Uttar Pradesh chief minister Yogi Adityanath meeting healthcare personnel on a visit to a hospital during the early days of the COVID-19 pandemic. Photo: PTI.
New Delhi: State elections are around the corner and political parties in Uttar Pradesh, India’s most populous state, have focused their campaign rhetoric on socio-economic development. An important influence of this force is the quality of the state’s healthcare, and assessing the state’s healthcare could serve to indicate how far the state has come in the last five years.
Uttar Pradesh is one of India’s eight socio-economically backward states, collected under the umbrella of the ‘empowered action group’. The state has made some progress in the last five years vis-à-vis its healthcare, but has also left a lot undone in the same period.
Every year, the NITI Aayog think-tank evaluates India’s states and Union territories on various healthcare parameters and ranks them accordingly. The Aayog’s report for the second round of this evaluation used 2017-2018 as the reference year – this is also when the state’s incumbent government came to power.
Comparing its numbers with the Aayog’s latest report – for the fourth round, for 2019-2020 – indicates that Uttar Pradesh has hardly improved vis-à-vis human resources for healthcare in the state.
According to the second round report, there was no shortfall of auxiliary nurse midwives (ANMs) and staff nurses at sub-centres in the state – but the latest report notes a shortfall of 11.23% (i.e. 11.23% of ANM positions at sub-centres are vacant).
Sub-centres are the lowest rung of India’s healthcare infrastructure hierarchy. They are usually managed by two ANMs each. The next rung is the primary health centre (PHC), which usually has 4-6 beds. At the top is the community health centre (CHC), typically a 30-bed hospital. Sub-centres are where most people first seek care.
The reports also said that the vacancies for staff nurses positions at PHCs and CHCs had grown from nil to 8.24%. Similar, vacancies for medical officers (i.e. MBBS-qualified doctors) have grown by 7.6%.
Fewer personnel means emptier buildings. “It was proposed to convert some of the rural health centres [PHCs and CHCs] to health and wellness centres as part of the Ayushman Bharat scheme,” Sunita Singh, a training officer with a civil society group called Sahayog, told The Wire Science.
“New buildings were built or renovation was done as per the requirement. But if there remains an acute shortage of health personnel, what are these buildings going to do?”
In addition to a personnel shortfall, PHCs have also been beset by a lack of diagnostic equipment. This situation, Singh said, often forces patients and their families to travel to district hospitals that are often at least 30 km away. “This, in turn, would mean loss of wages for that day for the patient’s kin, add to it the cost of transportation by a private vehicle. This meant a total loss of Rs 700-800, conservatively speaking.”
In its manifesto for the 2017 state elections, the incumbent Bharatiya Janata Party had promised ambulances in far-flung areas of the state that could be summoned in 15 minutes or less with just a phone call. This promise has stayed on paper.
The BJP manifesto had also promised every block would have a store of generic medicines – which are yet to turn up. Singh said there’s a persistent shortage of drugs at district hospitals and in health facilities in rural areas. Earlier, it used to be possible for district authorities to place a tender to purchase drugs. A couple of years ago, the state government changed the system to a centralised purchase model. That is, the state buys the drugs at the state capital and then distributes them from there to health facilities in districts and villages.
“Most of the time, the tender by the state authorities is not placed in time. This results in non-availability of medicines,” according to Singh.
The data reflects this reality. The National Accreditation Board for Hospital and Healthcare Providers, under the Quality Council of India, accredits CHCs based on certain criteria, mainly related to quality of service but also including availability of drugs. Fewer than 1% of CHCs and 1% of PHCs in Uttar Pradesh have been accredited thus far, according to the Aayog’s latest report.
Bureaucratic hurdles also gum up the delivery of health services. For example, the report measured the average number of days taken for the transfer of the Union government’s National Health Mission fund from the state treasury to the implementing agency functioning in districts and villages. The report says it took 118 days in Uttar Pradesh for this fund to travel downstream – the fifth highest in the country after Jammu and Kashmir, Bihar, Jharkhand and Punjab .
