A shameful national policy

A post from Facebook dated June 20th. I had posted this after a man was beaten to death in Rajasthan for protesting photos being taken of the women in his family defecating in public. Jan Swasthya Abhiyan's press release on the incident can be found here .

The 'naming and shaming' tactics being used in Swatch Bharat Abhiyan (SBA) are taking Indian polity to a new low. Whistling at defecating women is now common. Recently, when activists went to meet the District Magistrate in Sitapur to ask her to help protect their village from submergence (by the Sharada river) this monsoon, she asked them what they were doing to help SBA. Any and all tactics, including murder, are being used to bring down open defecation.

On cattle protection and protein deprivation

While preparing for a larger survey this February in Sitapur, we were recording background information as well as the weights of all members of 20 families in Madhubana, an active sangathan village. Prakash, a senior Saathi, was in charge of this task. He came by later looking a bit upset – 'कोई मेहरूआ ४० किलो से ऊपर हो तो बताना' translating roughly to 'Do let me know if you find any woman weighing more than 40 kg?'.

'Left Out' - a short film on denial of health rights in Karnataka

Over the past few years, I've helped organize meetings and consultations, produced reports and participated in research studies which documented various forms of denial of health rights in India, mainly Karnataka. Recently, while documenting cases for a planned public hearing with the National Human Rights Commission (which was later cancelled), I had the opportunity to collaborate in a project to video-document some testimonies. Thanks to Dipti Desai's persistence, these testimonies have been compiled into a short film 'Left out', which is available on YouTube here.
The stories are from across Karnataka and reveal how hard it continues to be to access health care and to pay for it...

The Universal Health Coverage Numbers Game

Some years ago, during a sojourn in Sitapur, we began discussing Rashtriya Swasthya Bima Yojana (RSBY), the National Health Insurance Scheme which provides 'cashless care' for hospitalisation at 'empanelled' private hospitals. The RSBY coverage limit is Rs. 30,000 per year for a family of five. I was already involved in the research of government-supported insurance schemes in Karnataka, and knew that while they gave poor families 'access' to private hospitals (there are denials as well), the devil was in the out-of-pocket expenditure that followed.

Here the tale was different:
"हमने उनको भगा दिया", "किन को ?”  "अरे, कार्ड छापने वालों को!"
which roughly translates to: “We chased them away”, “Who?”, “The card printers!”

Every year, the RSBY card has to be re-issued, so Third Party Administrators (TPAs) go to these villages to enrol people in the scheme at a cost of Rs. 30. But my friends in SKMS (Sangtin Kisan Mazdoor Sangathan) were fed up of getting a useless card - “We go to Sitapur city with this card to all the private hospitals, but no one gives us free treatment”. So they refused to get enrolled and asked the TPA to leave. One year, the District Collector got involved – he went to some villages and requested the villagers to cooperate! But as far as I know, some are still holdouts.

Addressing health inequities through community-led advocacy in Bangalore – experiences, successes and challenges

For some reason, I have not written much about my work in Bangalore. Maybe because it was 'paid' work and I spent so much time writing reports, updates etc. in the style that the organization and funders required. Well, now that the project has wound up, here goes... Below is a paper I submitted for the Medico Friends Circle (MFC) annual meet in February - I modified it slightly for this post. It is a long write-up (almost 2500 words) and a bit technical. But I think there are interesting stories in there...

Health care in India - making the poor pay

A few days ago, I visited a government hospital in Bangalore. The staff we talked to were unusually open and frank - possibly because some are new hires! I will give no specifics about this facility to protect them, but also because the problems they face are not unique.

The building has been recently renovated using crores of rupees, but there is barely any furniture, even for the staff. The operation theatre is not functional because of poor planning and construction, so while specialists are on staff, even minor operations cannot be conducted. For these expenses, the doctors were waiting for the release of Arogya Raksha Samiti (ARS) funds - these are untied funds that are to be used for repairs, emergency medicine purchases etc. We said that these were construction-related issues, so why should ARS funds be used for them? They said that they had asked the MLA and corporator, but hadn't received any support as yet, so this was their only recourse.

The hospital has a functional lab and lab technician, but only pregnancy and HIV tests are being conducted. For other tests such as thyroid and haemoglobin tests, reagents are required which have to be purchased. The hospital started collecting user fees recently and these will be used subsequently for such purchases. The one fund that they do have in abundance is the one for maternity benefits, which amount to Rs. 2000 per BPL (Below Poverty Line) woman, paid out in 3 instalments. The on-duty doctor mentioned that she had been generous in handing out these cheques earlier, disregarding some documentation requirements if the woman seemed genuinely poor. Also, she was allowing the woman's relatives to collect the final cheque (which had to be collected after delivery within a month). After all, the cheque is in the woman's name. But an audit of the hospital had generated multiple objections. The auditor had said that the documentation was incomplete and the signatures in the register did not match! The doctor said she would have to be more strict in the future.


The latest round (71st) of NSS data collected in 2014 shows that rural families spent, on an average ₹1587 for childbirth in a government hospital and urban families ₹2117. Major expenses include ultrasound scans (3 are required during pregnancy) and diagnostic tests, which are done in private labs. Neo-liberal economists and policy-makers might argue that these expenses are reimbursed for BPL families through maternity benefits, but as shown above the requirements get tougher and tougher for beneficiaries. Further, are only BPL card holders poor or vulnerable? Wouldn't it be cheaper and simpler to provide all these diagnostics under one roof? And user fees, among the most regressive forms of taxation (this actually discourages people from seeking essential health care, further impoverishing them) are being used to buy essential products!

I also realized how staff, especially the dedicated (of fresh!) ones, interpret the expenses of the hospital and its sources of revenue. They have little to no control over the funding from above. All they have are the user fees. One example - the fee for a rabies injection is ₹ 100 - apparently half goes to the department and half stays with them. Along with patients, front-line staff are also made responsible for funding health care! 

How do we talk about Universal Health Coverage?

Where health provisioning is concerned, Universal Health Coverage (UHC) has been the defining term for the past few years. WHO has taken it up with enthusiasm and the Indian government likes the word a lot too. In fact, recently Karnataka announced that it had achieved UHC!

I was at a meeting organized by WHO earlier this month, where a film was screened that talked about what UHC 'was' and 'was not'. But there were few specifics and all the visuals focused on antenatal and postnatal care. It is true that we, especially in India, have not yet achieved these basic targets. An example - the Community Health Centre (CHC) in Pisawan, where Sangtin Kisan Mazdoor Sangathan (SKMS) is active, does not have access to running water and its sole hand pump stopped functioning 2 years ago. Recently, a woman in labour left the CHC to find a place to urinate (the toilets there are always locked). She ended up delivering there.

But can UHC remain limited to ante- and post-natal care, deliveries, immunizations and some communicable diseases? When people have to go elsewhere for their other health needs, they will not necessarily return to government services for these. Barely half a kilometre from the Pisawan CHC is a private practitioner that even the poor in these parts rely on. He most likely does not have an MBBS degree (those who do display the information proudly!). A few years ago, he sat in a small shop-front clinic. Now he has an immaculate waiting room, a ward of sorts with a few beds and an examination room. Once as we waited to speak to him, he examined patients with all kinds of symptoms with the attention and 'human touch' that they do not get in the CHC. He wrote up long lists of medicines for most of them. This is the health care most Indians rely on.

To move from what we have to a system that promises true UHC (many health activists instead use the term Universal Access to Health Care), we have to better explain what we envision. I hope to work more on this in the coming months...