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Public Health System in UP: What Can Be Done?

This article offers a menu of options for reform of Uttar Pradesh's public health system. Though some actions have been taken after the introduction of the National Rural Health Mission in late 2005, a large number of very serious problems remain. Unless they are addressed, the monitorable targets of the Eleventh Five-Year Plan in regard to health and nutrition in India will not be met, since UP has such a large weight in the unmet needs of public health in the country.

PERSPECTIVEdecember 6, 2008 EPW Economic & Political Weekly46Public Health System in UP: What Can Be Done? Santosh MehrotraThis article offers a menu of options for reform of Uttar Pradesh’s public health system. Though some actions have been taken after the introduction of the National Rural Health Mission in late 2005, a large number of very serious problems remain. Unless they are addressed, the monitorable targets of the Eleventh Five-Year Plan in regard to health and nutrition in India will not be met, since UP has such a large weight in the unmet needs of public health in the country.It is common knowledge that social outcome indicators in the northern states are far worse than those prevail-ing in southern India. The outcomes are closely linked to the quality of services provided by the otherwise widespread and pretty adequate public health infra-structure. How effective the services are depends on how serious is the political commitment to improving the public health delivery. This has been amply demonstrated by the fact that Bihar, where the public health infrastructure is on many counts much worse than in Uttar Pradesh (UP), has recently shown a remarkable turnaround in the effectiveness of services and the utilisation of public health services has improved considerably, as the govern-mentof Bihar has demonstrated a politi-cal commitment to improve services.1 Given the improvement in health and education indicators in Rajasthan and Madhya Pradesh also in recent years, it appeared till recently that onlyUP and Bihar may remain within the erstwhile Bihar, Madhya Pradesh,Rajasthan,Uttar Pradesh (BIMARU) category of states.However, provided there is political commitment, there could be a similar turnaround inUP’s health system as well, given that in terms of health infrastruc-ture it is in most cases better endowed than Bihar. This paper diagnoses the problems with the government-provided health infrastructure, and goes on to suggest prescriptions for the medical malaise inUP.Section 1 examines the health outcome and output indicators for UP, apart from analysing the infrastructure and human resource gaps that the state faces, which are part of the malaise of the government health system inUP. Section 2 discusses a menu of options that the government has in terms of policy prescriptions. Section 3 reviews briefly the actions that the UP government claims have been taken to address some of the problems identified in Section 1, drawing upon the National Rural Health Mission (NRHM) funding and guidelines. It also highlights the specific problems that remain with the implemen-tation of the NRHM agenda of reforms in the government health system. The final section concludes.1 Diagnosing the Malaise In this situation analysis of the health indicators of UP, we will focus on a com-parison with only one other BIMARU state – with which most of the Indian intelli-gentsia bracketsUP – namely, Bihar. The comparison will also be with the Indian average for the same indicator.TheNRHM lays down the standards or norms that have to be achieved in the country. Therefore, theNRHM is making an effort to strengthen the public health system of: village level providers (at least one accredited social health activist (ASHA),anganwadi worker (AWW), village health drug day kit for 1,000 population); sub-primary health centre for five to six villages (with maternal and child health (MCH)/immunisation days) for population with a telephone link; primary health centre for 30-40 villages with round the clock services; and a block level hospital for 100 villages or 100,000 population.Child Health: Table 1 (p 47) shows that the indicators of child health inUP in 2005-06 (National Family Health Survey 3) are not only much worse than for India on the whole, but actually worse than those in Bihar.Preventable deaths of children under five have been dramatically reduced by public health interventions in all high-achieving developing countries in the world (Mehrotra and Jolly 1997) and also by high-achieving states in India. How-ever, inUP barely 23% of all children below two years of age have been fully immunised, or half the Indian average, and 50% less than in Bihar.Maternal Health:Institutional delivery is another good indicator of the demand for the public health system. Table 2 (p 47) The statistical assistance of Purnachandra Rao is gratefully acknowledged. Thanks are due to Naresh Saxena, A K Singh and participants at a Observer Research Foundation Seminar on UP, May 2008, for comments on an earlier draft.Santosh Mehrotra (santosh.mehrotra@nic.in) is consultant to the Planning Commission, New Delhi.
