Resource Constraints, Ambiguous Rules: How ASHAs Struggle To Provide Healthcare Even After 15 Years

Women who work as ASHAs are still considered volunteers and not paid salaries, even as the healthcare needs of the communities they serve increase.

Mumbai and Palghar: Suvarna Kamble (45), an accredited social health activist (ASHA) from Palghar, remembers a time when she brought a woman from Dhansar, a village in Palghar block of Palghar district, to a family planning clinic in Virar for a sterilisation procedure.

At 11 pm one night, the woman had called Kamble to report that her wound had begun to discharge a liquid that was sufficient to soak through the bedsheet she had been using to staunch the flow. At 4 am, her husband called to say that she was close to losing consciousness and the nearest hospital had turned them away.

Budget 2023: No Effective Rise for Health Deptartment, Experts Say

Though the allocations for the department rose marginally, it does not amount to much once adjusted for inflation. Experts also pointed out that the revised estimates for last year’s budget were lower than the budgeted estimate.

New Delhi: Union finance minister Nirmala Sitharaman’s proposal to allocate Rs 86,175 crore to the department of health and family welfare for the financial year 2023-24, on the face of it, meant an increase of 3.82% compared to the previous budget.

However, in real terms, it meant a decline, experts said. “While this appears to be an increase, adjusting with inflation, this is actually a decline in funds,” says Indranil Mukhopadhyay, a health economist, who teaches at O.P. Jindal University. The inflation for December 2022 last year was 5.5%. “Therefore, to say that the budget for the health department has gone up is not true at all,” he added.

Former president of the Public Health Foundation of India K. Srinath Reddy said the allocation signals that health was not a dominant priority. “The priority is economic development and to focus on the economic growth story of the country. It is understandable because the worst phase of the pandemic is behind us,” he asked. Asked if pre-pandemic budgetary allocations gave sufficient room to do it at the cost of health, Reddy said, “Not very much.”

The budget claimed that the percentage of GDP spent on health has gone up to 2.1%. Both the experts The Wire spoke to expressed doubts, saying it was not clear whether only the health budget has been included in making this calculation or schemes which apparently improve health but are that of other departments have also been taken into consideration. For instance, in her speech presenting the Union Budget 2021-22, Sitharaman, had claimed that the “health and wellness budget” had been increased by 137% – when she had included the funds allocated to the departments of health, health research as well as drinking water and sanitation.

Furthermore, the budget documents also revealed in the last financial year, the government failed to allocate to the department of health what it had proposed. Against the budget estimates of Rs 83,000 crore, the revised estimates stood at only Rs 76,370 crore for the FY 2022-23.

An analysis of budgets of five preceding financial years showed this is the first time where the revised estimate was lower than the budgeted estimate. 

Also Read: Eight Charts to Make Sense of Budget 2023

New announcements

Sitharaman, in her budget speech on Wednesday, announced the launch of a special mission to “eliminate” sickle cell anaemia by 2047. “It will entail awareness creation, universal screening of 7 crore people in the age group of 0-40 years in affected tribal areas, and counselling through collaborative efforts of central ministries and state governments.” According to the tribal affairs ministry, this genetic condition is widespread among members of tribes. One in 86 births among Scheduled Tribes suffered from it, the data showed.

There is no specific head in the budget documents to say how much would be spent this year on tackling sickle cell anaemia. The health ministry, though, has clarified that it will be a part of the National Health Mission – an umbrella scheme of managing various programmes in which the Centre contributes 60% and the rest is borne by state governments. No more details are available on this Mission.

It may be noted here that this is yet another elimination target that India has set for itself after missing deadlines for similar targets for other diseases. Kala Azar (elimination deadline 2020), and filariasis (2017) are two such examples. Now, their deadlines stand revised for 2023 and 2030, respectively. India also envisages eliminating tuberculosis by 2025 – a target that experts say may not be achieved.

The finance minister also announced plans to open 157 new nursing colleges. “This is a welcome move as it will not only make India self-sufficient in nurses but also help generate human capital for other countries, especially, which have an ageing population,” Reddy, currently the honorary distinguished professor at the Public Health Foundation of India, said.

However, it remains to be seen if the creation of more nursing colleges will fill up the vacancies in rural areas. The latest Rural Health Statistics of India revealed that the creation of more medical colleges has failed to solve the problem of inadequacy of doctors in rural areas.

Nurses receive COVID-19 vaccine dose, at a nursing training college in Thane, Friday, July 30, 2021. Photo: PTI

Pharmaceuticals

Yet another important announcement came regarding the pharmaceutical industry. “A new programme to promote research and innovation in pharmaceuticals will be taken up through centres of excellence. We shall also encourage industry to invest in research and development in specific priority areas,” Sitharaman said.

The budget documents reveal that a major hike in allocation for this department has actually been done under the head ‘development of pharmaceutical industry’. Under this head, Rs 1250 crore have been proposed as allocation against Rs 100 crore last year. Under this head, the biggest amount has gone to the subhead ‘promotion of Bulk Drug Parks’ (Rs 900 crore) and promotion of Medical Device Parks (Rs 200 crore), among other components.

The idea behind both these components is common – infrastructure facilities for drugs, or medical devices, as the case may be – to bring down their cost of production. Bulk drugs, or Active Pharmaceutical Ingredients (APIs) are the main ingredients, or raw materials, of a medicine. Both these schemes were launched in 2020. This hike has been hailed by the pharmaceutical industry.

But what has seen a decrease is the production-linked incentive scheme (PLI) for manufacturing of APIs. Though the Indian pharma industry is the third largest in the world, by volume, its dependence on the import of APIs has been a matter of concern for a long time. To reduce this dependence, and increase domestic manufacturing of APIs, a PLI scheme to handhold SMEs and MSMEs was launched in 2020 for 10 years.

