quest. The approval of the legal fraternity was very important to him as of the larger community. Monica Sakhrani After So Much Suffering Advocate Shahid Azmi, whose hahid was in love with the idea of He spoke about his childhood when he work centred on seeking to justice. Fighting against injustice was went to celebrate festivals with his Hindu redress the injustices suffered by Sthe driving force of his life. This is neighbours and their influences on him. what cost him his life. Had he looked the The Bombay riots changed it all for him – Muslim youth who were falsely other way and treated the testimonials of the harmonious coexistence; life would implicated in criminal cases, state oppression, structural violence and never be the same again. Like his death, his was shot dead on 11 February in systemic injustices as “cases” and not as his life was full of tragic events and was out of his Kurla office in Mumbai. He crusade for justice, he would have been alive the ordinary. He spoke about it sometimes today. The tragedy of Shahid’s death is the in context. Listening to him talk about his knew that he was targeted and tragic loss of possibilities of a life that will life in his usual matter of fact tone was an tried to take precautions, but now never be. His was a brilliant, astute altogether different experience, without he would not bring himself to mind, a thirst for knowledge, and a kind, precedent for a sanitised and protected turn his back on the people who loving heart. He combined moral courage middle class imagination. He lost his father with legal acumen. His work was his politics when he was seven and was brought up on frequented his office, seeking and his life. This was unpalatable to those the largesse of better off relatives by his justice. Having been through whom he opposed and fence sitters who mother. At 15, while returning home from acute suffering himself, Azmi would rather have a lawyer defend his prac- school after an exam in December 1992, a empathised with others’ suffering tice by calling it his “profession” – his bread, policeman holding a gun at his head, butter and jam. Instead, it was his passion threatening to kill him, confronted him in a at a fundamental human level. It and he took his cases personally. This led to lonely lane. He was lucky to escape in a would have been impossible for his being branded a “terrorist” lawyer, which moment of distraction when he ran for his him to live with himself had he label had a double entendre given his past. life. He once said that it was the most fear- given up this work. He never hid his past, as he believed that it ful moment of his life. Then, there was his was bound to catch up with him anyway. illegal confinement in the dungeons below With infinite patience and humility, he Red Fort for over 50 days and the torture he sought to convince people that he was not a went through there; and, his one-year of terrorist; he tried to explain his standpoint solitary confinement at Tihar until Kiran Bedi of justice to them. It was heart-wrenching to intervened to take him off it. Monica Sakhrani (monicasakhrani@hotmail. watch him try to win the approval of lesser At one point, he pretended to be mentally com) is at the Tata Institute of Social Sciences, mortals, and often fail. It was hard for him ill and was in a mental asylum for another Mumbai. to realise that in this profession, where the year in order to look after a mentally ill

Economic & Political Weekly EPW march 13, 2010 vol xlv no 11 25