PERSPECTIVEEconomic & Political Weekly EPW december 6, 200847shows that barely 22% ofUP’s mothers are delivering babies in an institutional setting, the same as in Bihar and again roughly half of the Indian average. 2 Only half of Indian women had at least three antenatal care visits for their last birth, but the share of UP women is only half of the Indian average; Bihar was doing worse in this respect. After birth, the mother should ideally receive health check-ups and supplemen-tary nutrition, and there are arrangements for this at the anganwadi centre (AWC). However, theAWCs in the entire country have been notoriously ineffective in per-forming this role (Table 2), but inUP they have functioned even worse than in the rest of the country. Health Inputs: Without clean water and sanitary means of excreta disposal there is little possibility of a dramatic improve-ment in health outcomes. The remarkable phenomenon here is that even in urban areas where piped water is available to three-fourths of the nation’s population, only 35% of urban UP residents have access to piped water (Table 3, p 48).The share of rural households that have a toilet is barely 16% inUP (same as in Bihar), and way below the national average (26%). Overall, a third of UP residents have access to a toilet facility, while that share is 45% in the country as a whole. Clearly, the Total Sanitation Campaign, the centrally-sponsored scheme of the ministry of rural development (depart-ment of drinking water and sanitation), has its work cut out for itself inUP as does the state government. What isremarkable is that 92% of hospitalisationcasesin rural UP were on account of infectious and parasitic diseases, especially for diar-rhoea and gastroenteritis. This indicates clearly the widespread problem of poor water quality and the absence of basic sanitation and hygiene (Jan Swasthya AbhiyanUP 2008).The Health Infrastructure:The popula-tion served in UP per government hospital, per government hospital bed, per doctor, per primary healthcare sub-centre, per primary health centre (PHC) and per com-munity health centre (CHC) are all system-atically lower than the national average, but at the same time in all cases better than in Bihar (Table 4, p 48). That clearly suggests that there is a desperate need to address the infrastructure disadvantage thatUP’s public health system suffers from and which should be funded from NRHM – which is already allocating some Rs 7,000 crore to UP (2006-07).The population served per government hospital in India on average is 1.45 lakhs, inUP it is 1.98 lakhs and in Bihar 8.7 lakhs. Similarly, the population served per gov-ernment hospital bed is 2,257 in India, but 5,646 inUP and an astounding 28,959 in Bihar. However, the situation is not so bad in respect of sub-centres andPHCs, in which case the population served inUP is reasonably close to the national average. In other words, the problem is primarily with government hospitals and with gov-ernment hospital beds.The remarkable situation is that inUP the number of sub-centres stood at 20,153 at the end of the Seventh FYP (1990) (after having increased from 15,653 at the end of the Sixth FYP in 1985); but the numbers did not increase during the EighthFYP (1992-97), nor in the Ninth FYP (1997-2002). Hence at the end of 2005, the number of sub-centres stood pretty much where it was at the beginning of the 1990s. Something very similar happened in res-pect ofPHCs inUP. Their numbers had doubled (from 9,115 at the end of the Sixth FYP to 18,671 at the end of the Seventh FYP). Over the EighthFYP the numbers increased by about 12%, but almost not at all during the Ninth and Tenth FYP peri-ods, so the total number ended up at only 23,236 by September 2005.Two other indicators are very impor-tant to determine the effectiveness of the public health system: the average rural population served by the population health infrastructure and also the aver-age rural area/radial distance covered by it. Both the average area (in sq km) and the radial distance (in km) inUP from sub-centres (1.91 km radial distance), PHCs (4.51 km), and CHCs (13.9 km) is less than the national average (2.61, 6.3 and 17.22 km, respectively) and not signifi-cantly different from that prevailing in Kerala. In other words, if the sub-centres, PHCs and CHCs were to function it would not be that difficult for people to actually seek medical care in them. However, part of the difficulty is that the average rural population covered by the primary healthcare infrastructure is higher inUP than the national average (6,416 as against 5,085 for sub-centres, 35,972 vis-a-vis 31,954 for PHCs, and 341,084 vis-a-vis 221,904 for CHCs). The further difficulty is, of course, that doctor and paramedical staff absenteeism from duty is endemic inUP, slightly more so inUP than in other states of the country (according to a World Bank study of 2004).In addition to the primary healthcare infrastructure discussed above,UP also has one of the country’s most extensive Table 1: Child Health IndicatorsIndicators UttarPradeshBiharIndia Rural Area Urban Area Combined Rural Area Urban Area Combined Rural Area Urban Area CombinedInfant mortality rate 75.0 64.0 72.7 63.0 54.0 62.0 62.0 42.0 57.0Child mortality rate – – 25.6 – – 24.7 – – 18.4Total fertility rate 4.13 2.95 3.82 4.22 2.87 4.00 2.98 2.07 2.68Children age 6-35 months who are anaemic (%) 85.7 82.5 85.1 89.0 75.8 87.6 81.2 72.7 79.2Children 12-23 months fully immunised(%) 20.5 32.6 22.9 31.1 45.6 32.8 38.6 57.5 43.5Percentage of children with a birth weight less than 2.5 kg – – 25.1 – – 27.6 – – 21.5– not available. Source: National Family Health Survey (NFHS-3), 2005-06. Table 2: Maternal Health Indicators(in %)Indicators UttarPradeshBiharIndia Rural Area Urban Area Combined Rural Area Urban Area Combined Rural Area Urban Area CombinedMothers who had at least three antenatal care visits for their lastbirth 22.6 40.9 26.3 14.5 36.2 16.9 42.8 73.8 50.7Trends in institutional deliveries 18.0 40.0 22.0 19.0 48.0 22.0 31.0 69.0 41.0Source: National Family Health Survey (NFHS-3), 2005-06.