According to a reply given in the Lok Sabha in July last year, India imported APIs worth Rs 35,249 crore in 2021-22, as against exports worth Rs 33,320 crore. In the two years prior to this, as per the reply, the exports though had slightly outstripped the imports – a trend that saw a reversal in 2021-22. Amidst this, the allocation for PLI linked to APIs this year has seen almost a four-fold decrease to Rs 100 crore.

No specific allocations for research and innovation

As far as research and innovation in pharmaceuticals is concerned, which the minister described in her speech, there seems to be no specific allocation as such. The details to roll this out may come later in the year.

The Association of Indian Medical Device Industry (AiMed), nonetheless, minced no words in expressing disappointment. In a press release, its coordinator Rajiv Nath said the government did nothing to bring down the dependence on imports of this equipment. “Though our honourable prime minister urges India to become Atmanirbhar in Medical Devices, the medical devices imports continued to grow at an alarming level by 41% in FY22,” he said.

Imports of Medical Devices from China went up by nearly 50% last year on account of low duties and convenience to import. These are the same domestic manufacturers, when imports got disrupted during the COVID-19 crisis, the government relied heavily on them to meet the rising demand for essential COVID items,” he added.

The department of health research, which functions under the Union health ministry, saw a cut from Rs 3,200 crore in last year’s budget to Rs 2,980 crore for the next fiscal.

The Biotechnology Industry Research Assistance Council (BIRAC), which functions under the Union science and technology ministry and played a crucial role in the development of COVID-19 vaccines in India, got Rs 40 crore – a hike of Rs 5 crore in absolute terms. BIRAC is a not-for-profit company that serves as an ‘industry-academia interface’ to aid innovation in biotechnology.

Representative image of pharmaceutical research. Photo: Louis Reed/Unsplash

The budget for the National Health Mission (NHM) – a combined programme of the National Rural Health Mission (NRHM) and National Urban Health Mission (NUHM) – which is arguably one of the biggest umbrella schemes of the health ministry that seeks to serve various verticals including the health of children and women, also came down from Rs  37,159 crore previous year to Rs 36,785 crore this year.

Under the Tertiary Care Programme of the Centre, all major non-communicable diseases, which are on the rise in India, are covered. To aid their treatment, the Union government transfers money to states for the implementation of schemes for cancer, diabetes and cardiovascular diseases, health care for the elderly, the national blindness control programme, telemedicine, mental health and tobacco control. Its budget was slashed to Rs 289 crore from Rs 500 crore.

Six Months, a Chance Discovery: How Controversial Assam PPE Kit Orders Were Uncovered

In a series of reports, The Wire and The Cross Current have revealed controversial COVID-19-related procurement orders when Himanta Biswa Sarma was Assam’s health minister.

Guwahati: The series of RTI-based reports on the Assam government’s procurement of COVID-19 related essentials filed by The Wire in collaboration with Guwahati-based news portal The Cross Current, was a protracted effort of over half a year undertaken in public interest. 

The process to collate detailed information from the Assam National Health Mission (NHM) was arduous and took these reporters about six months.

On September 10, 2021, The Cross Current, after consultation with The Wire, filed its first RTI application at the office of the principal secretary, health and family welfare department, Government of Assam. The RTI queries meant for the NHM were as follows: 

Please provide the following information regarding procurement of PPE kits, Rapid Antigen Test kits, ventilators and ICU beds to fight the Covid-19 crisis in Assam from March 15, 2020 till the date of furnishing information:

1) Copy of tender issuing notice against each procurement of the above mentioned items;
2) List of the parties with contact address with tendered amount against each procurement of the above mentioned items;
3) List of the selected party/parties against each procurement;
4) Copy of supply order against each procurement;
5) Received number of PPE kits, Rapid Antigen Test kits, ventilators, ICU beds, received against each supply order;
6) Supply order wise released amount of funds against each procurement;
7) Copy of quality test checked report against each procurement. 

The RTI application filed by correspondent Gautam Pratim Gogoi of The Cross Current in September 2020.

Over two months later – on November 26, 2021 – the NHM responded but only to query no. 5. The department provided us with a partial list of work orders issued to suppliers without mentioning an urgent supply order for PPE kits issued on March 18, 2020 to the chief minister Himanta Biswa Sarma’s wife’s company, JCB Industries. When the health department’s supply order was issued to JCB Industries, Sarma was the health minister.

On December 14, 2021, a letter was sent to the NHM director’s office seeking a complete list of suppliers (information) who were given work by the health ministry to meet the pandemic-induced public health crisis in the north-eastern state. The NHM thereafter forwarded the letter with the RTI application to the state government entity, Assam Medical Services Corporation Limited (AMSCL). 

Nearly three months later, on March 3, 2022, AMSCL yet again furnished another partial list of suppliers who were assigned work orders between March 18, 2020 and January 4, 2022. In this list though, it provided us at what rate the health department had issued the work orders to certain suppliers and the quantity received from each.

Meanwhile, The Cross Current filed another RTI application on January 10, 2022, at the NHM’s director’s office seeking a copy of 14 particular supply orders. The selection was arrived at after The Cross Current and The Wire accidentally came across as many as 50 COVID-19 related work orders issued by the NHM that were available in the public domain in its Inventory Management System. 

AMSCL, thereafter, informed us that those work orders were available at the Inventory Management System of the NHM but couldn’t be procured without a user ID and password. However, the NHM later conveyed to us that there was no bar on accessing those orders and could be accessed without any password. In other words, they have indeed been available in the public domain. 

The urgent supply order for PPE kits granted to JCB Industries prior to the national lockdown was first spotted by The Cross Current in the Inventory Management System, following which a copy was particularly sought as part of the 14 work orders.

Since the NHM didn’t include in the partial list provided to us through an RTI reply the urgent supply order issued to JCB Industries prior to the national lockdown, it would not have been possible for us to bring to the public domain that the then health minister Sarma granted a supply order to his wife Riniki Bhuyan Sarma’s firm without following a tendering/quotation process had we not accidentally come across it in NHM’s Inventory Management System.   

