Blog Archive - Page 55 of 130 - Accountability Initiative: Responsive Governance

Kerala’s Habitation Patterns and Vulnerability to Disasters

This blog is part of a series on policy decisions, the causes and consquences of the Kerala floods. The first blog can be found here.

They say that what is true of Kerala is generally not true of other states. That is not only true of its long standing position in the forefront of states with higher education and health indicators, but also of its spread out habitation patterns. For decades now, barring city states like Delhi, Kerala has had the highest density of people per square kilometre. The statement that Kerala is an urban-rural continuum is now made so routinely that it is a cliché. However, that is also not a recent phenomenon; Kerala’s spread out habitation patterns have been a feature of the past too.

Take my own ancestral village in Mankurussi village, Mankara Panchayat, Palakkad district. Here, not very far from the dense jungles of the Western Ghats, are the rich rice fields of Palakkad. The soil, contrary to popular notion, is not very rich in nutrients. Much of the clay and alluvium has been washed down from the low tumbling laterite hills into shallow valleys, now long since tended and moulded into paddy fields. The homes are crouched on these laterite hills; they may be as many or as few, depending upon the availability of water. Behind each such home there is usually a small, almost natural forest, known as a Thodiga. The trees vary in a Thodiga from the Palmyra to the locally known Kazhani, a twisted thorny tree that has excellent timber, to a few teak trees and the ubiquitous Jack and wild Mango. Thodigas act as water sinks, break the fall of the heavy rain, and soak it in like a sponge. They provide plenty for the family’s needs, from an occasional tree cut down for rafters and reapers for roofs – even the fibrous Palmyra transforms to dense timber over the years – to Jack and Mango fruit, mushrooms, Chena (amorphophallus yam) and Chembu (knows as Arbi in Hindi) and plenty of vines and shrubs useful for various Ayurvedic medicines.

To visit each home in Mankurussi, is not an easy task of just walking down a main street and a few side lanes. The old houses in Mankurussi dot the laterite hills and the village roads twists and turns through the Thodigas to reach them. There are people always on the roads, but one does not necessarily see their houses, tucked away as they are behind each home’s forest. And so, Mankurussi meanders into the next village and the next.

Back in the mid 1880s, when the British built their strategically important railway line linking Madras to Mangalore, the line dipped southward to Coimbatore and then went westward through the Palghat Gap, a 30 kilometre wide breach in the Western Ghats that provided the easiest entry to the west coast. The survey of the line went directly through the low laterite mound on which my forebears had built their mud and thatch naalukettu house; one with four sides and a courtyard enveloped within. My great grandfather, displaced from his home, built his next home on a hill not far away. The laterite was chipped away and a mud foundation rammed in. The walls were made of mud too, mixed with several ingredients, an art long lost to the world now, to provide an enormously strong structure that went up two floors. The earlier thatch was replaced with the more upmarket tiles in more prosperous times.

Over time, the homes in Mankurussi have become more modern. The old homes remain, but in their compounds are built new concrete boxes, brightly painted. Worse, in violation of the law that prohibits the conversion of low lying paddy land into other uses, homes have been built in them as well. The thodigas are now converted into more ‘useful’ spaces; these jungles have been replaced by rubber and coconut plantations. They are not quite the same thing; no leaf mold carpets the jungle floor.

With each such step, of replacing old ways with the new, the people of Kerala have become more vulnerable. Floods could inundate the houses in paddy lands, but what’s more, rubber and coconut plantations have not a fraction of the water absorbing quality of the thodigas they replaced.

When the rains hit Palakkad district last month, the Malampuzha dam was opened like the rest of the dams in Kerala, and water breached the banks of the Bharatapuzha River. The rain poured for several days, and water entered many modern concrete and steel homes. Those who built their homes in paddy fields were especially hard hit, as the flood waters rose. Yet, my grandfather’s hundred and thirty year old mud house, built without as much as a kilo of steel or cement stood impassively against the rain, with no damage at all.

Deforestation in Kerala, the colonial legacy and afterward

This blog is part of a series on policy decisions, the causes and consquences of the Kerala floods. The first blog can be found here.

To continue the chronology of events in the taming and deforestation of the Western Ghats with which I ended last week’s blog, in 1864, Dr. Dietrich Brandis, a qualified forester, was appointed as the first Inspector General of forests. He fortified the thinking of those days, that forests were a nearly inexhaustible resource for several materials essential for industrial progress, and therefore, the government had the first claim on whatever forests had to offer. His thinking dominated the provisions of the first Indian Forest Act, enacted in 1865. In 1878 the act was revised to provide for the classification of forests into Reserve and Protected forests and brought into force in provinces. In 1906, the Imperial Forest Research Institute established in Dehra Dun; it continues to be the premier institution for the training and capacity development of officials recruited into the Indian Forest Service. In 1910, a Board of Forestry was created at national level and in 1921, following the enactment of the Government of India Act 1919, forests become a provincial subject due to political reforms.

The institutional reforms of the last decades of the 19^th century, opened the floodgates – a grim metaphor in the light of the current devastation of Kerala – to the wholesale exploitation of India’s forests. These were destroyed extensively for timber, railway sleepers, charcoal (to manufacture producer gas that was used to run vehicles) and for food cultivation, forest conservation was basically focused on addressing colonial needs. Conservation was a monopoly; the ruthlessly guarded preserve of forest departments. They encouraged monocultures and planned afforestation, with scant regard, or even awareness of the grievous biodiversity loss that such policies would trigger. These tendencies found their peak during the First World War and then again, during the Second World War.

