O Kashmir! What has become of you?

O Kashmir! What has become of you? From the land of Charaka (the father of Ayurveda), Patanjali (the compiler of Yoga sutras), Bharata Muni (author of the Natyashastra), Abhinavagupta (the genius Shaiva sage) and Padmasambhava (who introduced Tantric Buddhism to Tibet) to being the land of retarded Abrahamic stone-pelters. How could we let this happen? Maybe we should look for answers in the worldly wisdom of the Panchatantra, which abounds with stories of lies, deceit, treachery and deception - everything that Kashmir stands for today. Oh, one more thing... Panchatantra is also a product of Kashmir. Hindustan se rishta kya? Om bhur bhuva swaha. ~ Ashish Dhar

Supply-side barriers to maternity care at health-sub-centres in rural India


Article can be accessed from PeerJ's official website.
There exist several barriers to maternal health service utilization in developing countries. Most of the previous studies conducted in India have focused on demand-side barriers, while only a few have touched upon supply-side barriers. None of the previous studies in India have investigated the factors that affect maternal health care utilization at health sub-centers (HSCs) in India, despite the fact that these institutions, which are the geographically closest available public health care facilities in rural areas, play a significant role in providing affordable maternal health care. Therefore, this study aims to examine the supply-side determinants of maternal service utilization at HSCs in rural India.

Data and Methods

This study uses health facility data from the nationally representative District-Level Household Survey, which was administered in 2007–2008 to examine the effect of supply-side variables on the utilization of maternal health care services across HSCs in rural India. Since the dependent variables (the number of antenatal registrations, in-facility deliveries, and postnatal care services) are count variables and exhibit considerable variability, the data were analyzed using negative binomial regression instead of Poisson regression.

Results

The results show that those HSCs run by a contractual auxiliary nurse midwife (ANM) are likely to offer a lower volume of services when compared to those run by a permanent ANM. The availability of obstetric drugs, weighing scales, and blood pressure equipment is associated with the increased utilization of antenatal and postnatal services. The unavailability of a labor/examination table and bed screen is associated with a reduction in the number of deliveries and postnatal services. The utilization of services is expected to increase if essential facilities, such as water, telephones, toilets, and electricity, are available at the HSCs. Monitoring of ANM’s work by Village Health and Sanitation Committee (VHSC) and providing in-service training to ANM appear to have positive impacts on service utilization. The distance of ANM’s actual residence from the sub-center village where she works is negatively associated with the utilization of delivery and postnatal services. These findings are robust to the inclusion of several demand-side factors.

Conclusion

To improve maternal health care utilization at HSCs, the government shouldensure the availability of basic infrastructure, drugs, and equipment at all locations. Monitoring of the ANMs’ work by VHSCs could play an important role in improving health care utilization at the HSCs; therefore, it is important to establish VHSCs in each sub-center village. The relatively low utilization of maternity services in those HSCs that are run solely by contractual ANMs requires further investigation.

अरुंधति सूजन रॉय और फिक्शन

अरुंधति सूजन रॉय के अनुसार 6 दिसंबर 1992 को कारसेवकों से भरी अयोध्या से चली साबरमती एक्सप्रेस 27 फरवरी 2002 को गोधरा जंक्शन पहुचीं जहां मंदिर न बना पाने से हताश कारसेवकों ने अपने आपको डिब्बे में बंद करके किरोसीन छिड़क कर आत्मदाह कर लिया ताकि दंगा भड़काया जा सके। हा हा। वैसे आपको बता दूँ ये फिक्शन लिखती है - पर इतना बुरा और अतार्किक फिक्शन लिखती है, ये मुझे नहीं मालूम था।

Shortage of frontline health workers in Uttar Pradesh.

Originally published at Governance Now.  

Improving the availability of health workers, particularly at the sub-centre level, has been one of the thrust areas of the national rural health mission (#NRHM). 
Back in 2005, most of the sub-centres in the country were run by a single auxiliary nurse midwife (ANM). ANMs were overburdened because of rapid growth in population in previous decades and growing number of central and state sponsored health programmes. Also, because they were the sole functionary at the sub-centre level, they had to manage the sub-centre and perform field visits simultaneously, which adversely affected their performance. To reduce the burden and improve their performance, the NRHM proposed deploying an additional #ANM. The programme also persuaded state governments to enhance the availability of male health workers (MHWs), who are vital to the effective implementation of various national disease control programmes, by filling existing vacant posts. 