Dr C. S. Verma, an associate of the Jan Swasthya Abhiyan (a pan-India civil society group) in Uttar Pradesh also corroborated the fact about the shortage of drugs in medical facilities to The Wire Science. “Lack of these basic facilities, including drugs, have ensured that the masses did not have adequate trust in public health facilities,” Verma said.
Verma further clarified that there wasn’t much of this trust before the Adityanath government either, but the current government was unable to bring about any change as such.
Both Verma and Singh pointed to another common development; that the decline of trust in public health facilities has led to the mushrooming of private facilities in rural areas of the state in large numbers over the past few years. “Poor people have no wherewithal to buy services from them but when there is no other alternative, they are forced to take loans or sell their property,” Verma said.
Nutritional indicators
The BJP had claimed in its last manifesto that it would make Uttar Pradesh a malnutrition-free state in five years. While that, as one would guess, would always remain an impossible goal, the recently-released National Family Health Survey-5 (NFHS) data showed that the state actually saw a reversal in progress on some nutritional indicators.
As per NFHS-5 data, 7.3% of all the 5-year-old children are severely wasted (that is, they have a skewed weight to height ratio) in the state. The NFHS-4 put this figure at 6.0%. The NFHS-5 was conducted for the period 2019-21 while the NFHS-4 was conducted for the 2015-16 period.
On the other hand, the proportion of children under 5 years of age who are overweight (weight-for-height), has also gone up from 1.5% to 3.1% between the two NFHS survey periods.
Anaemia was also on the rise. The proportion of anaemic children aged 6-59 months has gone up from 63.2% to 66.4%. However, anaemia among pregnant women had decreased by 5% points.
Breastfeeding practises are extremely important from a child’s nutritional perspective. State governments undertake awareness drives to improve on this front. A lot of stress is laid on initiating breastfeeding within one hour of birth. But the proportion of children that were breastfed in the one-hour window declined from 25.2% to 23.9% between the two survey periods. At the same time, however, the proportion of children who were exclusively breastfed for six months went up from 41% to 59%.
This indicates that the health institutions where delivery would take place were not able to provide enough scope or even equip the mothers with information that breastfeeding had to be initiated within the hour.
Other Indicators
Unlike states like Bihar and Madhya Pradesh, Uttar Pradesh has not improved in terms of mortality indicators. As per the second round report of Niti Aayog, the neonatal mortality rate (deaths of children in their first 28 days) was 30 per 1000 live births. This has now gone up to 32. The Under-5 mortality rate (number of deaths among children before they attain the age of five per 1,000 live births) did not decline and stood the same as what it was in 2017 – that is, 44 per 1000 live births.
Like most states, the full immunisation coverage for children in UP has improved from 84% to 95%. The proportion of institutional deliveries (deliveries taking place at a health facility) has improved as well, going from 50% to 60%.
Access to antiretroviral therapy (ART) drugs at health facilities for people living with HIV-AIDS, too, dropped from 57% in 2017 to 54% now.
The latest Niti Aayog report tried to peg Uttar Pradesh as having performed the best among India’s larger states by registering the highest incremental change relative to the past performance on various indicators. Uttar Pradesh’s score, which has been at the bottom of the ranking, jumped from 25.06 out of 100 in the base year (2018-2019) to 30.57 in the reference year (2019-2020) – a change of 5.52 points.
While this was, in fact, the largest increase in the score of any state, experts had told The Wire Science that if the baseline is low, the scope of incremental change would, obviously, be the highest. Therefore, the rationale in claiming that Uttar Pradesh had performed the best is flawed.
Sahayog’s Singh, who has been quoted above, says that a few schemes, especially conversion of rural health facilities to health and wellness centres, were launched with good intentions. “Therefore, to reject (everything) and say that nothing happened on the health front would not be entirely correct. What was lacking in the good intent was the will to convert it into reality,” she said.
JSA’s Dr Varma hoped the upcoming government would take a clue and do the needful for a state that currently lies at the bottom of the charts in terms of almost all important health indicators.