Even after the NHM’s statement that those orders could be accessed at its system, The Cross Current continued to seek the 14 supply orders it had originally sought from NHM through RTI, copies of which were ultimately provided by the Mission office on March 29, 2022.

In its defence, the office of the AMSCL, on March 3, 2022, had cited “the ongoing third wave of Covid pandemic with more than 8,000 cases being reported every day” and “the shifting of the AMSCL office to Narengi” as the cause for the delay in responding to the September 10, 2021, RTI application forwarded to it by NHM. 

Urgent supply order for PPE kits issued by health department to Meditime Healthcare owned by Ghanshyam Dhanuka, a business associate of Himanta Biswa Sarma’s family.

Urgent work order issued to Agile Associates for PPE kits owned by Rajib Bora, a Guwahati-based businessman seen close to Himanta Biswa Sarma.

A perusal of the RTI replies to us and what is available at the Inventory Management System of NHM leaves several questions unanswered still. Also, the NHM’s disinclination to provide details on time and in full to the RTI application, and sharing only partial information even after pursuing it through further correspondence makes it look like The Wire and The Cross Current have only hit the tip of the iceberg as far as how the pandemic related emergency procurement by the Sarma-led health department of Assam government was carried out. 

The slew of reports that stemmed from parsing the RTI replies can be read below:

Himanta Biswa Sarma Bragged About Buying PPE Kits From China. But an RTI Reply Says His Govt Never Did.

Exclusive: Before Lockdown, Assam Govt Gave ‘Urgent’ PPE Orders to Firms Linked to CM. Here’s How They Turned Out

Assam CM’s Wife Says PPE Supply By Firm Was ‘CSR’, Silent on Contract Details

Exclusive: How the Bulk of Assam’s Sanitiser Orders Went to Firm Linked With CM at Much Higher Rate

Exclusive: Businessman Close to Himanta Biswa Sarma’s Family Received Lucrative PPE Order

Exclusive: Why Assam CM Wife’s ‘CSR’ Claim Was Likely an Afterthought

Exclusive: Why Assam CM Wife’s ‘CSR’ Claim Was Likely an Afterthought

During the pandemic, the NHM sent acknowledgement letters to firms for CSR donations and to individuals, for contributions. There is reason why the official format used in those letters was not used for Riniki Bhuyan Sarma’s firm.

This report is a joint collaboration between The Wire and Guwahati-based news portal The Cross Current.

Read the earlier reports of the series: on ‘urgent’ orders to a firm owned by Himanta Biswa Sarma’s wife Riniki Bhuyan Sarma, the bulk of Assam’s sanitiser orders going to a firm linked to Himanta, and how a businessman close to Himanta’s family received a lucrative PPE order.

Guwahati: On June 1 The Wire and The Cross Current published a joint report on the Assam health department – led by now chief minister Himanta Biswa Sarma in 2020 – granting an ‘urgent’ supply order for PPE kits to Himanta’s wife’s firm without following a tendering or quotation process. 

Hours after the report was published, the CM’s wife Riniki Bhuyan Sarma who is the owner of JCB Industries – the company which got the PPE kit order – issued a statement on Twitter claiming that the partial supply of the safety gear made by it to the state chapter of the National Health Mission (NHM) was her business entity’s ‘CSR’ activity.

‘CSR’ is ‘corporate social responsibility’ through which companies contribute to social ends.

Three official orders pulled out of the state NHM’s Inventory Management System explicitly show a reader what the official acknowledgement of a ‘donation’ or ‘CSR’ activity around PPE kits or any other pandemic-related essentials contributed to the health department of Assam looked like.

Additionally, taking help from three state government communications, made available through RTI replies to The Cross Current by the health department, this report will demonstrate how Riniki Bhuyan Sarma’s ‘CSR’ activity was not originally meant to be so. 

First, take a peek at this official order below, issued by the NHM director’s office on April 24, 2020, a month after the national lockdown was declared by Prime Minister Narendra Modi. It is an acknowledgement by the NHM of the Tata Trusts’ CSR activity of supplying 25,000 N-95 masks to the state government for free. 

NHM acknowledgement of the Tata Trusts’ CSR activity by The Wire on Scribd

The official order, which mentioned the quantity of N-95 masks received from the Tata Trusts, also duly recorded the ‘total amount’ and agreed ‘rate’ sections of it as zero, thus reflecting the fact that the masks were supplied to NHM for free by Tata Trusts.

If this is how the state health department – then under chief minister Himanta Biswa Sarma – issued official acknowledgment letters to a private trust for CSR activity during the pandemic, here is a peek at another such order.

The order below was issued by the NHM director’s office in acknowledgment of a CSR activity by a public sector giant.

NHM acknowledgment of a CSR activity by Oil India Ltd by The Wire on Scribd

In this official letter to Oil India Limited on July 5, 2021, issued by NHM director S. Lakshmanan, the format of acknowledgement of receiving free pandemic-related essentials was the same.

Oil India supplied free 500 oxygen concentrators to the NHM amidst the public health crisis then and the department duly reflected it by recording the ‘total amount’ and ‘rate’ sections of the acknowledgement letter as ‘zero’ – meaning the goods contributed to the department were for free. 

Let us also look at an individual’s donation to the NHM.

This official acknowledgment letter was issued by the NHM director to Pomi Boruah, who was then the officer on special duty to the department.

NHM’s acknowledgement of Pomi Baruah’s contribution by The Wire on Scribd

As stated clearly above in the letter, Boruah contributed 200 PPE kits for free after lockdown – on April 18, 2020. Since this was a donation, the acknowledgment order also duly recorded the ‘rate’ and ‘total amounts’ as ‘nil’.

Now, let’s look at the official ‘CSR’ activity acknowledgement letter issued to Utpal Boruah of JCB Industries by NHM director Lakshmanan on March 27, 2020.  

