Blog Post Year: 2018

The Changing Shape of India’s Health Crisis

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. 

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.

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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.

  1. Their body-mass index (BMI) (weight in kg divided by the square of height in metres);
  2. Their nutrient and calorific intake; and
  3. 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.

Presentatio2_0.jpgadverse 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.

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.

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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.

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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.

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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.

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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.

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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 2nd child is anaemic, and the propensity of wasting has actually increased.

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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 5th 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)

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.

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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.

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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 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

#3 WALKING THE TIGHTROPE: THE FUTURE OF THE IAS

As the Indian bureaucracy completes 160 years, former Indian Administrative Service (IAS) officer T.R. Raghunanandan reflects on the decisions being taken by the government to reform the IAS and the impact these are likely to have. The first part of this blog can be found here. 

Things seem to be moving swiftly in the circles of IAS reforms. The idea of having a fourth level of examinations at the end of the Common Foundation Course, which I had said was unnecessary, seems to have been dropped for now, going by the reports in the papers. However, that has not laid to rest other questions, two of which considerably exercise the mind at the moment; the one of lateral entry at the Joint Secretary’s level and the other, of the stand-off between the elected government of Delhi, and particularly its chief minister, and the IAS. I propose to deal with the latter in this blog.

The circumstances of the current controversy on who is answerable to whom in Delhi, are well known. One would not hazard to look at the issues of the facts, because, depending on where one sits, one has a diametrically opposite view point on the facts that have led to the dispute between the IAS and the elected government. Suffice to say that there is tension between the two; and that is a masterly understatement.

Regardless of my personal views on the matter as to who is right or wrong at this point in time, I have long held that the crux of the issue was the delay by the Supreme Court in determining the exact boundaries of the responsibilities of the elected government of the union territory of Delhi and the Union Government. As long as these boundaries were hazy, there was ample scope for disputes between the union and the union territory’s elected government. Disputes of this nature almost always place the permanent bureaucracy in a sensitive position; as they are used as the arms and ammunition for political battles.

Sadly, last week’s Supreme Court order did not make matters clear. At the end of 535 pages of sometimes heavy reading; one is still at a loss to get answers to precise questions that needed to be answered. Broad statements such as that the Lieutenant Governor works under the aid and advice of the elected government, and that the two ought to work with a spirit of cooperation, hardly suffice when the tussle is about real issues on the ground; who issues transfer orders of staff, who recruits and who clears and undertakes procurement processes. It is not as if the Supreme Court were not aware of these matters, even though these might not have been framed into precise issues and questions to be answered by the court.

Once again, there is ample scope for the bureaucracy to be accused of favouritism and being subordinated, possibly under threat, to the union government.

What does the bureaucracy do in such matters? When faced with orders that contradict each other, what line of thought ought to be the norm?

The answer lies in the fundamentals, which is the hierarchy of orders or directives. Any student of public administration knows well enough that the working directives that drive governance on a day to day basis, such as rules, bye-laws, instructions and letters, only constitute a subordinate framework, which is subject to the law. The law, in turn, is subject to the provisions of the Constitution.

True, bureaucrats who take upon themselves the task of interpreting the Constitution may find themselves in a tight spot, because their interpretation might be disputed, particularly when it comes to the nuances of the separation of functions between levels of government. However, in this case, the Supreme Court has already given an interpretation, which needs to be acted upon. The key to understand such interpretations is to proceed in the opposite direction as one would if one were to be faced with a battery of rules and laws. One needs to comply with the broad principles and then fill in the detail.

Whatever may be the gaps in the interpretation of the Supreme Court, the judgment makes two clear and unequivocal statements. First, that the LG works under the aid and advice of the Council of Ministers, and that all matters in the State and Concurrent List, excluding subjects that are specifically excluded, come within the domain of the elected government. Surely, that is easy to interpret?

The problem arises when tactical positions are taken, with a view to the future, as to which position is to be supported. Such positioning by the bureaucracy, which comprises largely of ambitious loners, might yield benefits to individuals who ride the risks. However, it undermines the bureaucracy as a whole. Politicians are canny creatures; always on the lookout for chinks in the armour of the permanent bureaucracy. Over the years, politicians are no longer befuddled by the impassive barriers that the bureaucracy builds against quick and decisive actions; if an officer won’t do what the politician of the day wants, the latter will find a new officer to do their bidding.

