Monday, September 10, 2018
Sunday, September 2, 2018
How free healthcare became mired in corruption and murder in a key Indian state
Over the past year, India has been rocked by a series of corruption scandals involving public figures. Among the most notorious is that currently engulfing the National Rural Health Mission (NRHM), an ambitious, centrally sponsored, health initiative to improve the health of the countries poorest citizens (box). The saga—centred on India’s most populous state, Uttar Pradesh—has so far claimed the lives of four people, including two chief medical officers, and the jobs of several leading government figures. Eight people have been arrested in connection with suspected irregularities in the use of the public money allocated to the NRHM, and inquiries by India’s Central Bureau of Investigation (CBI) into other cases continue. As new, startling, facts come out in the media almost every day it seems much of the 10 000 crore rupees (£1.3bn; €1,5bn;$2bn) allotted to Uttar Pradesh under the initiative was siphoned away by the current and previous state government and did not reach or benefit the people for whom it was intended.
What is the National Rural Health Mission?
The NRHM was launched in 2005 to provide effective healthcare to rural populations, with special focus on 18 states with weak public health indicators or infrastructure. Its key goals are to reduce the infant mortality rate and maternal mortality ratio. The NRHM was meant to overhaul healthcare by building new clinics and hiring many more health workers.
The story really hit public attention when two chief medical officers in the state were murdered, one killed in broad daylight in October 2010 and another outside his home in April 2011. The murders were followed by the mysterious death of a deputy chief medical officer—who had been accused of one of the murders—in a district jail in June. And a water engineer who was part of a team setting up health infrastructure died on 23 January, allegedly by suicide.
There were rumours that the deaths were a fall-out of the rampant corruption in the implementation of the NRHM scheme. Alarm bells were ringing at federal level because Uttar Pradesh is such a key state. It has a population of 200 million, around 16% of the country’s total. More people live in Uttar Pradesh than in Brazil. Given its size and its higher than average mortality and morbidity rates (infant mortality is 63/100 000 births compared with a country average of 50 and maternal mortality ratio 359 v 2121), the state is key to the achievement of India’s health goals as well as the millennium development goals.
Corruption unveiled
Even before the murders the NRHM was under investigation for suspected irregularities. A government review in May 2011 drew attention to glaring irregularities during 2009-11. Indian Express, a leading Indian newspaper, was the first to reveal some of the review’s findings. It found that there was no open tendering to ensure competitive bidding; no clear rationale in the selection of the contracted agencies; and that in some cases payment was made in advance rather than linked to the progress of work. No follow-up action was taken on deficiencies in the work, and none of the agencies was penalised despite failing to meet deadlines—some were even awarded more work.
In June 2011, the People’s Vigilance Committee on Human Rights (PVCHR) a non-governmental organisation, wrote to the chair of the National Human Rights Commission (NHRC), asking it to look into the circumstances surrounding the death of the deputy chief medical officer in jail and institute a judicial inquiry.
“The presence of a sharp item in the prison cell alerted us to pursue the case.” Lenin Raghuvanshi, executive director of PVCHR told the BMJ.
In July 2011, India’s CBI began an inquiry into the misuse of funds and into the murders of the chief medical officers. The Uttar Pradesh government maintains that it has been keen to get to the bottom of the financial bungling. Two leading figures in the state government—health minister Anant Kumar Mishra and family welfare minister Babu Singh Kushwaha—were removed after the irregularities were detected. There has been a spate of other sackings as the CBI widens its net and a tainted image becomes a liability in the run-up to the state elections in February and March.
In the politically charged atmosphere, officials connected to the NRHM are wary of speaking publicly. My email queries to NRHM officers in Delhi and Lucknow, the state capital, did not get an acknowledgment or response.
Vulnerable population
The NRHM scandal in Uttar Pradesh underscores the ease with which health programmes can be abused when there are vast pools of poverty and illiteracy.
Munna Lal Shukla, who is a volunteer in Bharawan, Uttar Pradesh, for Asha Parivar, a people’s organisation working to empower poor people, said those who come to the local primary health centre are often illiterate and know little about government schemes. Villagers are used to being asked to pay bribes if they want urgent medical attention.
“Government doctors regularly prescribe medicines which are available only from private chemists. The prescriptions are written down on bits of paper. Patients are asked to come back to the health centre after they buy the medicines. The doctors note down the names of medicines bought outside in the primary healthcare register so that they can claim that the patients had got them from the health centre free of cost. It is a racket—the medicines that are meant to be given free of cost are “sold” on the black market to private chemists,” Mr Shukla said.