The text of this “appreciation” letter for CSR activity – seen below – clearly conveys the fact that 1,485 PPE kits supplied by JCB Industries to the NHM had already “served the health workers as well as patients”. This indicates two things:

1. That the intent to turn in the 1,485 PPE kits it had supplied to NHM as part of its ‘urgent’ work order of March 18, 2020, as ‘CSR’ activity was an afterthought and was done before the health department issued payment for that supply. 

2. That since those 1,485 PPE kits were received by NHM from JCB Industries as part of an urgent work order for 5,000 of them at the rate of Rs 990 per piece, the official format of the NHM director’s acknowledgment could not be used in this case. 

The NHM’s ‘appreciation’ letter to Riniki Bhuyan Sarma’s firm.

This is also the reason a cancellation order had to be issued to JCB Industries on April 6, 2020 (signed on April 4, 2020) explicitly stating its “failure in supplying the life-saving coverall protection kit in (on) time”.

The order cancellation letter also acknowledged that NHM received “only 1,485 nos [numbers] of kits out of 5000 kits” while also stating that it was a part of a “supply order placed to your company on M/S JCB Industries.” 

NHM’s ‘cancellation of supply order’ letter to JCB Industries, owned by Riniki Bhuyan Sarma.

The cancellation order was to officially close the ‘urgent supply order’ issued to JCB Industries for 5,000 PPE kits at the rate of Rs 990 each on March 18, 2020.

Understandably then, in the order issued to the chief minister’s wife’s firm – unlike in the letters issued to Tata Trusts, Oil India and Pomi Boruah – Lakshmanan’s letter mentioned, as can be seen below, the rate and the total amount sections. 

Urgent supply order for 5000 PPE kits at Rs 990 per kit by NHM to Riniki Bhuyan Sarma’s firm.

The total amount fixed for supplying those 5,000 kits to Riniki Bhuyan Sarma’s firm through preferential treatment was Rs 4,950,000 (49 lakh 50 thousand).

In the statement issued in response to The Wire and The Cross Current’s report, the chief minister’s wife said her firm didn’t “take a penny” for those 1,485 PPE kits but remained silent on wresting an ‘urgent’ supply order for the same kits prior to declaring them as her ‘CSR’ activity. 

Crucially, Riniki Bhuyan Sarma not only officially expressed her firm’s intent to supply PPE kits while her husband was the minister in the department but also got preferential treatment without going through the due process of tender or quotation. 

As per the government of India’s Code of Conduct for ministers (both Union and state), all state and Union ministers are to “ensure that the members of his family do not start, or participate in, business concerns, engaged in supplying goods or services to that Government (excepting in the usual course of trade or business and at standard and market rates ) or dependent primarily on grant of licenses, permits, quotas, leases, etc. from that Government; and report the matter to the Prime Minister, or the chief minister as the case  may be, if any member of his family, sets up, or joins the conduct and management of any other business.”      

The Government of India’s Code of Conduct for ministers, both in states and at the Union.

The Code of Conduct for all ministers – at the Union and all state governments – was approved by the Union cabinet at its meeting on January 24, 1992 in the Narasimha Rao era.

The 28-page Code of Conduct for Ministers, marked ‘confidential’, were shared by the Central Public Information Officer in November 2009 with New Delhi-based RTI activist Venkatesh Nayak.       

Note: An earlier version of this report had incorrectly stated the date of the NHM’s letter to Tata Trusts as ‘March 24’ (instead of April 24) and to Oil India as ‘2020’ (instead of 2021).

As Channi ‘Celebrates’ 100 Days as CM, Punjab Is Facing a Host of Protests

The ongoing protests have not only crippled teachings in colleges and universities but also the health system.

Chandigarh: From unemployed teachers, to health workers, contractual employees, truck operators and professors in colleges and universities, different sections in Punjab are protesting against the Congress government in the state for its failure to meet their various demands.

At many places over the past two weeks, protesters were gagged, dragged and even lathi-charged, with the opposition accusing the Charanjit Singh Channi government of apathy and high-handedness. These claims were only strengthened when unemployed teachers were literally dragged into police vehicles before Channi’s rally in Sangrur on December 15.

The government also seems to be keener on drowning out the protesters’ voices rather than engaging with them. On December 9, the government issued a bizarre order to cops in the state to play Gurbani and religious songs outside venues that Channi was facing to stifle sloganeering. Facing public outrage, Channi withdrew the order.

While the ongoing protests have crippled the education and health systems in Punjab, it did not stop Channi – who succeeded Amarinder Singh in September – from celebrating his 100 days as CM on January 1.

The major worry for people is that as COVID-19 cases rise, 12,000 health workers recruited under the National Health Mission (NHM) have been on a total work strike since November 12. As NHM staff members were on frontline COVID-19 duties, Punjab’s testing capability has subsequently dropped.

Punjab is trailing even in terms of vaccination coverage. While 64% of the eligible Indian population is fully vaccinated, Punjab’s coverage was just 45% as of December 30, 2021.

NHM president Dr Inderjeet Singh Rana told The Wire that the health workers should not be blamed for the indefinite work strike as they have been demanding regularisation of services for over five years.

“We gave several representations when Amarinder Singh was the CM and now to Channi as well, but all in vain,” he said.

He said In Himachal Pradesh, health workers recruited under the NHM are automatically regularised after three years of service. In Haryana, all NHM employees get the same salary and service benefits as regular staff. In Rajasthan, Andhra Pradesh, Tamil Nadu and half a dozen other states, NHM health workers are fully regularised.

“Why is there disparity in Punjab? While a regular doctor in Punjab is drawing over Rs 1 lakh in salary, a doctor recruited under the NHM gets paid only Rs 20,000. Many have left jobs because of low allowance. We have as many as 41 cadres working under the NHM in Punjab and each one gets just one-fourth the salary of regular health workers. This is despite NHM workers doing even more work than a regular staff member,” said Rana.

He added they had several meetings with the Channi government in the past two months but no progress was made.

“The NHM staff is the backbone of the state health system, working as specialised doctors, paramedics, nurses and even clerical staff. Over 100 NHM workers died due to COVID-19. The state’s response to our demand is shocking,” he said.