As it stands today, it looks as if more issues will be raised before the Supreme Court. In particular, the issue of who controls the services of the officers in Delhi, will be raised. However, whatever may be the outcome, the position of the bureaucracy as a permanent and objective servant of the political power of the people expressed through the latter’s representatives, will be undermined. The nice thing about a democracy is that political power changes hands, sometimes when one least expects it. But politicians also teach each other tricks that succeed.  Manipulating and playing mental games to subjugate the permanent bureaucracy is one of them.  

The views expressed are of the author only and do not represent an institutional stand.

Panchayati Raj: Empty Coffers and the Mirage of Local Governance

This year marks the silver jubilee of the 73rd and 74th constitutional amendments that led to the institutionalisation of Panchayati Raj in India. This was a landmark constitutional reform that had the disruptive potential to make democracy truly representative by ensuring decision making at the local tier, and holding governments accountable to people at that level. 25 years later, the slow pace of institutional reforms and the numerous bottlenecks have reduced Panchayati Raj Institutions (PRIs) to the role of paper-pushing agencies rather than a thriving arena of local governance.

The constitutional reforms primarily sought to bring about changes to the Indian political landscape through 2 mechanisms. First, it aimed at widening the democratic base and bring in political representation from across the country and across social groups. This has been fairly successful with elections to the panchayat seats being held regularly, and the number of elected panchayat representatives as of 2015 at 35 lakh i.e. an elected representative for every 3,700 people.

Secondly, the constitutional reforms aimed at creating PRIs as institutions of public service delivery and governance that would be responsive to local needs. This came against the growing realisation that real development could not take place without the participation of people.  Political and economic theory shows that PRIs are better placed to coordinate locally available resources with the local needs of the people. Initial experiments with conferring power upon people’s representatives also revealed a number of positives: teacher attendance in primary schools improved; block development officers became more responsive to people’s needs; and importantly people were able to air their grievances to the elected representatives and obtain relief through them. These were clear pieces of evidence that PRIs enabled greater accountability in governance.

Given this rationale, the constitutional amendment law created several institutional reforms that would animate PRIs as well-functioning grassroots public service delivery institutions. In that regard, the law identified 29 subject matters in the 11th schedule of the amendment for which PRIs held sole responsibility. PRIs were to be given complete powers to plan and execute schemes for the functions pertaining to these 29 subjects. Several institutions that would enable bottom-up decentralised planning were given statutory status. District Planning Committees (DPC) were to be constituted in each district by the state governments; The DPCs were meant to coordinate and consolidate the planning process across the PRI tiers and formulate a development plan for the entire district. Gram Sabhas, in which every citizen of the panchayat was a member gained constitutional recognition as the fora for discussion and deliberation of Panchayat plans and proposals. Additionally, panchayat members were also expected to give updates on status of implementation of different schemes in the gram sabha. Further, Panchayats in several states have de jure provided for the implementation of social audits. Social audits are a powerful way to independently evaluate the performance of PRIs by the people.

Despite these forays into making governance at the grassroots a reality, any progress on getting the institutional reforms underway has met with several roadblocks. As a result of India’s federal political setup, each state has the right to pass their own panchayati raj act to legitimise PRIs and determine the extent of decentralisation within their state. While all states have passed the state panchayati raj act, the de facto operationalisation of these principles has lacked political will and left most Panchayats across the country toothless.

A basic tenet of decentralisation requires that funds follow function. In most states in India, several functions have been transferred to one of the PRI tiers notionally. However adequate funds have not been allotted for the panchayats to execute these functions. All states were required to constitute State Finance Commissions every 5 years to recommend tax and non-tax revenue assignments and fiscal devolution from the states to the PRIs. But the SFC institution has come under scathing criticism. Rather than carry forward the spirit of decentralisation through timely reforms, SFC reports have oftentimes been retrograde. In other cases, the SFC recommendations have been disregarded by the state governments or accepted notionally but not implemented. Barring a few states like Kerala and Karnataka, most other states present a depressing trend on the fiscal devolution front.

The constant tussle for power between the state line departments and the PRIs has also not been resolved despite 25 years of supposed institutional reforms. Panchayats have been given control of functionaries in only 9 states, and even there the line departments are allowed leeway to constantly subvert the Panchayat’s authority to determine locally relevant plans. District Planning Committees (DPC) in several states are headed by the district collector or a minister once again undermining PRI control.

Without funds and functionaries to carry out the functions assigned to them, PRIs in most states exist as vacuous symbols of authority.

The proliferation of centrally sponsored schemes further curtails the Panchayat planning space.  Central ministries and state departments have set up parallel structures to implement development schemes on agriculture, health, education, social welfare, women and child development etc. all of which fall within the Panchayat functional domain. These parastatals by-pass the PRIs in all planning and decision making, and even when funds are routed through Panchayats it is given as “tied” grants. This reduces the role of PRIs to mere implementing agencies.

