What trips street-level bureaucracy?

“There’s many a slip ‘twixt the cup and the lip.” Nowhere is this proverb truer than in the government machinery of India that is tasked with the staggering responsibility of delivering various crucial services to the 1.3 billion inhabitants of this country.

Whether it is the police guaranteeing the security of the common citizen, the doctor attending to patients at the public health facility or the teacher imparting basic education to children in schools in remote areas, it is glaringly evident that citizens of India are being seriously short-changed in availing public services that are their inalienable right.

We in India, especially the middle class, are quick to blame the street-level bureaucracy (SLB) for faulty implementation of what we consider to be impeccably-designed policies.

Where does the truth really lie? An examination of the functioning of SLBs, covering anganwadi workers and their immediate supervisors in the Integrated Child Development Services (ICDS)*, reveals some home truths on where things are going wrong.

I. Policy vs implementation

The first unpleasant truth is that programmes as packaged in statutes and administrative regulations are not quite what the SLB implements on the ground. There are quite a few reasons for this:

Focus on a limited set of activities

While the ICDS manual prescribes several duties for the anganwadi worker, the ICDS machinery focuses only on supplementary nutrition provision to mothers and children. It excludes activities such as monitoring the growth of children, counselling of caregivers on health and nutrition, and early childhood education.

Food supply is the only concern of the officials of ICDS directorates and the departments at the state level. As a result, the anganwadi worker is considered to have done her duty if she has distributed take home rations (THR) to mothers and children aged under three, and handled cooked meals for children in the 3-6 age group.

Emphasis on paperwork versus outcomes

The anganwadi worker is also required to complete a huge load of paperwork on the supply of food and on the nutrition status of children, to be sent to her superiors every month. If these duties are completed and reports sent to the state and central governments regularly, there is no accountability for outcomes. For example, the nutrition status of children—as revealed by their height and weight
measurements, which are critical for determining and addressing stunting and wasting in children below five years—is never addressed in a systematic manner.

II. Leakage in programme implementation

The second shocking fact lies in the subversion of the supplementary nutrition programme by the contractor-politician-bureaucrat nexus. An average Indian state has around 75 lakh children aged below six. With a provision of supplementary nutrition at a rate of INR 6 per day to each child, the annual bill works out to approximately INR 1,350 crore. This huge budget lends itself to manipulation by vested interests.

A recent LANSA study documents the systematic siphoning of public money in Uttar Pradesh through this programme. While a few packets of the THR (daliya) are distributed to families, the bulk of the supplies are sold as cattle feed, giving additional illegal income to the anganwadi worker. Silence is bought through the complicity of all those who are part of the supply chain.

The situation is not much better in respect of hot, cooked meals, where the proceeds of funds received (even if irregularly) are distributed among all stakeholders, including the anganwadi worker and the ICDS supervisor, with very little reaching children in the form of improved nutrition.

III. Socio-cultural barriers

Traditional social prejudices and behavioural patterns also adversely impact the messages being understood and acted upon. Two examples come to mind. Promoting early breastfeeding within an hour of birth has been recommended for a variety of reasons. However, social practices have often militated against this, with the belief that the child must be fed specific fluids before breastfeeding is initiated.

In the area of sanitation, proper hygiene practices and the absence of open defecation are known to promote the healthy growth of children. A recent study by Diane Coffey and Dean Spears has attributed the failure in restricting open defecation in India to social and cultural forces unique to the country. These are centred around religious practices of purity and pollution and the consequent reluctance to locate toilets in proximity to the house.

While these instances reflect the demand factor impacting the efficacy of public services, there are also supply aspects that affect client response to public services.

IV. Inadequate infrastructure

Irregularly functioning Primary Health Centres, which are often closed when the citizen has spent time and money to make her way there, act as a disincentive to use public health facilities. The problem is compounded when the health provider behaves indifferently, and/or demands illegal payments. Such
experiences discourage citizens from using the facility and force many to shift to private doctors, sometimes of very dubious quality.

What is being done to address this?

India’s policy mandarins are frustrated by this lack of success at translating significant budgetary allocations and governmental effort into improved outcomes in different social sectors. They are, thus, increasingly seduced by direct cash transfers to clients and privatisation of health, education and
corrective services.

However, this approach still begs the question: are citizens guaranteed access to improved services? There will still be need for regulatory agencies that monitor how private agencies function, including the quality and pricing of their services. Poor governance in direct management of public service delivery systems can easily transfer to equally poor oversight of private providers.

Take the case of the Universal Basic Income (UBI), which has caught the fancy of academics and policymakers in India. Apart from the vital issue of who will be entitled to UBI, and its fiscal implications, the question of fair and equal access to services critical to human health and development is still a moot point.