Teachers on indefinite strike too

Meanwhile, teachers in universities and colleges across the state have now been protesting for over a month after their salaries were not revised as per the latest University Grants Commission pay scale. Punjab is the only state in the country that has not yet revised the salaries. Since December 1, teaching staff in over 180 government colleges and all six universities in Punjab are on an indefinite protest under the banner of the Punjab Federation of University and College Teachers Organisations (PFUCTO).

Teaching staff in Panjab University, Chandigarh are also protesting. Panjab University Teachers Association (PUTA) president Mritunjay Kumar told The Wire that it is unfortunate that the Punjab government remains unmoved despite all academic activities across universities and colleges being suspended for the past month, affecting over 50,000 students.

“The onus is on the government to act fast and take appropriate measures to end the impasse,” he added

He said, “We never wanted to go for an indefinite protest but what options are we left with? All states in the country have revised the salaries of college and university staff since 2018 onwards.”

30 lathi charges, two dozen police cases

Meanwhile, unemployed school teachers seem to have faced the brunt of the government the most. Protesters have been lathi-charged over 30 times and around two dozen police cases have been registered against the teachers.

Deep Banarasi, state press secretary of Unemployed ETT-TET Pass Teachers Union, Punjab, told The Wire that more than 20,000 eligible teachers are waiting for jobs in the state.

The Congress had promised the teachers before the 2017 elections that if they complete the elementary teacher training (ETT) and teacher eligibility test (TET), they would surely be given jobs.

But with the government failing to live up to its word, unemployed teachers have been protesting.

“So far, we have faced as many as 30 lathi-charges across the state. Over two dozen cases have already been registered,” he said.

The state government argues that it had advertised 6,635 vacancies for candidates who have ETT in August 2021 but the selection process was stayed by the Punjab and Haryana high court. The matter is still sub-judice.

Deep, however, claimed that the state is deliberately delaying the matter in the court by seeking adjournments time and again. “With the election code of conduct just around the corner, the current state government is basically trying to skirt the issue. But we will not let it happen and keep fighting,” he said.

Apart from teachers who have ETT and TET, those who have qualified B.Ed and TET are also protesting.

Sukhjinder Singh Dhillon, the state convener of Unemployed B.Ed-TET Teachers Association told The Wire that as many as 30,000 B.Ed and TET pass teachers do not have jobs in Punjab at present and another one lakh aspirants just appeared in TET recently. But ever since the Congress government came to power, just 3,700 posts of BEd teachers were filled.

“We are permanently on protest in Jalandhar near the residence of Punjab education minister Pargat Singh since October. Yet the government is silent on giving us jobs,” he said.

He said, “We did a survey of four districts alone in Punjab where it was found that as many as 12000 B.ED teachers posts are vacant. But education, it appears, is not a priority for any government. They are just promoting private school education at expense of government schools. Where will poor students go in such a situation?”

While Aam Aadmi Party leader Arvind Kejriwal came out to support the unemployed teachers by joining the protest in Mohali last month, Punjab Congress chief Navjot Singh Sidhu reciprocated by joining the protest of guest teachers in Delhi.

Dhillion said that while leaders are good at pulling off gimmicks, when it comes to providing jobs, none has a roadmap. “It is important to fill up teachers’ vacancies in government schools since the level of education is already very bad,” he added.

Contractual staff in other depts also up in arms

Harkesh Kumar Vickey, president of the PRTC Contract Workers Union, told The Wire that there are close to 8,500 contractual employees working on different wings of government transport companies – PRTC, PUNBUS and Punjab Roadway.

“We had suspended our protest on December 22 after the state government assured us that the decision to regularise our services has already been taken. But the matter is still pending. We are holding a meeting on January 5 to take a call on resuming our protest since the present establishment is not serious about our demand. They are fooling us with false promises,” he said

On this issue, CM Channi put the blame on the Punjab governor. He said the state government has already passed legislation in the special session of the assembly after thoroughly working out all the modalities to pave the way for the regularisation of contractual employees. But the governor has not given it his nod.

Channi said the chief secretary and even he had personally met the governor to get the file cleared.

In a statement issued on Sunday, Punjab governor Banwarilal Purohit hit back at Channi, saying the latter’s claim that he was deliberately stalling the regularisation of contractual employees was “factually incorrect.” A statement issued by the Punjab Raj Bhawan said the file concerned had been sent back to the Chief Minister’s Office with six queries for clarification.

“This file was duly received by the CMO on December 31, 2021, and the reply to the queries is awaited… Once the reply comes, the Bill will be re-examined at the Governor’s Secretariat,” the Governor said.

Meanwhile, truckers’ unions in Punjab are also up in arms against the state government for its failure to fix minimum carriage rates.

Sukhwinder Singh Brar, convener of the All Punjab Truck Ekta Union told The Wire that Punjab currently has over 1.5 lakh small and big trucks. All operators are facing huge financial losses due to competition from other states, he said.

“We demand that the state either restore the truck unions it dismantled a few years ago or fix carriage charges,” he said.

He said in order to complete, several truck operators are forced to overload their vehicles against the rules. “This will stop if the state implements a fair price policy, he added.

Fund Transfer Delay Common Cause for Concern in States’ Health Performance 

Why are there such jarring variations in states’ overall performance?

The Health Index, titled Healthy States, Progressive India, published some time ago, presents an assessment of states and Union Territories, based on their health performance. 

The second edition of the report was an outcome of NITI Aayog’s resolute optimism that a ranking exercise would encourage a competitive approach for potentially better outcomes, and would therefore be crucial for meeting sustainable development goals (SDGs). It takes the period 2017-18 as the reference year, and 2015-16 as the base year.  

The Index evaluates the status of health in each state at two levels: overall performance and its incremental improvement.

Overall performance is an aggregate measure based on indicators in three domains: health outcomes, governance and key inputs and processes. It is judged on the basis of the composite index score, and accordingly categorises the states as ‘Front-runners’, ‘Achievers’ and ‘Aspirants’. 