Kerala was not immune to these national trends. The Princely States of Cochin and Travancore followed the same path to prosperity. The Mullaperiyar dam was built on the upper reaches of the Periyar river a century back; the British needed the dam to take water over the Western Ghats to the parched rain shadow areas of Madras Presidency lying to the east of the Ghats. In the foothills of the Western Ghats to the east of Chalakudy, where much of the recent devastation by floods has happened, the Rajah of Cochin built the Chalakudy tramway, a wood fired narrow gauge railway line, which was entirely devoted to moving timber from the lush, tropical forests, to the river and the main railway line below. No trace of the line remains today, except for the embankments of the old railway line.

There was a clear conflict between the recognition of traditional rights of people and the needs of government too. And to the credit of conscientious people within the government, there were plenty of differences of opinion too, regarding the idea fostered by the Government of India that forests ought to be the government’s preserve. The Madras Presidency for instance, initially rejected the adoption of the 1876 Indian Forest Act on the ground that the traditional practices and rights of people to use forest produce were not recognised in this law. Later on, they buckled to the relentless pressure of the Government of India, and relented.

The first 25 years following independence saw a continuance of colonial forest policies. The National Forest Policy 1952, while it drew attention to evolving systems of balanced and complimentary land-use, checking denudation in mountainous regions, river bank erosion, and sea erosion and sand dune shifting, establishing tree lands for community utilisation in order to deflect pressure from forests and improving grazing grounds and fuel wood availability, also spoke the language of exploitation. It said that forests must be managed for the sustained supply of timber and other forest produce required for defence, communications and industry and maximisation of annual revenue in perpetuity consistent with the fulfilment of the needs enumerated in the policy. The integration of princely States and nationalisation led to further loss of forests. Even though the biodiversity conservation movement began to pick up, it was not strong enough to stem the progressive loss of forest habitats. The focus continued to be on revenue earning from timber and commercial forestry. The subject of ‘Forests’ was also shifted from the State list, to the Concurrent list in the Constitution.

In Kerala, after Independence, the lower reaches of the Periyar’s tributaries were dammed by the Peechi and Vazhani dams and the main river was again dammed by the Idukki hydro-electric project. An engineering achievement that involved an underground power house as well. Finally, not less than thirty five major and minor dams have been constructed in Kerala. Each one of them has considerably submerged precious forest and diminished the sponge like quality of the Western Ghats. The only success of any note by conservationists was the successful thwarting of the idea of building a dam in the Silent Valley in the northern part of the Western Ghats. This would have destroyed the habitat of several rare species of animals and plants, including that of the Lion Tailed Macaque, a shy, tree dwelling primate that is rarer than the tiger in India.

Seeing the rigor of Research firsthand

Output of research projects are very often received with a generous dose of polarisation. Those who propound the very same ideas that the research project unearths, support it vigourously in a manner that disregards even glaring deficiencies in the study, and those who hold contrary opinions refuse to see any merit in the project while giving it a fresh coat of political colour. What is most unfortunate is that, in the process no one seeks to appreciate the academic rigour that goes behind any scientific inquiry.

If anything, this is the most profound lesson I have learnt spending a whole month interning at the Accountability Initiative. I joined at a time when they were intensely involved in designing a survey that they were going to use to ask front line workers questions about how the Integrated Child Development Services (ICDS), a Centrally Sponsored Scheme, delivers services and fund flows.

After working for many months in preparing a questionnaire, they spent days with their field team, analysing each and every question in detail, examining its context, relevance and in light of the kind of data a question of such a nature would help produce. Many more hours were spent deciding the best way to proceed with the survey and in arranging the logistics of the whole business.

Sitting through these days made me realise something that is often overlooked. Academic research isn’t all about the glamour of TV appearances or armchair opinion making. It is in the tedium of the minutiae, in the granularities of detail, that the true scientific spirit lies. For example, when questionnaires had to be prepared for different front line workers who were in charge of different organisational duties and responsibilities, the same questions had to be framed in a different fashion for each of them in a manner that reflected each worker’s role in the organisational hierarchy.

In a world incessantly focused on the lowest common denominators of life, this was a startling revelation. In all matters we expect the most condensed, bite-sized summary to be presented to us for our consumption. But the problem is that such a summary very often abstracts away the many complexities one expects to encounter in any scientific inquiry which hold the key to our understanding of phenomenon.

It was a great privilege to have witnessed up close all these tireless efforts and this experience made me understand something even broader in scope: That the pursuit or quest for the truth and the discipline it demands of its seeker is as important as the truth itself. Or to put it simply, how we design the survey and how we plan it are as important, if not even more important, than the final results we collect, collate and analyse.

How Kerala was made vulnerable to Natural Disasters

This blog is part of a series on policy decisions, the causes and consquences of the Kerala floods. The first blog can be found here.

There has been much discussion about the increased vulnerability of Kerala and Kodagu in Karnataka, to disasters of the magnitude that we saw recently. These have ranged from gentle and sorrowful remonstration, to strident ‘I told you so’ conclusions voiced by everybody from environmental activists, to religious bigots.

Yet, the question remains, how did we come to such a pass? Is this a recent phenomenon, or something that has taken a long time in coming?

As a Malayali, I was always intrigued by the maps of Indian empires that I saw in my school history books. Regardless of who or which group was the monarch of India at any given point of time; Ashoka, Harsha, Akbar, Aurangzeb or the Marathas, most of the tiny bit of the south-west of the Indian Peninsula was left out of their boundaries. A simple ‘Cheras’ written across that unconquered bit, was all that the history books would say about what we were, in the past. The truth is that for much of recorded history and probably for millennia before, the western coast of India and particularly, the Kerala coast, was impenetrable for armies that came from the north or the east by the land route. The Western Ghats were an impenetrable barrier to them – thick forests and fear of disease, dangerous animals and unknown threats deterred conquerors.