PERSPECTIVEdecember 6, 2008 EPW Economic & Political Weekly48publicly-funded ayurveda, unani, siddha, yoga, naturopathy, homeopathy (AYUSH) hospital and dispensary systems in the country. While India has 3,198 such hos-pitals, UP alone had 1,973 of them, or nearly two-thirds. In addition, it had 1,871 such dispensaries, of the over 21,000 in the country. In other words, quite clearly the primary health infrastructure inUP is not exactly poor. The real issue is the kind of services provided by the personnel employed there.Health Personnel and Their Facilities: The impact of the infrastructure shortfall has a corresponding shortfall in staff. Although the ASHA is the community out-reach worker as of 2005, the auxiliary nurse midwife (ANM) or multi-purpose fe-male worker is the real front line health provider within the public health system, located at the sub-centre. The number of ANMs required inUP was over 20,000 (as of September 2005), a number twice as large as in the next highest state and the shortfall was of the order of 3,198, which was greater than the shortfall (relative to requirements determined by norms) in all other states taken together. If staff is going to be found at the health facility, there is a higher likelihood that patients will be attracted to them. One factor determining whether medical staff will arrive at work is if they have staff res-idential quarters at the health facility. Of the 20,521 sub-centres (as of September 2005), 32% had ANM quarters and in most of them theANM was actually living in the quarter (5,183 of 6,494)(Table 5, p 49). But given that two-thirds of the sub-centres did not have staff quarters, it would be hardly surprising if theANM rarely showed up for work.Even if staff showed up for work, they can do their job only if minimal facilities are available: water supply, electricity and all weather approach road. Of all sub- centres inUP, 59% did not have regular water supply, 75% did not have electricity, and 56% were without an all weather ap-proach road (Table 5). Under such condi-tions, it is no surprise that the public health infrastructure suffers from under-utilisation of its facilities.Even more shocking is the state of PHCs. None of the UPPHCs had a labour room as of September 2005; none had an opera-tion theatre, only 50% had four to six beds and information about a 24 hour delivery facility was not available. All these bare minimum facilities were available in most of the other states. Nutritional Outcomes: It should have shocked the nation that half of India’s children are malnourished (2005-06) and the situation has not improved at all since 1998-99, the last time a compa-rable survey was done. UP is doing as badly as India on average and not much worse, though its child rate of underweight is lower than that of Bihar. However, it is unclear wheth-er this is any con-solation, since a higher proportion of UP’s children are stunted compared to Bihari children, while Bihari children are doing worse in terms of wasting. The most important intervention by the government to address malnutrition has been the Integrated Child Development Scheme (ICDS), withAWCs in each village. TheAWC is supposed to provide six services: (a) supplementary nutrition; (b) pre-school education; (c) immunisation; (d) health referrals; (e) growth monitoring; and (f) health check-ups. But for AWCs to pro-vide these services they have to be univer-sally available.UP has one-seventh of all theAWCs operational in the country, and the number is likely to increase, since AWCs are to rise in number to universalise ICDS, as per the instructions of the Supreme Court. But forAWCs to function, they must have theAWWs and helpers; but over 15,000AWWs and 17,000 helpers are in short supply, and have to be appointed (funds for which are made available by the central government).Even if the shortfall in infrastructure and staff were met, the real issue is whether the parents perceive the pro-gramme to be effective. The evidence from both theFOCUS Survey in 2006 as well as the NFHS 3 in 2005-06 does not seem to be encouraging. One reason is that the government ofUP has shown little interest in switching from centrally procuredpanjiri, which is currently dis-tributed to children and mothers by way of supplementary nutrition, to hot cooked meals – which is the practice in at least 15 states around the country but is also a requirement as per instructions of the Supreme Court. Public and Private Expenditure on Health: The state of primary healthcare in UP is partly reflected in the fact that compared to the rest of India, patients have to spend more out of their pocket, with private health expenditure as a pro-portion of total health expenditure being 92%, way above the national averageof 79% (Table 6, p 51). This is partly a reflec-tion of the fact that theUP government’s health expenditure per capita (Rs 84) is less than half the average of all states of India (Rs207). At the same time, private health expenditure per capita inUP is way above the national average, even though it has one of the lowest per capita incomes in the country. It is obvious that high pri-vate