The incremental progress, on the other hand, is calculated as the change in composite Index scores as compared to the base year. It is thus an indication of the levels of momentum in states to realise health gains over the period from the base year to reference year. 

Enormous degree of variation

There is significant variation in states’ overall performance. The composite index score of ‘Front runners’ is higher than 58.88, while that of ‘Aspirants’ has dwindled to below 43.74. The ‘Achievers’ hovered between 43.74 and 58.88.

The score for Kerala, ranked as the best performer for the second time, stands at 74.01, and Uttar Pradesh at the bottom end of the list has scored 28.61.

Andhra Pradesh (65.13), Maharashtra (63.99), Gujarat (63.52) and Punjab (63.01) are the other top performing states.

Also read: Why the Boost to Healthcare in Budget 2019 Should be Viewed With Caution

Together with Uttar Pradesh, Bihar (32.11), Odisha (35.97), Madhya Pradesh (38.39), and Uttarakhand (40.20) emerged as the least performing states.      

There is wide disparity on the incremental progress too. States showing nil or even negative incremental change fared as ‘Not Improved’, those with 0.01 to 2.0 points increase as ‘Least Improved‘, an increase of  2.01 to 4.0 points marked them as ‘Moderately Improved’.

The ‘Most Improved’ ones reflected more than a four point increase. Among the larger states, twelve states displayed a positive incremental change in the Index score. But only seven out of these twelve states made significant incremental progress leading to improvement in the overall performance position.  

Haryana was judged as the ‘Most Improved’ state as its health score increased the maximum, from 46.77 to 53.51. Rajasthan and Jharkhand too registered significantly high incremental performance.

Haryana qualified for this position not only on account of progress in most health outcome indicators like NMR (neonatal mortality rate), U5MR (Under 5 Mortality Rate), LBW (low birth weight in newborns) and SRB (sex ratio at birth), improvement in process related indicators too.

Healthcare continues to be accessible only at extremely high economic costs and social hardship to a vast number of people, Photo: Reuters

These indicators ascertained the proportionate size of vacant staff at the level of nurses, medical officers, institutional delivery, and the pace in which the fund flows from Centre to the spending unit. Bihar, on the other end, displayed the most negative incremental change.  

Need to probe input and process indicators 

The Index does a good job in providing a broad overview of performance of health services. The next step is an analysis of the areas highlighted in the report to examine the fundamental causes behind the problem.

As noted, the composite index discussed above is composed of 23 indicators, representing three domains – health outcomes, governance and information, key inputs and processes. 

This article narrows down its focus on the sub components of the third domain, pertaining to key inputs and processes. Some important indicators of this domain include time taken for National Health Mission (NHM) funds to reach the implementation agencies, number of functional health facilities, proportion of vacant health care provider positions in public health facilities, like nurses, doctors, ANMs, specialists.

Also read: ‘Health for All’ as a Political Question

These indices need to be probed further to understand the causal factors resulting in deficits, and corresponding low scores for many states.  There is a need to identify action areas for states, and apply the right strategies for improving their health outcomes. Only when each state takes this course for maximum incremental improvement, will the nation’s performance on health services go up. 

Delays in fund flow

A Centrally-Sponsored Scheme cannot be implemented efficiently at the ground-level without ensuring that funds from the Centre reach the implementing agencies in a timely manner. 

Data on the status of flow of Central NHM funds highlights huge dissimilarity in states (and UTs) in terms of the average number of days taken to transfer the fund from the Union level to Health Society responsible for expending these funds. A delay in fund transfer has a corresponding adverse effect on its utilisation. 

Telangana has the most efficient system with the transfer happening on the same day. Bihar and Jharkhand are plagued by delays up to 191 and 187 days respectively.

Some others like Odisha, Madhya Pradesh, Tamil Nadu, and some smaller states like Tripura, Meghalaya and Mizoram are affecting the fund transfer relatively sooner. 

Average number of days for transfer of Central NHM fund to implementing agency

NHM is governed by complex administrative procedures. An earlier study shows that the NHM budget has a break-up of over 1000 heads, with a very limited flexibility for utilising funds. The funds can be released by the state government only upon the issuance of a Sanction Order (SO).

Also read: Baghel Government Fails to Tackle Renal Failure in Chhattisgarh Village

This is a major factor contributing to the delays. Bottlenecks are also created by the fact that State Health Societies (SHSs) and the implementing agencies lie outside the administrative purview of the states.

Furthermore, the NHM budget has a break-up of over 1,000 heads, with a very limited flexibility for utilising funds, adding to the complicated architecture of fund release processes.

As a result, a high share of expenditure gets crowded in the last quarter of the financial year compounding the problem of low utilisation. Therefore, urgent efforts are needed to amend the rules and procedures that govern the release of public funds, with a focus to correct these systemic problems as a key strategy. 

Conclusion

It is hoped that the findings of this report lead to more intense discussions on issues of fund flow delays across states, in the policy circles. Fund transfer delay, and associated complexity is an area most states need to focus on. Both the Centre and the States need to take steps to mainstream the sector by addressing these deficiencies.

Interestingly, states who have been investing in nutrition and primary health care have managed to fix the systemic deficiencies, and are the high scorers in the Index. 

Achieving the SDGs on health will be difficult without understanding the causal factors of cracks in health care system. It is high time that the government paid attention to these loopholes that have long impeded progress in such an important sphere.

The impetus of the intensive process of bringing out the Health Index can be used to drive the nature of health services and kick start reforming institutional processes.   

Happy Pant is with the Centre for Budget and Governance Accountability. The views expressed in this piece are those of the author, and don’t necessarily reflect the position of CBGA. You can reach him at happy@cbgaindia.org 

Elections 2019: Have Politicians Delivered on Maternal Health Conditions?

It is worth to look a constituency-wise look at maternal health conditions, as just three states meet the target of 70 or fewer deaths per 1 lakh live births.