Yet, it was not as if Kerala was totally isolated; it looked outward to trade through the coast. For millennia, there is evidence of Kerala’s vibrant trade with other coastal powers and trading communities, ranging from Aden, through the Persian gulf, from the ports of what is today Pakistan and the more northerly western ports of India, to Mesopotamia and the Roman empire. Apart from the silk route, Kerala was probably the best way to get to the fabled riches of the east.

The renaissance saw an increase in European naval rivalry in the Arabian Sea, and after the venturesome Portuguese dominated the area in the sixteenth century, the British finally gained ascendancy, restricting the Portuguese and the Dutch in this region.

Britain on the other hand, had been cleared of its thick forests during the Bronze age itself. What forests remained were cut down to build warships and military hardware, required for their constant wars with European powers. Those of you who visit Europe and Britain and marvel at their efforts of conserving their greenery, often do not realise that their forests are but a tiny fraction of what they were. You can go for bracing treks in them, with nary a thought about what might happen to you.

Taking a walk in a forest in the Western Ghats is risky. There are at least six creatures that could kill you, if you left snakes out of the equation; Elephant, Gaur, Tiger, Leopard, Bear, Wild Dog.

Yet, the Western Ghats as it was, provided Kerala sustenance and succour. It attracted the area’s heavy monsoon rain, but also soaked it like a sponge and released the water over the year, into bountiful streams and rivers.

As Europe and Britain plundered their forests for timber to build their warships, they turned their eyes towards their burgeoning empires in the East.

Kerala was an easy target, once Britain was firmly ensconced in India. The forests were cut down with hardly a thought for their conservation. And the rivers flowed down to the estuaries and ports, not only with water, but with huge logs as well.

British colonialisation resulted in widespread destruction of forests starting from the latter half of the 18th and the early part of the 19th Century. In 1800, a Commission was appointed to inquire into the availability of teak. Six years later, the first Conservator of Forests was appointed to organise timber supply from the West Coast. This resulted in over-exploitation of teak forests along the Malabar coast for ship building for the British Navy, apart from the cutting down of Sandalwood trees of South India for the European market. In 1846, with most natural teak exhausted, the age of monocultures started, with the first teak plantation raised in Nilambur in Wayanad district of Kerala.

In 1855, the Government of India issued a memorandum outlining the rules for forest conservation across the country. Conservation, not in the sense of preservation of the biodiversity for future generations, but for the purpose of further exploitation, largely for the benefit of colonial powers.

Kerala Floods: Disaster resilience and an uncertain future

This blog is part of a series on policy decisions, the causes and consquences of the Kerala floods. The second blog can be found here.

The last couple of weeks have not been happy ones. Kerala, my home state, has been pounded by incessant rains the likes of which have not been seen for nearly a century. Kodagu, a beautiful hill district in my home away from home – Karnataka – has also been severely battered. People in both places have reacted with their customary fortitude. Governments have responded fast and alongside people across the country have quickly, with typical Indian generosity, contributed in cash and kind to the needs of the marooned and the rescued. True, there have been some discordant notes, with a few expressing glee at the suffering and hinting at divine retribution, but all of these trouble makers have been quickly put in their place by a groundswell of scorn and disgust from ordinary people.

People have low attention spans, though. So, as soon as the deluge of photos, selfies and videos on social media move to the next big thing, others will forget the event and move on. But for the survivors, this is only the beginning of a long climb back to normalcy. They will return from the relief camps to find their homes devastated, their precious belongings destroyed and their lives disrupted.

We will forget the last two weeks as a bad dream, till the next deluge.

And deluges, there will be. Probably stronger and more dangerous.

Without much scientific basis to support my observations, I have noticed a significant change in Kerala’s weather patterns. As a child, I remember the monsoon arriving with plenty of fanfare on the 1^st of June – Edavapaathi, they call it – half way through the Malayalam month of Edavam. In April and May, the weather would grow oppressively hot and humid. There would be occasional thunderstorms, but they would not last more than an evening. The air would be suffused with the perfume of wet soil; it was only much later that I discovered that there is a word for it – petrichor. And then, as June came, it would bring a dark wall of unbroken cloud from the Arabian Sea. With a drum roll of thunder to herald its arrival, the falling rain would be accented by daggers of lightning. We children would run inside, terrified and excited. The yard would fill with water and we would tear up old exercise books to make boats, and rather nastily, in retrospect, float hapless ants in them as passengers. Sometimes conscience would strike and we would splash along our boats, intercepting them before they rushed into ditches, and deposit the bewildered ants back at their nests. We would imagine them recalling to their mates their sailing adventures and then settling down to a hearty meal at home.

After that initial grand entrance, the monsoon would settle into a steady rhythm. It would rain for weeks, never letting up. But the rain would be as gentle as a sigh; there would be no direct sunshine at all. The land would absorb the water like a sponge and then, when saturated, would give up their hoard, softly, into the rivers and backwaters.

Not any longer.

While on an average Kerala still gets more or less the same quantity of rain that it did previously, the number of rainy days seem to have diminished. There are sharp localised storms of unexpected violence, with howling gales uprooting trees and cloudbursts that disappear as quickly as they form. A couple of years back, my ancestral village was hit by one such storm during the pre-monsoon period, leaving hundreds of uprooted trees in its wake and disrupting electric supply and telephone connectivity for days on end. They say that severe storms are going to be the norm due to climate change, but whatever the science behind such predictions might be, there seems to be a discernible pattern in that direction.