expenditure is not only inequitable (as it adversely impacts the poorest people in one of the poorest state of India) but highly inefficient, since UP has one of the poorest health outcome indicators in the country. Table 3: Water and Sanitation(in %)Indicators UttarPradeshBiharIndia Rural Area Urban Area Combined Rural Area Urban Area Combined Rural Area Urban Area CombinedHouseholds using piped drinkingwater 2.0 34.8 10.3 1.2 19.8 4.2 27.9 71.0 42.0Households with access to a toiletfacility 16.0 83.7 33.1 16.2 73.0 25.2 25.9 83.1 44.5Source: National Family Health Survey (NFHS-3), 2005-06. Table 4: Health Infrastructure as on March 2006Particulars UttarPradeshBiharIndiaPopulation served per government hospital 198,143 868,712 145,137Population served per government hospital bed 5,646 28,959 2,257Population served per doctor 23,986 NR 15,122Population served per sub-centre 8,931 10,245 7,671Population served per PHC 50,077 55,303 49,062Population served per CHC 4,74,824 12,96,457 2,84,446Government hospitals include central government, state government and local government bodies.NR = information not received, NA = not available. Source: National Health Profile, 2006.
PERSPECTIVEEconomic & Political Weekly EPW december 6, 2008492 PrescriptionsA Menu of Prescriptive Options The situation analysis of outcomes inUP demonstrates in no uncertain terms that the public health system is not delivering; this implies that public health is not prior-itised by policy. Moreover, there is a clear impression from the government of UP (GOUP) policies that the focus of the gov-ernment health system still remains cura-tive and clinical care, rather than preven-tive and primary health services – when in fact, the focus should be exactly reversed, with the latter taking primary priority over the clinical care services.Given that UP has among the worst health indicators in the country,UP needs to be at the forefront of the efforts to im-prove health outcomes. This is especially important since UP is one of the only six states in the country where the number of poor has not declined for over 30 years (1973-74 to 2004-05, according to NSS sur-veys), and in fact, it is one of the six states where the number of poor has actually in-creased to 54 million in 2004-05. It is also well-known that poor health outcomes are highly correlated to poverty.Preventive/Promotive MeasuresThe following public health measures need to be addressed.(1) There is a need for doctors in rural areas, since qualifiedMBBS doctors have shown unwillingness to live and work in rural areas. To address the need for doc-tors in rural areas, both the UP govern-ment and the Planning Commission’s Eleventh FYP make a case for starting a three-year as opposed to the current five-yearMBBS course. There is an urgent need to initiate such a course inUP, with the objective of part meeting the needs for rural doctors; once appointed these doctors would be required to serve in rural areas for at least three years. The UP government should initiate such a course in medical colleges at the earliest. (2) There is a large body of “registered medical practitioners” (RMP) of highly un-even quality inUP, who claim to provide medical services. There are essentially two types of such providers (even though both may be lacking in verifiable qualifi-cations and credible training) – complete quacks and those who have some medical experience. There is no alternative to to-tally eliminating the first category – and it is entirely un-clear what ac-tion the UP government is contemplating to achieving this task. The point is not to enforce a ban that al-ready exists, but rather to weed out the system of illegal registration of such “RMPs” that has flour-ished. At the same time, the public would need to be educated that without a legal registration, a RMP is a quack, and should not be approached. The second category, however, needs to be incorporated into the health provision system, through a process of professionalisation focused on their training – which could serve as a means of incentivising and thus legitimis-ing them. The Rajasthan Registered Medi-cal Practitioners Association has adopted a criteria to identify such providers who could be “professionalised” through regular training. This requires that theUP health department prepare a checklist to facilitate identification of such providers, who would then be provided training at existing training schools forANMs andASHAs.(3) There is need for greater synergy in the training efforts of the National Institute for Health and Family Welfare (New Delhi) andUP’s State Institute of Health and Family Welfare (SIHFW, Luc-know). The State Institute needs to lead the training of the second category of RMPs. However, it is likely that the SIHFW would itself be understaffed, and would therefore need additional trainers in order to undertake the large-scale training of potential RMPs that would be required to meet the needs of the population. The NRHM funds are already available under the flexi-pool of funds from the central government for hiring consultants at the SIHFW in Lucknow, to strengthen the faculty to conduct such training. (4) Training of rural practitioners should be to promote and actively support public health measures, including immu-nisation, oral rehydration therapy for diarrhoea, diagnosis and treatment of pneumonia, support of family planning and the regular provision of oral contraceptive pills, condoms and other spacing methods. They should, at the same time, recognise and refer the more severe and chronic health conditions, especially tuberculosis (TB), leprosy, kala-azar, Japanese encepha-litis, malnutrition, human immuno defi-ciency virus (HIV), etc, to the PHC.