India’s maternal mortality rate is high and accounts for 20% of global deaths occurring due to preventable causes related to pregnancy and childbirth. Though the maternal mortality ratio has dropped from 212 deaths per 100,000 live births in 2007 to 130 deaths in 2014-16, the decline is not enough to meet the Sustainable Development Goal target of 70 deaths per 1,00,000 live births, and only three states – Kerala, Maharashtra and Tamil Nadu have been able to meet the target till date.

The 2018 Health Index spearheaded by the government’s policy think-tank, the NITI Aayog, and the Ministry of Health and Family Welfare have highlighted large gaps in overall performance of health indicators between the states and union territories.

However, having data at the sub-state/district level will help improve health indicators and the latest initiative by the Harvard University and partners based on the NFHS-4 have mapped development indicators, and procured data reveals high burden of maternal health in West Bengal, Madhya Pradesh, Uttar Pradesh and Bihar.

Anemia is a known cause of maternal deaths and risk factor for low birth weight. This is a major determinant for infant morbidity, mortality and long-term impact on health outcomes in adult life. Evidence suggests ante-natal care and institutional delivery as key health interventions to reduce maternal and child deaths.

Despite the evidence, almost 53% women in India continue to suffer from anemia, and the absolute gap between the highest and lowest prevalence across parliamentary constituencies is 57.5%. West Bengal, Jharkhand, Dadra and Nagar Haveli, Chandigarh and Rajasthan have the highest proportion of anemic women.

Constituencies with the greatest proportion of anemic women are Purulia in West Bengal, 80%, which is represented by Mriganka Mahato of the All India Trinamool Congress, Dadra and Nagar Haveli has 75.9% affected women, which is represented by Natubhai Gomanbhai Patel of the reigning BJP, then 74.4% in Chandigarh, Singhbhum in Jharkhand also has the same number of 74.4% of anemic women population, and Belurghat in West Bengal too has (74.4%) of women who suffers from the iron deficiency disease of anemia. These constituencies are represented by the BJP’s Kiron Kher, BJP’s Laxman Giluwa and the TMC legislator Arpita Ghosh respectively.

Kerala, Nagaland, Manipur and Mizoram have the lowest prevalence of anemia. Thiruvananthapuram, which is the constituency of INC’s Shashi Tharoor, has 22.5% of women suffering from Anemia. However, the northeastern state of Nagaland has the lowest prevalence of this disease amongst its female population, which is a mere 23.5%. The constituency is represented by Tokheho Yepthomi of Nationalist Democratic Progressive Party.

Credit: State of Nutrition among Children in Parliamentary Constituencies of India 2018. Tata Trusts: Mumbai, India

Low birth weight (LBW) prevalence in India is 18%, with no substantial decline in the incidence over the past few decades. The two constituencies with highest LBW are Mandsaur and Ratlam from Madhya Pradesh. Mandsaur has a LBW ratio of 35% and Ratlam of 30.5%. Both the constituencies are represented by BJP’s Sudhir Gupta (Mandsaur) and Kantilal Bhuria (Ratlam) respectively.

Followed by BJP’s Manoj Rajoria of Karauli-Dhaulpur in Rajasthan with a rate of 28.3%, Rampur in Uttar Pradesh has 27.5% and is ruled by BJP’s Nepal Singh, Sambhal in Uttar Pradesh has 27.1% and represented by BJP’s Satya Pal Singh, North West Delhi area in NCT of Delhi has 26.8% of LBW represented by Udit Raj who was with the BJP but now defected to Congress. Ujjain in Rajasthan has 26.8% of LBW, here the sitting MP is Chintamani Malviya of BJP. The absolute gap across parliamentary constituencies is at 31%, with the Northeastern state of Mizoram (4.1) with lowest prevalence of LBW.

The Indian guidelines on maternal health recommend at least three antenatal (ANC) visits, but data shows poor coverage of ANC, averaged at a mere 31% across the 543 constituencies of the country. The worst are across Uttar Pradesh and Bihar with eight constituencies below 10% women who availed minimum of four ANC visits.

Constituencies with low coverage are Bahraich in Uttar Pradesh 4.4% of BJP’s legislator Savitri Bai Phoole, Begusarai in Biha 7.9% of BJP’s Bhola Singh, Katihar in Bihar 8.9% of Nationalist Congress Party’s Tariq Anwar, Nalanda in Bihar 9% represented by Janata Dal’s Kaushalendra Kumar, Darbanga in Bihar 9.4% of BJP’s Kirti Azad, Madhepura in Bihar 9.6% of Rashtriya Janata Dal’s Pappu Yadav and Kaisarganj in Uttar Pradesh 9.9% of BJP’s Brijbhushan Sharan Singh. The government should make efforts to increase the level of awareness and knowledge among women about the adequate utilisation of antenatal care services.

The safe motherhood intervention-Janani Suraksha Yojana (JSY) under the NHM was launched with objective of reducing maternal and infant mortality by promoting institutional delivery among pregnant women. An observational study on JSY has found it to increase institutional delivery but calls for improved implementation programme. This is depictive from the average of 35% women availing services across the 543 parliamentary constituencies.

There are 15 constituencies which have a very low coverage (less than 5%) of women availing these health services. These are spread across Gujarat parliamentary constituencies of Ahmedabad West (1.6%) of BJP’s Kirit Premjibhai Solanki, Rajkot (3.7%) of BJP’s Mohanbhai Kalyanji Kundariya, Banas Kantha (4%) of BJP’s Haribhai Chaudhary, Gandhinagar (4.1%) of BJP’s Lal Krishna Advani, followed by Maharashtra’s Aurangabad (3.1%) of Shiv Sena’s Chandrakant Khaire, Satara (3.8%) of NCP’s Udayanraje Bhonsle, Jalna (4.7%) of BJP’s Raosahib Patil, Parbhani and (4.9%) of Shiv Sena’s Sanjay Haribhai Jadhav.