In 2005, when the NRHM was launched, the public health system in UP was highly inadequate and inefficient with respect to the needs of the population. Since then, the state has received thousands of crores of NRHM funding every year from the central government to improve its healthcare delivery system. However, to what extent it has been put to good use is not known. Media informs us that all is not well in UP. As per reports, the execution of the NRHM in the state has been mired by rampant corruption and misuse of funds. For instance, in 2011, about Rs 100 billion were siphoned off by politicians, bureaucrats and medical officers from the NRHM funds provided to the state. The investigation into this scandal is still underway. Moreover, the state has been unable to utilise thousands of crores allocated to it under the NRHM for the year 2015. 

Such reports can make you wonder what is going on in UP’s public health system? Has it been able to realise any of the NRHM dreams of strengthening public health system or the NRHM funds have gone down the drain? In this article, my focus is on health sub-centres, the lowest level of publicly funded health facilities in India. I ask three questions: First, has UP been able to increase the number of sub-centres to match its burgeoning rural population? Second, has it been able to provide an additional ANM and an MHW in all sub-centres as envisaged by the NRHM in 2005? Third, are there enough health worker supervisors in the system?  

Number of sub-centres
Let us first have a look at the numerical adequacy of sub-centres. As per the Indian Public Health Standards (#IPHS), ideally, the average population served by a health sub-centre (HSC) should not be more than 5,000 in plain areas and 3,000 in hilly areas. 

The terrain in #UP is not undulating, however, the population covered by HSCs is currently well above the IPHS recommendation – about 7,500 people per sub-centre. This calls for setting up more sub-centres in the state. But how many more? The number of sub-centres has increased from 18,577 in 2005 to 20,521 in 2015. Unfortunately, this growth is neither sufficient to stave off the pressure from the burgeoning population nor enough to meet the IPHS recommendation. Currently, there are over 155 million people living rural areas of the state. This means that in order to fulfil the IPHS standard for sub-centres, the state will need to establish additional 10,500 sub-centres. 

Health workers
As for health worker availability, the IPHS recommends that each sub-centre should have at least two ANMs and an MHW. Accordingly, the state should have 41,042 ANMs for its 20,521 sub-centres. Unfortunately, there are only about 23,500 ANMs positioned at HSCs, which means that most sub-centres do not have a second ANM even a decade after the NRHM was launched. This number has remained stagnant over the years. The latest district level household survey reveals that the proportion of sub-centre with two ANMs in UP is the lowest among all states. Even Bihar is ahead of UP. The lack of a second ANM at sub-centres adversely affects the performance of the existing ANM as she is forced to share her time between the headquarters (the sub-centre) and the field (villages). She is neither able to focus on maternal and child health services nor on immunisation, family planning and infectious diseases prevention activities that require her to travel to villages to cover the target population.

MHWs were introduced in the 1970s. They implement several public health measures such as collection of drinking water samples, environmental sanitation, school health, family planning, infectious disease control, adolescent health programmes, and other national health programmes. By 1990, UP was successful in recruiting enough MHWs to serve its population. Soon after, in an unwise move, the government decided to shut down all training schools for male health workers in the state. This is when the shortage of MHWs began to build up. 

The crisis that started in the early 1990s has grown despite the fact that the central government, under NRHM, promised to bear the burden recruiting MHWs provided that the state sanction and recruit a second ANM for their sub-centres. In 2005, about 69% sub-centres did not have an MHW. The situation has further deteriorated over the NRHM period. Currently, the share of such sub-centres in the state has risen to 85%. This shortage may have serious implications for the surveillance, treatment, prevention, and control of communicable diseases such as malaria, dengue, chikungunya and Japanese encephalitis in the state.