(5) The GOUP needs to encourage the attachment of rural practitioners to quali-fied doctors that would result in a continu-ing relationship of guidance and upgraded knowledge. (6) Now that the GOUP has finally de-cided, following the very successful expe-rience of the Tamil Nadu Drug Procure-ment Corporation, to create a drug pro-curement corporation of its own, drugs should be made available withRMPs,PHCs and sub-centres. An audit mechanism has to be created that also monitors PHC doctors’ prescriptions behaviour, since doctors tend to prescribe drugs that are not available in the PHC pharmacy – since there is collusion between outside private pharmacies and those of the PHC. The PHC doctors’ prescriptions should naturally be based on a list of generic essential drugs. Use of such drugs would increase the effectiveness of the treatments prescribed byRMPs and PHCs and sub-centres, and discourage the use of injections; together such actions would enhance the credibili-ty ofRMPs in the eyes of the public, and thus increase their practice.(7) Research evidence over the years and across the country shows that the best doctor is the government doctor who is engaged in private practice. The govern-ment doctor’s salary should, therefore, have two components: a base salary in the form of a retainer; a second component, based on performance measured entirely on the number of patients seen. Table 5: Facilities Available at Sub-Centres(as on September 2005)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 ANM Quarter ANM Living Supply Motarable in Sub-Centre Approach QuarterRoadUttar Pradesh 20,521 6,494 (32) 5,183 12,083 (59) 15,332 (75) 11,572 (56)Karnataka 8,1434,493(55)4,493 nananaKerala 5,094 2,528 (50) 1,659 1,292 (25) 913 (18) 351 (7)Figures in bracket give the corresponding percentage. na-not available.Source: Rural Health Statistics in India 2006.
PERSPECTIVEdecember 6, 2008 EPW Economic & Political Weekly50Population-Based Public Health MeasuresSanitation: There is little likelihood of a decline in child malnutrition rates or IMR unless coverage of safe sanitation im-proves. The Total SanitationCampaign (TSC) requires the states to compete in engineering behavioural changes; the lat-ter requires that villages are declared open-defecation free (ODF) zones. Of the 70 districts inUP, only 30 have more than 33% sanitation coverage. The GOUP cannot expect much improvement in addressing malnutrition and reduction in communicable diseases in the absence of a serious effort to implement the TSC programme, and without advancing the date (2012) for coverage of the entire state. Malnutrition: The National Family Health SurveyIII (2005-06) shows that UP’s child malnutrition rate is 47%, while the national rate is 46%. The ICDS cover-age is low, even though the Supreme Court has for several years been instruct-ing state governments to universalise ICDS, and to end contractor-driven sup-plementary nutrition. However,UP risks being now in contempt of the Supreme Court if it continues with the contractor-driven supplementary nutrition. Second-ly, the allocation for ICDS is being signifi-cantly increased during the EleventhFYP for ICDS; the programme must be rapidly universalised, with a focus on scheduled caste communities, since it is their ham-lets which are currently under-provided inUP withAWCs. Immunisation: The immunisation pro-gramme has been overtaken by the focus on the “polio plus” campaign, to the detri-ment of the entire immunisation effort. Not surprisingly, the increase in the immu-nisation rate in UP between 1998-99 (NFHS2) and 2005-06 (NFHS 3) was barely 3 percentage points, from 20% to 23%. It is obvious that polio might be a special pro-blem besetting UP in particular, but it can-not be addressed at the expense of the remaining preventable diseases.Campaigns: There is a special need to adopt a campaign approach in the following areas on an urgent basis, since these are low-hanging fruit which can be plucked by the GOUP to bring about quick results: (1) Data shows that reducing or eliminating births that occur less than 24 months apart could attain the greatest re-duction in child mortality. However, unfortunately the entire health and family welfare programme is oriented towards sterilisation, when it should be focused on increasing birth spacing through condom use. Also, child bearing in the age group of below 20 is five times more as compared to the 35 plus age group, and these births are at short birth intervals (Second Human Development Report of UP 2007). The mean age at marriage inUP remains