Besides these, three BJP constituencies of Karnataka Bangalore North (4.3%) of Sadanada Gowda, Bangalore South (4.3%) of late Ananth Kumar and Bangalore Central (4.3%) of P.C. Mohan are also under availed by the residents of these area.

The poor utilisation of services under the JSY, also reflects the low rate of institutional deliveries, with the sole exception of Gujarat attributed to the success of state run program, Chiranjeevi Yojana for improving access to institutional deliveries. Uttar Pradesh, Bihar, Jharkhand, Nagaland and West Bengal top the list of parliamentary constituencies with less than 50% institutional deliveries.

Of the 14 constituencies with less than 50% institutional deliveries, nine of them fall under the BJP. Namely Shrawasti in UP 35.6% of Daddan Mishra, Sitamarhi in Bihar 37.3% of Ram Kumar Sharma, Bahraich in UP 37.9% of Savitri Bai Phule, Sheohar in Bihar 43.4% of Rama Devi, Singhbum in Jharkhand 44.9% of Laxman Guliwa, Purvi Champaran in Bihar 45.1% of Radha Mohan Singh, Dumariyaganj in UP 45.3% of Jagdambika Pal, Darbhanga in Bihar 47.1% of Kirti Azad, Kaisarganj in Uttar Pradesh 48.9% of Brijbhushan Singh and Madhubani in Bihar 49.1% of Hukumdev Narayan Singh Yadav.

The data reveals clear inequality in maternal health across parliamentary constituencies in terms of maternal mortality rate and uptake of services like ANC or institutional birth. There are overlapping constituencies with poor performance of maternal health indicators like poor utilisation of JSY, less than 10% women receiving IFA tablets and low rate of institutional delivery. The parliamentary constituencies includes Bahraich, Shrawasti, Kaiserganj, Sitapur in UP. Besides, Sitamarhi and Sheohar in Bihar.

Social accountability mechanism seems to be lacking among majority of parliamentary constituencies. BJP with the biggest stake which is 268 out of 543 have the worst affected constituencies in terms of maternal health indicators. The NITI Aayog 2018 Health Index calls for regular tracking of health indicators at the state level with repetitiveness of priority areas.

A step further would be to go sub-state level to districts as well as parliamentary constituencies to have a greater degree of accountability of the MP’s for implementation of programs on maternal health. And also develop monitoring mechanisms for improved maternal health outcomes. The Member of Parliament Local Area Development Scheme could also be utilised for development of those areas which are on priority list and need immediate action.

This article was originally published on Observer Research Foundation.

Budget 2019: Underfunding of National Health Mission Continues

Former NHM Mission Steering Group members say there is a visible failure in strengthening the public health system.

The funding for the National Health Mission (NHM), the expanded form of the flagship programme of NRHM initiated in 2004 to strengthen the public health services, has been dropping consistently over the years.

In the financial year 2016-17, the government of India allocated Rs 19,437 crore for the NHM. This was a 2% increase over the 2015-16 allocations, but a dismal 1.18 % of the GDP expenditure. The 2019-20 interim budget has raised the allocation for the NHM from Rs 30,683 crore in 2018-19 to Rs 31,745 crore. This is close to the actual spending on NHM during 2017-18, which was Rs 31,510 crore.

Also Read: India’s Defence Budget is Nearly Five Times the Health Budget

In the past, during the meetings of the Mission Steering Group (MSG) of the NHM, we, as then members, consistently raised our concern regarding the mission’s underfunding. We are still grappling with the fact that public facilities in most parts of the country fall far short of the need and do not provide free access to medicines and diagnostics.

There is a visible failure in addressing the critical issues around strengthening the health system, such as access to generic medicines and diagnostics, freeze on recruitments in health sector, and contractualisation of health workforce. There is a huge deficit of human resources, which rises to over 80% in the case of specialists. Allocations for reproductive and child health (RCH) have been falling steadily from 40% to 15%. Maternal and child health, malnutrition, etc., have not received any priority either. Similarly, the funding for communicable diseases fell by 27%.

Ayushmaan Bharat envisages expansion of primary healthcare by upgrading the sub-centres to health and wellness centres (HWC). However, a significant proportion of sub-centres currently are reported to have poor infrastructure, are heavily understaffed and do not have the equipment or the drugs required for their functioning. For a sub-centre to be successfully upgraded to a HWC, it is important to allocate more funds.

Though the allocation for the NHM for 2019-20 has been raised, it is only an increase of Rs 1,062 crore over the 2018-19 budget, which does not even cover the prevailing inflation rate. The amount set aside for HWCs for 2019-20 is Rs 1,350 crore. Because HWCs are a new intervention, allocations should be in addition to expenditure on the existing NHM interventions. Here, it is obvious that the increased allocation to HWCs would have to come at the expense of other interventions, which is is extremely problematic.

Also Read: Budget 2019: Ayushman Bharat Gets Rs 6,400 Crore, But to Benefit Private Sector

In contrast, in this interim budget, the public funded Ayushmaan Bharat health insurance scheme (PMJAY) has received a major hike from Rs 2,000 crores to Rs 6,400 crores, even though it only covers selective in-patient care. Outpatient care, which accounts for the bulk of healthcare expenditure that people spend, is completely ignored by the PMJAY. The advocates of this scheme say outpatient care is not amenable to insurance mechanisms. This is a clear and deliberate intention to gradually weaken the public health system and move towards an insurance-based model of healthcare. However, such a move at the expense of the public health system will lead to disastrous results for a country like India, where a large section of population is poor and is critically dependent on public provisioning of healthcare.

The need of the hour is to revert attention to the NHM, which emphasised strengthening the public health systems for providing comprehensive care. There is also a requirement for higher levels of investment and human resources in this endeavour, not just a targeted package of curative services that the PMJAY aims to provide.

Sarojini Nadimpally, Yogesh Jain and Amar Jesani are ex-members of Mission Steering Group of the National Health Mission.