Blame has been placed on uncontrolled urbanisation and the rapid increase in construction in sensitive hilly and coastal areas, for the magnitude of the current disaster. There is no denying that people have contributed to their vulnerability by such construction, but this is not a problem that will go away by stating it. Public policies on habitation and disaster resilience have to be crafted, or if they exist, have to be implemented strictly. That in turn carries political implications; nobody wants to be the first in line to advocate for a tough stand to be taken on stopping construction in no-go zones. And furthermore, there are other questions as well; what are the best and least impactful ways to provide housing for all? Who pays for the implementation of climate change mitigation policies, which may range from removing or retro-fitting constructions to protect them, to crafting a transportation policy that reduces the footprint of roads and bridges, which disrupt natural water flow channels?

My blogs over the next few weeks will attempt to look at these issues from the perspective of governance and public finance. I hope to go beyond discussing the immediacies of handling relief measures in the aftermath of a natural disaster, to looking at what may be done to mitigate future damage.

One thing seems to be clear, though. Disasters of the nature of what Kerala and Kodagu are experiencing now, are not going to go away. We have to be prepared for worse.

Sustainability and Accountability Issues of Common Service Centres

Wouldn’t it be great if each citizen in the remotest of parts of our country has easy access to all key government services? By easy access, I mean that citizens are able to use these services by visiting a nearby centre without the hassle of spending hours travelling to faraway government offices.

The central government has attempted to make this otherwise distant dream a reality by introducing the Common Service Centres (CSC) scheme under the Digital India Programme. Many states have set up such centres in the last three years with the purpose to provide IT-enabled services to citizens, especially in the rural and remote areas where accessibility has been a major challenge. The central government plans to establish at least one CSC in each of the 2.5 lakh Gram Panchayats across the country by the year 2019. These centres are supposed to function as access points for the delivery of essential public utility services, social welfare schemes as well as healthcare, financial, education and agriculture services. They will be run by local entrepreneurs. Services that a citizen can expect from such centres are Government to Citizen (G2C) services like online filing of passport applications, requests for PAN cards, Aadhaar cards, birth and death certificates, and the withdrawal of money from accounts much like in the case of banks. These centres also have the flexibility to offer Business to Citizen (B2C) services that include mobile recharge and bill payments, and the renewal of dish TV subscriptions.

At first glance, the setting up of CSCs looks like a revolutionary step towards providing last mile service delivery from a single access point in remote areas. However, multiple challenges in the manner in which this scheme is currently being implemented have become apparent. These challenges can be broadly grouped into two categories. First, concerns with respect to long term sustainability of these centres and second issues that highlight an accountability gap. I recently participated in a workshop organised by the Azim Premji Foundation where these issues were discussed and debated in detail based on the findings of a sample survey on CSC owners and citizens accessing CSC services across 10 districts in Jharkhand. Among the workshop’s participants were CSC owners, members of the government and Civil Society Organisations. The primary matter of concern that emerged in discussions was this – can CSCs operate as businesses maximising profits for owners while simultaneously playing the role of public services providers? Also, are enough checks in place so as to make them accountable to the people they serve and provide quality services?

Sustainability Issues

CSC owners are local village level entrepreneurs (VLEs) trying to make a livelihood out of the PPP model (private-public partnerships). While most of the G2C services are offered at rates decided by the government, some basic services like banking are offered for free. There appears to be an understanding in government circles that CSCs should provide a large number of services to expand their profits so as to remain viable. Herein lies a dichotomy. While these centres aim to be self-sustainable by way of profits, they are also expected to work as public service agents by facilitating citizens in accessing services in areas that are difficult for the government to reach.

Many village-level entrepreneurs in Jharkhand pointed out that the average profit earned by them in the current commission-based model is quite low (ranging from Rs 3,000 to Rs 6,000 per month). They cannot charge the citizens beyond the rates prescribed by the government for the services offered. At the time of writing this blog, although we do not have enough data on the average monthly incomes for CSCs in other states, representatives from Rajasthan who participated in the workshop also confirmed similar levels of profits with wide monthly variations. In the current design of the scheme, it is not possible to ensure a basic minimum income. Will the entrepreneurs sustain themselves on such low levels of income in the long run? A question mark is also raised on whether CSC owners can then put a limit to free services offered by their centres and focus more on paid G2C and B2C services. This ties in closely with a third and a fundamental issue- should citizens be charged at all for G2C services that are otherwise available for free in government offices and funded through the taxpayers’ money? For now, answers seem few.

Also, all the services offered by the CSCs are online digital services which require uninterrupted and speedy internet connection throughout the day. However, poor internet connectivity in many of the interior villages in Jharkhand hampers efficient service delivery to the citizens. This results in delay in service provision as well as poor quality of the same. Without a well-functioning digital network in place, these centres cannot perform their role as envisaged by government.

Accountability Gap

The PPP model of the CSCs presently lacks a strong grievance redressal mechanism in case of failure in providing a G2C service for any reason. For instance, if a certain service applied through a CSC is rejected or if benefits of a certain scheme do not reach a citizen, an entrepreneur running the CSC cannot be directly held accountable because he merely acts as a facilitator and not being part of the government, he does not have any decision making authority in the provisioning of the service. In such a scenario, a citizen finds it difficult to approach a government authority directly for grievance redressal since he was coordinating with the CSCs till that point. Even if a citizen chooses to lodge any complaint against a CSC, there is no clear-cut formal route of doing so that assures timely response. Of course, there are phone numbers or email ids mentioned online by government, but that does ensure necessary action within a certain specified timeframe. In such a scenario, the essence of efficient service delivery at the last mile is lost.