Health workers’ supervisors
The long-standing shortage of ANMs and MHWs in the state has led to a shortage of their supervisors (lady health visitor and male health assistant) as well. Each primary health centre (PHC), which usually covers six sub-centres, should have a male health assistant to supervise MHWs deployed at sub-centres. Every PHC in the state had a male health assistant in 2005, but unfortunately the situation has deteriorated since then. As of 2015, male health assistants are available only in about 28% of PHCs. The availability of lady health visitors (LHVs) in the state has not improved either. The proportion of PHCs with LHVs has declined from 89.7% in 2005 to 54.7% in 2015. As a result, the burden on existing LHVs has increased as many of them now have to supervise double the number of ANMs.  

Cause of the crisis
So, it is natural to ask what is causing this crisis in the state. Why has Uttar Pradesh not been able to improve the availability of its sub-centre level health workers even though the central government has been supportive since the launch of NRHM in 2005? 

It seems that the current health worker crisis in the state is largely a result of past health worker recruitment policies. In the 1990s, the government was convinced that they had enough ANMs and MHWs in the system. Therefore, it decided to shut down all its health worker training schools and institutes. However, when NRHM was launched in 2005, the government realised that it needed more health workers to serve its burgeoning population. The attrition of the workforce that was recruited in the 1970s and 1980s was occurring rapidly at that time, so it drew up plans to increase the number of health workers back in 2008. However, the plans never took off. 

The state could have recruited health workers for posts rendered vacant by attrition but it chose not to, mainly because training new recruits would require making a massive investment in its training institutions that have been lying defunct since the early 1990s. 

None of the 70 ANM training centres in the state are fully functional due to inadequate physical infrastructure and lack of academic and administrative staff. About 60% of all sanctioned posts for tutors at these training centres are vacant. Moreover, none of these training centres has a principal. Similarly, there are about 11 regional health and family welfare training centres and 30 Anchal Prashikshan Kendra to train MHWs. These centres were supposed to restart pre-service training and a decision in this regard was taken in 2008. However, the decision was never seriously implemented. As a result, the shortage of MHWs intensified. 
The shortage of LHVs mainly stems from non-recruitment of ANMs and dysfunctional LHV training centres in the state. ANMs who complete five years of service are given six months in-service training at these schools to get promoted to the post of LHV. For training these supervisors, there are four health schools in Lucknow, Allahabad, Agra, and Bareilly. Unfortunately, none of these training centres are currently operational, mainly due to lack of public health nurse (PHN) tutors even though a number of posts are sanctioned and the budget is available. Fresh PHN tutors are not being trained in the state because the only PHN tutor training centre in the state has not been operational since the last 27 years due to various reasons. 

The extent of apathy towards the issue of shortage of health workers prevailing in the state government and bureaucracy can be gauged from the fact there has been no increase in the number of sanctioned posts for any of the sub-centre level health workers (except ANMs) or their supervisors during 2005-2015. Even for the ANMs, the number of sanctioned posts is still way below the current requirement as per the IPHS. It is problem that the government should consider urgently because recruitments can be made only against sanctioned posts. It cannot recruit health workers arbitrarily. 
Apart from the above mentioned reasons, the huge workforce crisis that the state is witnessing is a result of the lack of vision for its rural public health facilities. Currently, the state does not have any framework for medium- or long-term health workforce planning. It is strange that the state still uses the 1991 census population to calculate the need for health facilities and health workforce. Moreover, the state also lacks a central health workforce database that could help policymakers in keeping an eye on health workforce dynamics in its public health system. 

It can be concluded that the state is suffering from a huge shortage of both health facilities and health workers even after a decade since the launch of NRHM. In fact, shortages have intensified over the NRHM period and any effort made to fill vacant positions in the state can be best described as highly inadequate and ineffective. Therefore, the government should seriously take a stock of current shortage and devise a plan to deal with the problem in a phased manner. The immediate task for the state government should be to do whatever it takes to operationalise at least some training schools, if not all, to start filling existing vacant posts as soon as possible. However, if it wishes to end the crisis of basic health workers and their supervisors within the next five years, it should think about operationalising all training schools to their full capacity. Besides, the government should establish more sub-centres and sanction new posts as per the IPHS norms. 

Singh is a researcher at Portsmouth-Brawijaya Centre for Global Health, Population, and Policy, University of Portsmouth, UK.