around 16. Thus campaigns are needed to discourage child bearing among women less than 20, to raise the age of marriage, and encourage birth spacing. (2) By far the largest differential between female and male child mortality is in the age group 1-5 (i e, not in the first year after birth), with female child mortality being much higher. Females under one year may be less disadvantaged relative to males because children of both sexes are breast-fed. After breast-feeding stops, the poten-tial for differential treatment of boys and girls increases. Clearly, a campaign is needed informing people all the facts, and advising corrective action within the household.System-Wide Needs of Infrastructure: First, the shortage of ANMs arises because the training centres have not been con-ducting training since 1992 – encouraging a de facto privatisation of the healthcare system in the state ofUP. During 1992-2004 pre-service training ofANMs did not take place; training was restarted only in 2004. There are 40 ANM training centres in the state, each with a training capacity of 60 per batch. Of these 30 have been made partially funcitional. There is a problem as regards the availability of tutors, which should be resolved, by hiring them on a consultancy basis for temporary periods, against funds to be drawn from NRHM. In addition, there are 30 district training centres which are non-functional at present, and should be reactivated, and if necessary, funds utilised fromNRHM for the purpose.The GOUP has made a request to the central government that as part of a pack-age for Bundelkhand and Poorvanchal regions of UP, three new requirements should be met. First, Jhansi needs an All-India Institute of Medical Sciences (AIIMSS). The ministry of health of the union govern-ment has already decided, meanwhile, that of the six new AIIMSs being created in the country during the Eleventh FYP, one should be set up in Varanasi. Second, the GOUP would like to see a National Institute of Virology (NIV) in Gorakhpur, to helpUP address the prob-lem of Japanese encephalitis, a disease which is endemic in the north-east of UP (UP accounts for 60% of India’s cases of Japanese encephalitis). The NIV in Pune already has an outpost in Gorakhpur. However, it is not entirely clear what pur-pose will be served by a new national in-stitute, when one already exists; nor was it made clear how a national institute of virology will resolve the problems of sani-tation, water quality and hygiene, which are the underlying and proximate reasons for the high incidence of Japanese encephalitis in the sub-region. Nevertheless, a NIV has already been sanctioned for Gorakhpur by the central government. Third, medical colleges in UP are severely short of staff; so the GOUP wants the union government’s to provide finan-cial support to create new medical colleges to train such staff. However, it is not clear how the latter is a solution to the problem of staff shortage in medical colleges. Apparently, the real problem is that while the existing UP medical colleges do get enough good applications for staff for clinical faculty positions (eg, medicine, surgery), they do not for para-clinical (social and preventive medicine, pharmacology, etc) and for pre-clinical (eg, biochemistry, physiology, anatomy). This is because not enough students wish to register for post-graduate training in the latter two sets of disciplines as they prefer only clinical dis-ciplines. If existing medical colleges can-not adequately staff faculty positions for para- and pre-clinical positions, it is totally unclear how creating new medical colleges will solve the problem. Fourth, to fill vacant positions for doc-tors in rural PHCs, GOUP is making the legitimate case for creating a new course
PERSPECTIVEEconomic & Political Weekly EPW december 6, 200851which will require fewer number of years than the current five years for a medical (MBBS) degree. Fifth, the GOUP also made a case for budget support from the central govern-ment to create new medical colleges, with total capital costs being shared equally between the state and central govern-ments. Based on the norm of one medical college for every 50 lakh population, there is indeed a deficit of 24 medical colleges in UP. There are 11 medical colleges inUP – seven in the public sector and four in the private sector. By contrast, the southern states more than meet the norm. Naturally, the southern states produce more doctors thanUP, althoughUP’s population is much larger. However, the southern states have a larger number of private medical colleges than public ones. UP, on the other hand, has failed to attract private invest-ment in medical education. Sixth, even if new medical colleges were to come up inUP, without putting in place a mechanism to ensure that the doc-tors produced by medical colleges will actually be willing to serve in rural areas, it is unclear how the larger supply of phy-sicians and surgeons will solve the prob-lems with the health delivery system. Tamil Nadu has an effective system to ensure that doctors employed by the gov-ernment actually serve in rural areas, which the GOUP has signally