Is there a solution?

The few short-lived successes in child nutrition programmes in certain states have been the result of inspiring bureaucratic leadership, backed by political commitment. Unfortunately, results show only as long as the bureaucratic champion is around.

But long-term success in reducing key indicators of malnutrition, such as stunting and wasting, require sustained efforts to put in place functional systems that can operate irrespective of personalities and governments. These include:

1. Evidence-based, nutrition-specific and nutrition-sensitive interventions, backed by committed government budgets and active participation of different government departments and agencies.

2. Health and nutrition protocols that are scrupulously followed, with rigorous monitoring of child nutrition outcomes to ensure accountability.

3. Empowering local governments and frontline workers and supervisors with financial and administrative authority to deliver meaningful outcomes.

Above all, the political and bureaucratic leadership in the various states must provide a conducive and supportive environment for the effective functioning of SLBs, something that has been sorely lacking till now.

*ICDS is the largest programme in the world devoted to the care of pregnant and nursing mothers and children under 6 years of age.

This article was originally published on India Development Review (IDR), the country’s first independent online media platform for leaders in the development community. You can access the article here

Himalayan Blunders in Healthcare – Gorakhpur and Beyond

 

This article was originally published on Indus Dictum, a site where thought leaders from diverse fields, spanning business and technology to politics and modern law, contribute unique insights and experiences. 

In a country which is seemingly inured to bad news, the news of the deaths of a large number of children, infants and adults in a major hospital in Gorakhpur, Uttar Pradesh (UP) was like an atom bomb being dropped.
Predictably, the blame game started immediately, with every opposition party and every media hack trying to pin
the blame on someone, preferably the head honcho of the state. The previous Chief Minister was loudest in his criticism, forgetting that he had presided over the destinies of the state (and its health systems) till just a few months ago. In this atmosphere of cynicism and one upmanship, we are in danger of losing sight of the disease and focusing merely on the symptoms.

Let us start with some visuals, which convey the bald facts about the state of amenities in the Paediatric and Neonatal Intensive Care Units (PICU and NICU) of the hospital in question, the Baba Raghav Das (B.R.D.) Medical College and Hospital, the major tertiary health facility in the city of Gorakhpur, the bastion of the present Chief Minister of UP. These are reproduced from a tweet from Rahul Verma (@rahulvermao8) based on the replies to a Right To Information (RTI) query of 2011.

 

 

Baba Raghav Das

 

The RTI reply of early 2012 gives telling evidence about the lack of facilities in the hospital (in particular, the nonfunctioning of critical life-saving equipment because of poor maintenance) and the significant staff shortages in both medical and nursing staff. Although this is a slightly dated reply, there is little reason to suppose that matters have greatly improved in 2017, given the disclosure that lack of oxygen supply to children and neonates could possibly have been a prime cause of the large number of deaths.

Department of Peditrics

 

The reply, which is signed by the Head of the Department of Paediatrics of the hospital, shows that 50% of the qualified medical posts are unmanned and 4o% of the nursing posts are not filled in. Even more disheartening is the state of affairs in respect of critical equipment in the ICUs. The incubators, pulse oximeters and infant ventilators are not working, while 16% of the cardiorespiratory monitors are non-functional.

Only a detailed enquiry will (hopefully) establish the truth of the allegation that one of the primary causes for the deaths was, apart from encephalitis, the shortage of oxygen supply in the paediatric and neonatal wards. I am not too sanguine about the truth in this regard coming out given the conflicting statements from politicians, doctors and bureaucrats on when payments were released to the oxygen supplier and on whether oxygen shortage was in fact responsible for the deaths.

Details

But the issue goes far deeper than that of lack of oxygen supply alone. It is a pointer to the systemic rot in UP’s public institutions and in its systems of governance, a malaise that can be seen across institutional structures in different Indian states. Nowhere is this better exemplified than in the condition of India’s health systems.

UP’s public health care systems do not reach many of its citizens, especially the most vulnerable. This is partly due to the low percentage of public expenditure on health systems, as reflected in a 33% to 40% shortfall of over 31,000 health sub-centres, over 5000 primary health centres and 1300 community health centres in the state (as reported in the Financial Express). On top of this is the abysmal functioning of even such public health care institutions as do exist at the primary and secondary levels and the resultant lack of confidence of the public in these facilities. With primary and secondary public healthcare services not adequately available in Gorakhpur and its neighbouring districts, Sant Kabir Nagar, Siddharth Nagar, Maharajganj, Kushinagar and Deoria, the public is forced to come to a tertiary care facility even for ailments that can be treated at lower levels. A large hospital that already suffers from shortage of funds and skilled manpower, poor management, and corruption, is thereby further overburdened. The National Family Health Survey of 2015 (NFHS-4) data reveals the poor quality of health services that mothers and children receive. While 5% to 10% of mothers receive full antenatal care,
medical check-up of neonates in the first two days after birth ranges from 9% to 25%. About 66% of children in the 12-23 month age group are fully immunised in Gorakhpur and Deoria districts, with the percentage falling to just over 40% in the other four districts.