Jharkhand is a forerunner in establishing CSCs in the country. The survey findings revealed that there is an emerging misconception among citizens in the state that CSCs are substitutes for government offices. For instance, CSCs in Jharkhand offer Aadhaar registration as per the rate decided by government. Wherever such centres are functional and offering this service in remote localities, additional camps are not set up by the government. As a result, a user has no choice but to visit the CSC and in the process ends up paying from their pocket, which could be accessed for free in a government-run camp. Similarly, the survey revealed instances of CSCs being projected as substitutes for banks for basic banking services such as deposit and withdrawal of cash. In the absence of a strong accountability mechanism, such practices can lead to confusion and also breed corruption because a large number of CSCs do not have the facility of passbook updation, which for many rural citizens will be the only valid way of tracking funds in their accounts. Should a CSC be working as a substitute for a government office?

So, should I be as thrilled as I was the first time I learnt that CSCs have been set up in remote villages across the country and would function as a point source to access a range of government services? I still feel the setting up of CSCs is a great move but certain changes are needed to make them accountable, efficient and sustainable. A strong accountability mechanism ensures a formal route for grievance registration and redress, regular government supervision and monitoring of the centres for enforcement of mandates, transparency through mandatory display of rate-list for all services offered among other things are required. At the same time, changes such as developing a mechanism for the CSC owners to earn some basic assured monthly income, and urgent investment in rectification and development of broadband internet connection in rural areas will be important for the long-term sustainability of the CSCs so that they can successfully play their role as last mile public service providers.

India’s new tryst with government health insurance

This Budget season, Finance Minister Arun Jaitley committed to launch the ambitious National Health Protection Scheme (NHPS) with thumping applause from the House. The enthusiasm was understandable as out-of-pocket medical expenses make up over half of the total health spending in India. Recognising India’s huge out-of-pocket health spending as catastrophic[1], this scheme has been touted to alleviate the burden of health expenses of the poor by way of insurance.

NHPS forms an essential part of Ayushman Bharat as it aspires to provide secondary and tertiary health care coverage alongwith the revamped Health and Wellness Centres for primary care. Deliberations are currently on as health societies and departments around the country are busy figuring out the design and implementation of this new scheme which shall subsume RSBY and run parallel to other state insurance schemes. NITI Aayog too has created multiple subgroups to deliberate on the feasibility of its design and benefit packages. Keeping the modalities of the scheme aside, there are certain essential questions we need to ask. Firstly, what is India’s current situation with regard to health spending? And secondly, what are our past experiences of government sponsored health insurance schemes?

The extent of spending on private medical care

The Out-of-pocket expenditure (OOPE) by Indian households stands at a whopping 63% of the total health expenditure. Meanwhile, the health expenditure by the government has been a mere 1.13% [2] of the GDP (or 29% of the total health expenditure)[3].

This is primarily because the government’s capacity to provide secondary and tertiary care is still limited in most states. As a result, around 58% of the country’s rural population and 68% of the urban population seek private hospitalised treatment. They foot their medical bills from household income/savings in rural (68%) and urban areas (75%) followed by borrowed money. The figures for the latter are higher for rural (25%) than urban (18%) areas. India’s household health spending has been a major determinant in pushing poor households towards impoverishment[4].

Government spending is low, even within the health expenditure- the Union government contributed only 37%[5]. The centre’s low allocation on health has been explained with its lower tax to GDP ratio, limited fiscal space and changing political priorities in the past. This year the budget for RSBY was increased three-fold to Rs 2,000 crore. It is however unclear whether this budget will cover the target beneficiary number of 10 crore families per year under NHPS.

The realities of implementation

India’s past experiences with government financed health insurance schemes have not been seamless as envisioned. Lower claims to premium ratio have led to the underutilisation of payments made by the government to insurance agencies[6]. If such a trend continues with NHPS, where the risk burden of premium payment is entirely on the government, the benefits expected from the government’s increased expenditure on health will naturally only be marginal. With the new National Health Policy seeking to bring in private partners to fill in critical gaps in healthcare, there is yet to be clarity on the engagement between government and private insurance agencies for NHPS.

Also, beneficiaries seem to be lukewarm to the idea of health insurance coverage. 29% of Indian households have only 1 member covered under any health insurance scheme. The figures look grim seeing the differences among states – with 75% of households in Andhra Pradesh insured compared to only 4% in Manipur. Interestingly, there isn’t much difference between rural and urban areas in terms of insurance coverage. In 2014, 86% of the rural and 82% of the urban population were still un-insured with 91% of the bottom 20% quintile class of urban areas out of coverage[7]. The possible explanation for this exclusion could be the urban population enrolled under RSBY faced a higher price as compared to its rural counterparts with no marked difference in inpatient expenditure[8].

Operational inefficiencies such as delays in payment to empanelled hospitals, staff shortages, lack of autonomous fund managers, weak management information systems and lack of procedural knowledge of the insured will only add up to the challenges of reducing out of pocket expenditure of rural households.

As it has been announced to be an expansion of the already existing RSBY, it is likely to be designed as a government sponsored health insurance scheme with/without a token contribution from beneficiaries. This financing approach for India is a deviation from the general trend of lower middle income nations towards healthcare. Most developing nations either leave insurance on OOPE, risk pooling among formal sector employees or take a social health insurance approach where both the government and formal sector pool the risks and cover the poor[9]. Though each country varies in regard to its organisation of public and private providers, payment systems, regulation and disease burden, India taking the burden on itself should therefore make sure this scheme is more effective.

As any other newly rolled out large scale programme, NHPS too will take time to figure what works and what doesn’t to reduce OOPE. Going forward we should take into account the plethora of past experiences and focus on its financing model and sustainability, variation across states in terms of disease burden, rural-urban differences and the possible operational lacuna. Certain states such as Andhra and Tamil Nadu are already running successful insurance schemes which could offer possible direction for NHPS.