failed in en-suring. Besides, there is a provision in the EleventhFYP for converting some district hospitals into medical colleges, through the public-private partnership mode. Seventh, in addition to the measures proposed to revive the government health system inUP, there is a nation-wide pro-posal to introduce health insurance for the below poverty line (BPL) families. There are one crore BPL families inUP (BPL population is 5.4 crore). With a pre-mium of Rs 500 to provide coverage of Rs 30,000 perBPL family of five, theGOUP will need Rs 500 crore to cover the cost of health insurance premium to cover all BPL families. TheGOUP is willing to contribute Rs 100 crore of the Rs 500 crore required; it also believes that families could be re-quired to contribute Rs 100 per family to-wards the premium (or Rs 100 crore for all BPL families per annum). The remaining Rs 300 crore would need to come from the central government. A pilot project (with a GOUP allocation of Rs 10 lakh) has been initiated. Urgent action is needed to quickly put in place the project, so that the learning from the project could be used to universalise health insurance forBPL families inUP. 3 Changes under NRHMIt should be recognised that within the last year, some changes have indeed occurred inUP’s public health system – thanks to theNRHM. It should be noted, of course, that health is a concurrent subject in the Constitution, and state govern-ments are dominantly responsible for health provisioning. TheGOUP has claimed that the following actions have been taken and improvements in services have occurred.Janani Suraksha Yojana has already in-creased the number of institutional deliv-eries by more than twofold. It is proposed to operationalise one district women’s hospital and at least two CHCs per district as first referral units during 2008-09. This unit will be well equipped to perform cae-sarean operation and intensive neonatal care. Dai training is being implemented in big way so that at least one to two trained dais are available for every 1,000 popula-tion who will help the community to deliver in hygienic conditions at home, if institutional delivery is not possible.Presently, 300 out of 823 PHCs are func-tional round the clock (24×7). All PHCs will be functional as 24×7 during 2008-09. Three staff nurses are being contracted at each PHC and six at each CHC under NRHM. Contractual lady doctors of the Indian sys-tem of medicine at PHC level in phased manner are being appointed. The pilot was initiated in 10 districts at two block PHCs each and is being expanded now. The comprehensive child survival pro-gramme has specially been designed for UP, where communication strategy for behaviour change, home-based care of the new borns and integrated manage-ment of neonatal and childhood illness has been combined for best results. In the first phase 17 districts have been selected (one from each administrative division of the state) with highestIMR and availabili-ty of minimum required infrastructure. All the medical officers, staff nurses, ANMs and ASHAs are being trained under the project. Fixed day, fixed time, fixed place schedule is being followed for village level monthly immunisation days.As regards malnutrition, a bi-annual Bal Poshan Swastha strategy is being im-plemented in all the districts with the help of UNICEF andICDS. Iron administration has been included for pre-school children underNRHM, and also compulsoryIFA to all pregnant women. Iodine deficiency control programme has been expanded underNRHM umbrella.As regards, the poor health infra-structure sub-centre and PHC construc-tion isunder way in a phased manner under NRHM. CHC upgradation and strengthening of district hospitals as per IPHS is also underway in phased manner underNRHM.TheUP government’s self-assessment of its achievements after NRHM needs to be itself evaluated. We will rely upon two sources for such an evaluation: the NRHM’s own Common Review Mission ((hereafter NRHM Mission Review) by a combination of independent and government special-ists and experts in November 2007)3 and also an evaluation by the Jan Swasthya Abhiyan (hereafterJSA report) an inde-pendent NGO that has been surveying states where the NRHM has been imple-mented over 2006-08. What emerges is the following:Throughout the country the ASHA pro-gramme is a major component of the NRHM strategy. The Janani Suraksha Yojana is another visible and welcome Table 6: Public and Private Expenditure on Health, 2001-02States Health Expenditure (in Rs 000s) Public Exp Private Exp Per Capita Expenditure (in Rs) as a % of as a % of TotalTotal PublicPrivateTotalExpenditureExpenditurePublicPrivateTotalUttar Pradesh 1,40,88,564 17,40,25,330 18,81,13,894 7.5 92.5 84 1,040 1,124Bihar 77,08,790 5,74,55,419 6,51,64,209 11.888.192687 779India 21,43,91,018 81,81,04,0321,03,24,95,050 20.879.2207 790 997All India public expenditure including expenditure by the MOHFW, central ministries and local bodies, while private expenditure includes health expenditure by NGOs, firms and households.Source: National Health Profile 2006, National Health Accounts and M/o.Health and Family Welfare, GOI.