Not surprisingly, then, rates of child undernutrition, morbidity and mortality, as well as maternal mortality rates (MMR), are high in this region. Mortality rates of under-5 children vary from 76 to 116 per woo live births and of infants (o-i year) from 62 to 87 per woo live births, with 8o% of the infant mortality rate being accounted for in the first 28 days after birth. Stunting and underweight rates in under-5 children exceed 40% and 32%, with well over io% of children falling in the wasting category. MMR in the Basti and Gorakhpur mandals, where these districts are located are 304 and 302 respectively per 100,000 live births (all mortality figures are taken from the Annual Health Survey 2012-13 of Uttar Pradesh, conducted by the Census Commissioner of India and undernutrition figures from the NFHS-4 data). All these figures are distressingly high and place many of UP’s districts in the same league as war-torn states of Africa in health and nutrition indicators.

Indus dictum

The underlying morbidity and mortality proneness of the population in this region, especially its children, is exacerbated by the surrounding external environment. In their recently published book, Where India Goes: Abandoned Toilets, Stunted Development and the Costs of Caste, Diane Coffey and Dean Spears have highlighted the contribution of the practice of open defecation to high stunting rates in children. Open defecation has persisted despite the Swachh Bharat Abhiyan, because of the notions of pollution associated with latrines in the house and the reluctance to empty the pit latrines. The Japanese Encephalitis (JE) virus, to which a large number of the present deaths are attributed, is spread by the Culex mosquito breeding in the swampy paddy fields which are a feature of eastern UP. With traditional immunisation rates themselves being low in this region, it should be self-evident that the two doses of the JE virus immunisation are also not covering a significant portion of children. Insanitary conditions coupled with poor immunisation rates and failure to reach health care early to affected persons — especially children — constitute a lethal combination that contributes significantly to high mortality rates.

This deadly cocktail of factors is aggravated by the endemic corruption in the health and nutrition sectors in UP. The scam in the National Rural Health Mission in UP has been facilitated by politicians and highly placed bureaucrats, including some from my former service, the IAS. Fictitious purchases of medicines for which payments were made were facilitated by doctors and officers of the health department in collusion with suppliers. This disease is by no means confined to UP: nearly every state in India is prone to this syndrome, given the centralisation of purchase powers in the state secretariats. In fact, the purchase of medicines is mostly made keeping in mind the interests of politically-linked powerful suppliers, with no analysis of the disease and illness pattern in different areas of the state, which would enable a scientific assessment of the type and quantum of
medical supplies required. States are loath to adopt the pattern of Tamil Nadu, which set up the Tamil Nadu Medical Services Corporation over two decades ago to streamline the procedure for procurement, storage and distribution of essential drugs and medicines to government medical institutions throughout the state. UP has a similar scam operating in the ICDS sector, which is meant to provide wholesome take home rations to mothers and under-3 children, and hot cooked meals to children in the 3-6 year age bracket. A recent LANSA study details the systematic misappropriation of huge sums from the ICDS budget for lining the pockets of the politician-bureaucrat-contractor nexus.

Once again, in the ritual breast-beating that is going on in the media, there is the real danger that we will revert to the “business as usual” approach after a short hiatus. The Harvard economist, Lant Pritchett, characterised India as a “flailing state”, not quite failed like many of its Asian and African confreres but where accountability is extremely weak and where there is little control of the head over the limbs of the state. Even this is a very
charitable interpretation given that, in the Indian context, the limbs behave just as the head dictates. What I wish to highlight is the need to focus on systemic processes and institutions rather than personalities and political formations. As the preceding paragraphs seek to establish, a combination of factors — man-made and natural — have contributed to the ongoing crisis in India’s health systems. Rather than looking for temporary scapegoats, the need for an overhaul of the system is overdue (one possible solution is outlined by the Foundation for Democratic Reforms). The acid test for the new government in Uttar Pradesh has arrived, whether it will tread the same beaten track of its predecessors or chart a new path to governance and the arrival of achhe din in UP. Else, we will be left to exclaim “Even you, Brutus?”