[1] Catastrophic health expenditure occurs when out-of-pocket (OOP) payments for health services consume such a large portion of a household’s available income and the household may be pushed into poverty as a result.

[2] National Health Profile 2018 records it at 1.28% of GDP as of 2017-18 BE.

[3] THE- Total Health Expenditure includes both current and capital expenditure.

[4] Fu, 1999

[5] NHA 2014

[6] NIPFP report

[7] NSSO 2014 on Health

[8] Jayakrishnan et al, Pharmacoeconomics, 2016

[9] Hsiao and Shaw, SHI for Developing Nations, The World Bank, 2007

MGNREGS’ accountability measures on wages weak

Clear rules that hold the entire government machinery accountable for delays in wages do not exist under the Mahatama Gandhi National Rural Employment Guarantee Scheme (MGNREGS), a team of researchers who have studied the programme for over 2 years have found.

“Overcentralisation of the architecture has meant that accountability structures have been diluted,” said Dr Rajendran Narayanan, Assistant Professor at Azim Premji University, at the inaugural Policy In-Depth session hosted by the Accountability Initiative. Thus, the state government, the Union government and banks are never put under scrutiny for what is the legal right of workers.

MGNREGS is a flagship scheme of the Government of India (GoI) which aims to provide at least 100 days of guaranteed wage employment in a financial year (FY) to every rural household that demands work. The MGNREGS provides a legal guarantee that wages be paid within 15 days of the completion of work and closure of the muster roll. The study, which analysed over 9 million transactions across 10 panchayats per district in 10 states from 2016-2018, found significant delays at each step in the payment clearance process.

Wage payments are first made under the National Electronic Fund Management System (Ne-FMS) on completion of the work week. A pay order known as a Fund Transfer Order (FTO) is generated at the Block or Panchayat. Once approved and signed by states, the GoI approves the FTO digitally and wages are electronically transferred to the State Employment Guarantee Fund. Funds are then transferred to an individual worker’s bank or postal account.

The authors found that delays are being calculated only till the FTO is sent to the Centre which means the time taken to process the FTO and transfer wages to workers’ accounts is not being taken into consideration. Just 21 per cent of the payments made in FY 2016-17 were made on time, while in FY 2017-18, only 32 per cent of the wage payments made in the first two quarters of the financial year had been made on time.

Additionally, the law mandates compensation to be paid at the rate of 0.05 per cent of the unpaid wages per day for the duration of the delay beyond the 16th day of the closure of muster rolls. There is a failure to accurately calculate delays since the definition of what constitutes a ‘delay’ does not include the actual delay till the payment of wages to beneficiaries. As a consequence, a major portion of compensation remains unaccounted. For FY 16-17, the amount of delay compensation reported for the whole country was only Rs 519 crore. The true total delay compensation is, however, estimated at around Rs 1,208 crore. Of the reported amount, only about 4% has been paid.

Even after the wages are credited, it takes much longer for the workers to access their wages due to a weak banking and disbursement architecture. These intervals too are not captured in the centralised system.

As per Accountability Initiative’s latest analysis on MGNREGS, pending liabilities (additional expenditure incurred by states over and above their funds available due to increased demand within a financial year) is seeing an upswing. In FY 2015-16, states had payments due amounting to Rs 566.99 crore. This increased to Rs 1,162.37 crore in FY 2016-17.

In FY 2017-18, as on 20 July 2018, states had already accumulated pending liabilities amounting to Rs 2,959.53 crore. Given the demand driven nature of the scheme and its legal mandate, GoI is meant to reimburse states for this additional expenditure, but the trend of accumulated higher state expenditure as a proportion of funds points to the urgent need for reform.

In all, the absence of provisions that put in place accountability measures for the wage payment process has had far reaching consequences on programme implementation. This is in spite of the fact that MGNREGS has proven to be a landmark on securing accountability at the local level through its emphasis on social audits conducted by citizens. When will wage payments, the other aspect of this critical rural livelihood programme, be accorded the same status in existing MGNREGS guidelines?

The presentation by Dr Rajendran Narayanan during the session can be accessed from here, and the study can be found here.

To download Accountability Initiative’s latest analysis on the MGNREGS, visit this page.

India’s stunted progress on child health

How far has India progressed on securing welfare of all? This blog is part of a series which uses data to unpack the status of health, education and policy reforms in India’s 71st year of freedom.

Despite nearly 71 years of independence, children are still bound by malnutrition and poor health, a result of absolute poverty and an ineffective state. It is widely recognised that health issues from nutritional deficiencies in childhood can have a compounding effect in adult life. Inadequate healthcare can be debilitating to society at large from multiple vantage points: public participation, individual freedom, and labour supply. Healthier citizens are more able to participate in public life and public activities, can choose from a larger set of opportunities, and are more capable in their jobs. Simply put, healthier individuals are able to do more, be more, and contribute more (for more on this see my colleague Avani Kapur’s piece). A critical question stares us in the face at this juncture: what is the actual status of child health in India?

Dire Straits for Children

There are several indicators that reflect the long-term health and nutritional experience of an individual or population. One can check whether a child is stunted, underweight, or wasted[1]. Studies have linked stunting to lower cognitive development, among other unfavourable outcomes. Stunting is caused by long-term insufficient nutrient intake and frequent infections, and the effects are largely irreversible. In addition, cognitive development is also impaired by anaemia (low haemoglobin caused by iron deficiency). Wasting is a result of acute significant food shortage and/or disease, and is a strong predictor of under 5 mortality. Figures reveal that over 16 per cent of children in India are severely stunted, as many as 58 per cent children are anaemic, while close to 7 per cent are severely wasted.