PERSPECTIVEdecember 6, 2008 EPW Economic & Political Weekly52component. Untied funds have been an-other successful component at all levels, provided to the sub-centre, PHC and dis-trict hospital.4 Hospital development soci-eties (Rogi Kalyan Samitis) have also been formed in most states, and along with the provision of untied funds to them are act-ing as enablers of facility development. The Indian Public Health Standards (IPHS) have been introduced, and widely circu-lated; they are acting as a valuable bench-mark for facilitating states to reach desir-able levels of both infrastructure and human personnel.Of the 13 states visited by the NRHM Review Mission almost all have reported increased performance in terms of abso-lute attendance and to a lesser extent in terms of quality of care. Since we started our analysis in Section 1 by comparing UP’s performance with that of Bihar, it is worth quoting the NRHM Review Mission’s summary finding on Bihar: ...(there is an) increaseinblockPHCOPDs [out-patient department examination of patients] from 39 per month two years ago to over 2,500 per month now for many months, and from 7,000 institutional deliveries in government institutions in October 2006 to over 100,000 deliveries in October 2007…Given the low utilisa-tion of public services in Bihar as reported by NSSO 60th Round 2004-05 (5% out- patient and 11% in-patient treatment in government institutions), this is indeed outstanding. There is a confidence that the public system shall deliver quality healthcare services and people are flock-ing to the public system to utilise services even on holidays and over weekends.We turn our attention now to UP’s performance underNRHM, by key subject.ASHAsThe guidelines state that the selection of ASHAs should be done in consultation with all the villagers. She should be a married/divorced woman residing in the village. At least three-four consultations should be done with the villagers and a final list should be approved in the gram sabha. The JSA Report for UP finds that 56% of the ASHAs were selected in a meeting, the remainder were recommended with-out such procedures. There could be an opportunity for auto-correction since poorly selectedASHAs, who were expect-ing regular remuneration or a government job, tend to drop out and replacements could be done better.Drug kits are supposed to be given to each ASHA. The review mission report notes that while drug kits have been given to all Mitanins (ASHAs by another name) in Chhattisgarh, and about 50% of ASHAs in Rajasthan and Assam, they are not yet distributed inUP, since drug procurement is not complete. This deprives the programme of much effectiveness.International development and relief NGO seeks staff for Regional Office based in DelhiDocumentation and Information OfficerDanChurchAid South Asia, Delhi Office is looking for a well qualified person to3Be responsible for developing documentation and information material for internal and external use for DCA Regional Office South Asia 3Be responsible for providing support and capacity building on communication and media to DCA partner organisations3Be responsible to support and provide input to DCA Denmark Media unit 3Function as Focal Person for Most Significant Change method 3Be an active, critical and constructive member of DCA South Asia teamApplicants for the job must have the following qualifications: a postgraduate degree in communication, journalism or social sciences with excellent writing skills in English and Hindi. The candidate must have minimumfive years of working expe-rience as communication/information worker in national/international NGO with similar responsibilities andfield work experience in advocacy an advantage.The candidate must havefirm personal commitment to social equity and equal rights. The position requires strong analyti-cal, facilitation and writing skills as well asfluency in wriĴen English and Hindi. The Regional Office needs a person with a strong commitment to her/his work, excellent interpersonal communication skills and a sense of humour. Willingness and ability to travel and beflexible is essential. The national position will be based in DCA Regional Office, New Delhi.Preference will be given to women candidates. Candidates should send their applications to sadocinfo08@gmail.com. Deadline for applications is19. 12.08. Candidates will be invited for an interview in the beginning of January in Delhi. Only short-listed candidates will be contacted.DanChurchAid is an independent Danish faith-based organisation working on humanitarian emergency response; rights based develop-ment; information and advocacy in partnership with secular and church-based organisations. DCA is commiĴed to promoting equal opportunities for women and men from different caste, ethnic and religious backgrounds and encourages candidates of diverse backgrounds to apply for this position. For further details about DCA visit our website www.danchurchaid.org.

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