Mr Shukla and other villagers have been staging hunger strikes and demonstrations in front of the Bharawan health centre for many years. The first one took place in 2002, before the NRHM was launched.
The agitation forced senior medical officers from the district headquarters to come down to Bharawan. For a while, the health centre even prominently displayed the list of medicines that the centre stocked on the wall outside, as demanded by the villagers. But things have reverted to the bad, old practices.
Sandeep Pandey, a Lucknow based leading Indian social worker, pointed to the political patronage being given to corrupt and criminal practices. “In Uttar Pradesh, it is a given that you have to pay something to access the benefits of any government scheme. Everyone accepts this. There is not a lot of corporate money here. There is a lot of ‘development money’ because of the problems and the size of the state. Government welfare funds or commission from big projects are the two key sources of funds for politics,” said Mr Pandey.
The CBI investigation into the NRHM in Uttar Pradesh is perhaps the largest anticorruption investigation that the agency has ever taken up in a state. The CBI is expected to investigate a gamut of irregularities since the mission’s launch in 2005-6. A CBI spokesperson told the BMJ that “investigations are continuing” and the agency would not make a formal statement at this point.
But a CBI press statement on the NRHM dated 4 January 2012 provides examples of the malpractices plaguing NRHM operations in Uttar Pradesh. One investigation concerns a £1.7m contract to upgrade 134 district hospitals.2 The contract was awarded by a division of the state water utility on the basis of bogus documents, and the company used substandard materials, costing the government around £700 000. Four cases have been registered in connection with irregularities in awarding contracts in the procurement of medicines, medical equipment, and publicity material by the director general of family welfare. The procurement was done through state owned public sector utilities, which paid prices that were four to five times higher than the prevailing market rates.
“Leakages are reported from other government schemes too, but in the case of NRHM in Uttar Pradesh, it was organised looting of government funds. NRHM did not really take off in Uttar Pradesh as it did in other states. Components of NRHM such as purchase of medicines and equipment, hiring of taxis, and publicity related expenditure provided great scope for siphoning off funds through false and inflated invoices,” Ajit Singh, director of the Institute of Development Studies in Lucknow, told the BMJ. The institute evaluated the NRHM and the healthcare system for India’s Planning Commission in 2010.
Despite stellar economic growth in the past two decades, India lags behind many other developing countries and emerging economies in healthcare. Health insurance covers less than 20% of the population. Most Indians pay for treatment out of their pocket. Though India is now considering moving towards universal healthcare, to date, its public expenditure on health has been among the lowest in the developing world. But clearly, infusion of cash alone will not deliver results in places where they are most needed, such as Uttar Pradesh. “Monitoring will have to be revamped, at the field level, and at all stages,” said Mr Singh.
Callousness and corruption on the wards
The chill outside matched the cheerlessness inside the maternity ward in Bharawan primary health centre in Hardoi district in the northern Indian state of Uttar Pradesh. During a visit last December, I saw young women huddled in shawls on foam mattresses with frayed covers, a wash basin with no working tap smeared with red betel nut stains, and locked doors on the toilet attached to the ward. A dog was foraging in the trash can in the maternity ward. A few feet away, a young woman sat on a bed, staring at the wall opposite her. The worn-out blanket and bed sheet were her own. The woman had delivered a baby girl the night before. Sadly, the baby had died in the early hours of the morning. What went wrong? Neither the woman, nor her family members, crouching on the floor, knew. The hospital staff had told her to take the baby to Lucknow, the state capital, about an hour and half’s drive away. But the family was poor and did not have the money for a private ambulance; as they tried to work out the logistics, the baby died.
Bharawan health centre has been upgraded recently using NRHM money and has a new, unused, building. Large posters proclaiming the benefits of the NRHM and initiatives such as the safe motherhood scheme adorn its walls. But vital infrastructure like an ambulance is still lacking.
The woman held up a plastic packet, which contained mostly multivitamins. Government health centres and hospitals are supposed to give medicines free of charge to poor patients but medical staff at the hospital had asked the family to buy them from a private provider at a cost of 300 rupees (£3.82)—almost three days wages for a farm labourer. A female attendant in the health centre, who declined to be identified, told me she had no idea why the toilets attached to the maternity ward were kept locked. As for the stray dog, there was a ready explanation: “This is India. There are dogs in villages. What can we do about it?”
Notes
Cite this as: BMJ 2012;344:e453
Footnotes
- Competing interests: The author has completed the ICJME unified disclosure form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declares no support from any organisation for the submitted work; no financial relationships with any organisation that might have an interest in the submitted work in the previous three years; and no other relationships or activities that could appear to have influenced the submitted work.
- Provenance and peer review: Commissioned; not externally peer reviewed.
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