On August 15, 2016, in his Independence Day address, Prime Minister Narendra Modi promised a safety net of up to Rs 100,000 for families who lived below the official poverty line. This programme, however, may do little for people who lack access to qualified medical personnel.
Up to 62 per cent of government hospitals don't have a gynaecologist on staff and an estimated 22 per cent of sub-centres are short of auxiliary nurse midwives (ANMs) -- together, gynaecologists and ANMs are the frontline of the battle against infant and maternal mortality -- according to our analysis of District Level Household Survey (DLHS-4) data. At the same time, health facilities are fewer than required, which means that the actual shortfall in personnel is much higher.
Our other findings:
-- In 30 per cent of India's districts, sub-centres with ANMs serve double the patients they are meant to.
-- As many as 65 per cent of hospitals serve more patients than government standards require; the number rises to 95 per cent if we include hospitals with a gynaecologist on staff.
-- Almost 80 per cent of all public hospitals serve twice the number of patients that government standards specify.
Consider these statistics in light of India's slow progress in reducing maternal and infant mortality. Despite the fact that eight in 10 babies were born in hospitals in 2011-12, up from 41 per cent in 2005-06, according to government data, India continues to have the highest rate of infant mortality among BRICS nations, as IndiaSpend reported in May 2016.
From 256 women who died per 100,000 live births, according to National Rural Health Mission (NHRM) surveys in 2004-06, India's maternal mortality rate (MMR) improved 30 per cent to 178 deaths per 100,000 live births by 2011-12, but this is worse than countries in the neighbourhood, such as Sri Lanka (30), Bhutan (148) and Cambodia (161), and worst among the BRICS countries: Russia (25), China (27), Brazil (44), and South Africa (138), according to the World Bank's latest estimates.
The NRHM was launched in 2005 to provide affordable healthcare in rural areas, improve healthcare quality and reduce maternal and infant mortality. In 2013, the mission was rebranded as the National Health Mission (NHM) with two components, NRHM and National Urban Health Mission (NUHM).
The budget for NRHM in 2005-06 was Rs 6,713 crore, which rose 67 per cent to Rs 11,196 crore in 2015-16. And, through the roll-out of Rashtriya Swasthya Bima Yojana (RSBY) insurance programme in 2008, the government of India has demonstrated a concerted effort to help the poor pay for medical expenses.
But, even as the number of sub-centres rose 5 per cent, from 146,026 in 2005 to 153,655 in 2015, according to Rural Health Statistics (RHS) data, a critical element of the public-health system continues to falter: There aren't enough doctors and nurses.
Our analysis of DLHS data reveals that a large proportion of healthcare facilities across India don't have the required number of trained medical personnel on staff, creating impossible caseloads for those on duty. This problem is most pronounced in public hospitals and rural areas, which serve the most vulnerable Indian citizens.
Much has been written about absenteeism amongst public sector employees and its impact on basic public services, including its impact on the quality of health services. The absenteeism rate across the public education and health sectors in India was 40 per cent, tying with Indonesia, according to 2006 study conducted across primary schools and primary health centres in six countries.
Much less attention has focused on the vacancies in public-sector employment and especially the public-health system. While the number of healthcare facilities across India has increased substantially, as we indicated, the count of medical personnel has not kept pace -- and rural facilities have the largest gap between the supply and demand of basic health services, as measured by vacancies.
Since the launch of NRHM, two rounds of DLHS (round 3 in 2008 and round 4 in 2013) have been conducted which highlight the staffing gaps in maternal and child health.
Gynaecologists play a crucial role in ensuring safe and healthy pregnancies and deliveries. Even with the increase in the number of facilities nationally, the number of practicing gynaecologists has not increased significantly. In 2008, the number of government hospitals -- including CHCs, sub-district hospitals (SDHs) and district hospitals (DHs) -- was 4,423, of which only 1,633, or 37 per cent, had a gynaecologist. In 2014, the number of hospitals rose to 6,318, but only 2,409, or 38 per cent, had a gynaecologist.
In short, DLHS-4 indicates that close to 62 per cent of hospitals do not have a gynaecologist on staff.
The government of India increased funding to the health sector through NRHM and put out the India Public Health Standard (IPHS) in 2007 (updated in 2012) which prescribes healthcare standards for facilities and personnel.
These updated standards aim to address the shortfall in doctors and other staff in public-health facilities. There should be at least one sub-centre per 5,000 people, and each sub-centre should have at least one ANM on staff, according to IPHS standards.
Similarly, IPHS prescribes one CHC per 120,000 people and one gynaecologist per CHC. As per these norms, India needs more than 10,000 gynaecologists in its public-hospital system. However, according to RHS data, there are only 3,429 sanctioned posts for gynaecologists across the country, of which only 1,296 have been filled. In other words, if we use IPHS as reference, CHCs have no more than 12.6 per cent of the gynaecologists they should. This number increases if we only assume the number of sanctioned posts as benchmark.
In the public debate over how to ensure high-quality public services for all Indians, vacancies must stand alongside absenteeism as a critical area for improvement. Until these vacancies are filled, infrastructure investments and financial safety nets will fall short of ensuring adequate access to quality healthcare for the poorest Indians.
(07.09.2016 - In arrangement with IndiaSpend.org, a data-driven, non-profit, public interest journalism platform. Prateek Mittal is a Research Associate for Evidence for Policy Design (EPoD) India. EPoD India works on a variety of research-policy partnerships aimed to bring insights from data and research to bear on public-sector policies. Vartika Singh is a Research Manager for EPoD India. The views expressed are those of IndiaSpend. Feedback at respond@indiaspend.org)
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