(The article appears in the May 16-31, 2017 issue of Governance Now)
- See more at: http://www.governancenow.com/news/regular-story/parody-of-the-health-mission#sthash.Ur2kEOtr.E7xlBSze.dpuf

तेजस एक्सप्रेस

तेजस एक्सप्रेस ले आओ या महामना, भारतीय कभी नही सुधरेंगे। मैं जब भी हवाई यात्रा करता हूँ, तो एक चीज नोट करता हूँ, भारतीय होगा तो भारतीय को देख मुस्कुराएगा नहीं, खीस निपोर कर एयर होस्टेस से बार बार शराब मांगेगा। जितनी देर में एयर होस्टेस सबको नाश्ता बांट कर आती है, उतनी देर में हिंदुस्तानी अपनी गिलास खाली करके फिर से शराब मांगने के लिए तैयार हो जाता है। कहेगा फ्री मिल रही तो क्यों न पियें। हेडफोन तो छोड़ो, लोग कंबल भी उठाकर घर ले आते हैं। पब्लिक वाशरूम में से साबुन चुरा ले जाते हैं। सरकार को चाहिए कि ये बुलेट और सुपरफास्ट लक्ज़री ट्रेन का चक्कर छोड़े और वही लोहे पर जड़ी लकड़ी वाली फँटियों वाली ट्रेन ही चलाये। हिंदुस्तानी वही deserve करते हैं। हिंदुस्तानी महामना और तेजस जैसी ट्रेन्स में चलने के लायक ही नहीं हैं।

मैनचेस्टर 2017

वैसे तो मुझे किसी धर्म (रिलिजन), सम्प्रदाय, पंथ, विचारधारा इत्यादि से कोई परेशानी नहीं है, समस्या नहीं है। समस्या तब शुरू होती है जब कोई रिलिजन मुझे (काफिर, नॉन-बिलिवर) उसमें विश्वास न करने के लिए नरक में जलने योग्य या मृत्यु का अधिकारी बताता है। जब कोई धार्मिक (रिलीजियस) पुस्तक नॉन-बिलिवर्स खिलाफ जहर उगलती है। जब वो अपने फोलोवर्स से काफिरों के कत्ल करने का आह्वान करती है। जब कोई पंथ, सम्प्रदाय या विचारधारा दूसरों को नीचा दिखाकर खुद को श्रेष्ठ साबित करना चाहता/चाहती हो। ऐसी किताब, धर्म, पंथ, सम्प्रदाय, विचारधारा के प्रति मेरी घृणा आपको बार बार देखने को मिलेगी। चाहे वो कुरान या बाइबिल के फोलोवर्स हो, या फिर पंडो की पसंदीदा मनुस्मृति के, या फिर दास कैपिटल के दास हो, या फिर अम्बेडकर, साहू या परशुराम के। आततायी किसी भी प्रकार के हो, उनका विरोध करो, जब मौका मिले, कुचल दो। उपचार जरूरी है, नहीं तो एक दिन वो तुम्हें ऊपर पहुँचा देंगे, जैसे उन्होंने परसों मैनचेस्टर में 20 लोगों को ऊपर पहुँचाया है या कुछ दिन पहले रेड कॉरिडोर में सैनिकों को मौत के घाट उतार दिया।

केवल गांधी ही क्यों?

बैंक ऑफ इंग्लैंड की करेंसी नोट्स पर रानी एलिज़ाबेथ द्वितीय के साथ साथ एडम स्मिथ की तस्वीर है, जेम्स वाट की तस्वीर है, चर्चिल की तस्वीर है, चार्ल्स डार्विन की तस्वीर है, पिन इंडस्ट्री में डिवीज़न ऑफ लेबर की तस्वीर है। हमारे यहां रुपये पर गांधी के सिवाय कोई दिखता ही नहीं। मेरा सवाल ये है कि सिर्फ गांधी ही क्यों? क्या नोटों पर हिंदुस्तान का प्रतिनिधित्व पाणिनी, आर्यभट्ट, सुश्रुत, चरक, माधव ( केरल स्कूल ऑफ मैथेमेटिक्स एंड एस्ट्रोनॉमी) इत्यादि नही कर सकते? केवल गांधी ही क्यों? क्यों हमारा गौरवशाली इतिहास हमारी नोटों और सिक्कों पर से गायब है?