These poor outcomes are in part, borne of inadequate diets – less than 10 per cent children (6-23 months) receive the minimum acceptable diet[2]. Starvation deaths still occur, as sheer poverty and deprivation has precluded a large number of people from being able to feed themselves or their children restricting their future lives. Age-appropriate vaccination[3] coverage also remains low (27.4 per cent), thereby compounding the magnitude of the health problem. The state of child health in India is grave. Successive governments have recognised this and put into action various programmes to tackle the issue.

Anganwadi Centres are vital, but fall short of requirements

The Poshan Abhiyaan (National Nutrition Mission), launched in March 2018, has been one such step and aims to address malnutrition through convergence across ministries, improved technology, and better targeting. It is premature to know of its impact, yet, critical in the battle against malnutrition have been Anganwadi Centres (AWCs) under the longstanding (since 1975) Integrated Child Development Services (ICDS) programme. As part of the programme, children and lactating and pregnant mothers have been eligible to cooked meals, health check-ups, and immunisation services.

Even today, AWCs do not cover all children who require these services: only 1 in 2 children received any service according to NFHS 4 data. A quarter of ICDS beneficiaries are malnourished, a number that has increased from 15 per cent in 2015 to 25 per cent in 2017, as per analysis by the Accountability Initiative. This shows that even as ICDS coverage is expanding to include those who need it most, malnutrition remains a problem among those that avail ICDS services.

The quality of services provided continues to be weak. Out of ICDS beneficiaries, less than half received food supplements in 2015-16. Only 70 per cent Anganwadis had drinking water facilities, and 63 per cent AWCs had toilets.

In light of such deficiencies, funding by the government is meagre. The government seems to have given short shrift to increasing the amount spent on child health, which has remained stagnant for successive years. Expenditure on supplementary nutrition declined by 6 per cent between 2015-16 and 2016-17. Anganwadi workers and helpers are still treated as ‘honorary workers’, and are paid a lean amount (approximately ₹5,100 and ₹2,820 respectively, on average), unadjusted for inflation. Furthermore, they are not entitled to minimum wages, according to the government. For the amount of work, and the skill required, such low pay can be distressing and as a consequence has led to strikes by workers time and again in various states to demand better pay. Additionally, of all sanctioned posts for Anganwadi workers, 8 per cent were vacant, as on March 2017. Vacancies are even higher among supervisors, which weaken monitoring, implying that even fully functional AWCs may not run efficiently.

Since the Anganwadi system is a critical asset in the fight against malnutrition, what are the consequences of these lapses for the poor, who critically depend on public health programmes?

Wealth IS health, in most cases

There is stark inequality in how children of the poor and rich survive. Out of 1,000 live births, 72 infants of the least wealthy 20 per cent don’t survive until their fifth birthday, compared to 23 for the wealthiest. For those among the poorest and worst off who do survive, more than half are stunted, and almost half are underweight. Clearly, poor and deprived children are worse off than their richer counterparts. These inequalities continue to persist later in life and affect educational and occupational opportunities, and aggressively exacerbate income and wealth inequalities even further.

The rich and privileged don’t have to depend on weak public services, and have the resources and social capital to afford quality healthcare in private hospitals, which are out of the reach of the unprivileged. The wealthiest 20 per cent can afford better healthcare than the least wealthy. This seems to be true across several indicators – from access to vaccinations, to malnutrition and mortality rates at various stages of childhood.

However, inequalities are not limited to wealth, or income. Caste and gender marginalisation persist in society, and these reflect in child health outcomes as well. Children of lower castes, or girls, face further issues due to their marginalisation by societies. Intersections of these inequalities adds to an already complex problem.

Sluggish improvement in outcomes: Does time heal all wounds?

A look at data from the last two decades reveals the extent of the progress the country has made. Over time, especially after India liberalised its economy in 1991, the quantity and quality of services provided has improved. However, progress isn’t as smooth as one would expect. Malnutrition has reduced, but not on all indicators. There has been a 10 percentage point reduction in stunting in the decade before 2015-16. However, every 2^nd child is anaemic, and the propensity of wasting has actually increased.

Compared to malnutrition, there has been marginally better progress in the survival rates of children. At the same time, under 5 mortality still remains very large. Of every 1,000 children born, 30 do not live beyond a month, about 41 do not live beyond a year, and about 50 children will die from birth till their 5^th birthday.

It is thus clear that despite several government programmes, including the presence of ICDS since 1975, severe malnutrition in childhood has persisted over time, and is much worse for the poor and unprivileged sections of society. This has clearly restricted people from rising up the income and wealth scale, and the impact in time and money lost on private spending due to weak public nutrition services that should be easily accessible, is incalculable. The current government has responded with recent programmes like the Poshan Abhiyaan and the Rashtriya Swasthya Bima Yojana. The former includes a slew of activities involving at least 10 Union ministries and components as diverse as medical intervention, behaviour change, capacity building of frontline workers, and technological innovations, among others. The latter seeks to improve access to healthcare by providing insurance. Moreover, the renewed focus on sanitation is a welcome step. The hope, somewhat ambitiously, is to reduce stunting from 2 in 5 children to 1 in 4 children by 2022. The question is, will the government’s efforts be able to mend lapses of the past, and set the system on rapid course correction?

Inputs by Avantika Shrivastava

India increasingly faces dual burden of malnourishment: under-nourishment & over-nourishment. While 2/10 people are thin, 2/10 are overweight. Know about this emerging challenge to the public health system in the second part of this series.

[1] Stunting refers to low height-for-age, being underweight refers to low weight-for-age, and wasting refers to low weight-for-height. Moderate and severe malnourishment refer to people below two and three standard deviations below the normal, respectively.

[2] 4+ food groups, breastmilk, other milk products, and are fed with appropriate frequency.

[3] BCG, measles, four doses of hepatitis B, and three doses each of DPT and polio vaccine (excluding polio vaccine given at birth)

The Changing Shape of India’s Health Crisis

There has been sea change in the kind of diseases that are making people in India unhealthy with the disease burden among adults now shifting to non-communicable conditions. Improvements in health and nutrition have been only marginal in the last two decades, leading to a dual challenge of a shifting disease burden and malnutrition in India. This blog gives a glimpse into the current health challenges facing adults in India.

A shifting disease burden and new challenges

There are three main contributors to ill health – the first are communicable, maternal, neonatal, and nutritional diseases, the second encompasses non-communicable diseases (NCDs), and the third comprises injuries. Communicable diseases are spread through contact with infected people, contaminated objects, disease carrying insects, and through air and water. Diseases not caused by infectious agents or are non-transmissible are called non-communicable diseases (NCDs). For example, the flu is a communicable disease, while cancer is not.

In the last three decades, India has undergone an epidemiological transition – that is, the disease patterns have changed. Mortality due to communicable, maternal, neonatal, and nutritional diseases has decreased, but the contribution of NCDs to health loss and death has nearly doubled from 1990 to 2016.

Unfortunately, while NCDs are responsible for a majority of deaths, easily preventable diseases continue to haunt a large number of people resulting in a compounded disease burden. Diarrhoea, lower respiratory, and other common infectious diseases still contribute to approximately 1 deaths out of 6 in the country.

The Dual Burden of Malnutrition

As with diseases, India is also increasingly facing a dual burden of malnourishment: under-nourishment and over-nourishment. A useful measure to understand varying contributions of different ailments to the total losses suffered due to illness, is the disability-adjusted life year (DALY). It is a measure of overall disease burden, expressed as the number of years lost due to ill-health, disability, or early death. What is telling is that the contribution of nutritional deficiencies to DALYs has increased between 1990 and 2016 in India, indicating that nutritional problems persist and require urgent action.

To get a sense of how healthy someone is, one can look at three different aspects of a person’s nutrition profile.

Their body-mass index (BMI) (weight in kg divided by the square of height in metres);
Their nutrient and calorific intake; and
Their heights during adulthood.

Measuring health through BMI suggests that approximately 4 in 10 people in the country are outside the ‘normal’ range: 2 out of 10 are thin, and 2 out of 10 are overweight. Between 2005-06 and 2015-16, the proportion of mildly thin women declined by 10 percentage points, but the proportion of severely thin women has only decreased minimally (2 percentage point decline). On the other end of the BMI spectrum, the percentage of overweight and obese women has increased as well. Similar trends can be observed for men as well. Moreover, NFHS-4 data shows that the very poor are likelier to be thinner than ideal (normal BMI range – 18.5 to 25), and the rich are likelier to be overweight.

adverse maternal outcomes and health risks for unborn children. This has likely contributed to the consistently demoralising state of child health in India. Therefore, while undernourishment has always been a problem, over-nourishment is rapidly emerging as source of alarm.

Nutrient consumption has declined, despite incomes rising

Another useful measure to study the changing pattern of India’s health burden, is a look at consumption patterns, specifically the consumption of nutrients. In their article reviewing trends in food intake and nutrition in India, economists Jean Dreze and Angus Deaton point out that calorie consumption has been declining in rural areas. A calorie decline can be partly explained by a decline in calorie requirements due to economic development – such as mechanisation in agriculture, a drop in physically demanding tasks like carrying water over long distances, the emergence of sedentary jobs, etc.

The decline in calorie consumption seems acceptable, if calorie requirements have indeed declined. But the intake of proteins and other nutrients has declined too, with the exception of fat, revealed by the increase in the number of overweight and obese people.

The decline in proteins and other essential nutrients is particularly concerning, especially because this has occurred despite rising incomes, increasing per capita expenditure on food, and relatively stable prices– indicating that people are consuming fewer nutrients and calories per rupee spent, or that people are consuming more expensive nutrients and calories.

Gender biases exacerbate an already dire situation

Finally, the third indicator of long-term nutritional status of the population is to look at heights of adults. Taller populations are better-off, more productive, and live longer, according to various studies. Given the staggering amount of stunting during childhood in the country, it isn’t surprising that Indians are among the shortest people in the world, as Deaton points out. While Indians have been growing taller, Indian men have been doing so at more than three times the rate of Indian women. This suggests that nutritional gains have been unequally shared across men and women.

Inequalities between men and women, borne of patriarchal tendencies, highlight the fact that tackling this crisis is complicated. Inequality and subsequent distribution within the household is something that health programmes ought to focus on, and there is a need for a concerted effort to change the way people think about these things.

A shift in the disease burden comes against the backdrop of more people accessing private healthcare options due to an already weak public health system. These options are far costlier than government healthcare, and a large number of people have to shell out huge amounts of money, which pushes people further into poverty. Is the government spending enough? Is it reprioritising to account for the shift in the disease burden and current trends in malnutrition, and is it spending smartly? Do we have the public infrastructural capacity to deal with the diversity of health problems? And what would be the consequence for preventable health issues that can be easily dealt with – what policy makers like to call ‘low-hanging fruit’? While there is no straight answer, it seems the government has recognised the need for change in direction albeit not prioritised it. I take a closer look at this in my next blog.

Avani Kapur and Avantika Shrivastava contributed to this article.

The first part of this series can be found here.