Thus, even as we have moved past the rhetoric of the need for greater democratic decentralisation and are in the implementation phase of PRIs, the state of affairs of Panchayati Raj in India dampens any exuberant romanticism that once surrounded it. One can only hope that sustained political participation at the grassroots level would soon translate into a strong demand for clear mandates of local functioning, greater ability to raise revenues and more autonomy of the Panchayats.

“सिस्टम की जटिलताओं की ओट में छिपे अधिकारी”- एक वास्तविक अनुभव

जैसा की आप हम सभी जानते हैं कि हम लोग सरकार को किसी न किसी तरह कर के रूप में पैसा देते हैं | सरकार भी उस इकठ्ठे किये गए पैसे से अपने अधिकारीयों के माध्यम से हमें सेवाएं देने का काम करती है | परन्तु सवाल यह उठता है कि यदि सरकार में बैठे लोग ही अपना काम सही से न करें या फिर लापरवाही बरतें तो उसका प्रभाव किन लोगों पर सबसे ज्यादा पड़ता है? यह सवाल तब और भी संजीदा हो जाता है, जब सेवाएं देने वालों के ऊपर बच्चों के भविष्य निर्माण की जिम्मेदारी हो |

मैं इसी से जुड़ी कुछ महीने पूर्व हुई एक वास्तविक घटना को आप सभी के समक्ष साझा कर रहा हूँ | यह बात मेरे गाँव की एक महिला शिक्षक की है जो पास के लगभग 1 किलोमीटर दूर स्कूल में मुख्य शिक्षिका के पद पर कार्यरत हैं | स्कूल सुबह 9 बजे शुरू होता है पर बावजूद इसके मुख्य शिक्षिका अपने स्कूल में अक्सर 12 बजे पहुँचती हैं | कई बार तो यदि उनका मन नहीं करे तो वह स्कूल भी नहीं आतीं | पंचायत भी ब्लॉक शिक्षा अधिकारी के समक्ष मुख्य शिक्षिका के बारे में शिकायत कर चुकी है लेकिन अधिकारियों की तरफ से उन्हें चेतावनी से ज्यादा कुछ नहीं मिला |

यह मार्च 2018 के पहले सप्ताह का दिन था, जब स्कूल में बच्चों की परीक्षाएं चल रहीं थीं | दिनचर्या के अनुसार आज मुख्य शिक्षिका स्कूल में नहीं आई थीं परन्तु आज का दिन बाकी दिनों से कुछ अलग था | जिला परियोजना अधिकारी सर्व शिक्षा अभियान अचानक स्कूल में परीक्षा के दौरान औचक निरिक्षण करने आ पहुंचे | दुसरे अध्यापकों से जानने के बाद मालुम चला कि बिना स्कूल को जानकारी दिए मुख्य शिक्षिका आज स्कूल नहीं आयीं हैं | जिला परियोजना अधिकारी ने सभी रजिस्टरों का निरिक्षण किया और पाया की कोई भी रिकॉर्ड पिछले काफी महीनों से अपडेट नहीं किया गया है | इसी बीच पता नहीं कैसे मुख्य शिक्षिका को अधिकारी के पहुँचने की सूचना मिली और उसने पड़ोस के एक लड़के के हाथ में छुट्टी की अर्जी भिजवा दी | लेकिन मुख्य शिक्षिका ने जल्दबाजी में अर्जी की तारीख में वर्ष 2018 की जगह 2017 लिख दिया था | गुस्साए अधिकारी ने तुरंत शिक्षकों को स्कूल प्रबंधन समिति के सदस्यों, अभिभावकों एवं पंचायत के सदस्यों को स्कूल में आने को कहा ताकि मुख्य शिक्षिका के विरुद्ध कड़ी कार्यवाही की जाये |

अभिभावकों ने अधिकारी के सामने मुख्य शिक्षिका के बारे में बात रखते हुए बताया कि उनकी वजह से शिक्षकों एवं बच्चों के ऊपर काफी नकारात्मक असर पड़ रहा है | अधिकारी ने स्वयं पत्र तैयार करके सभी मौजूद लोगों से हस्ताक्षर करवाये | अधिकारी ने लोगों को आश्वस्त किया कि उच्च अधिकारी से इसके बारे में शिकायत की जायेगी तथा यह सुनिश्चित किया जायेगा कि मुख्य शिक्षिका के विरुद्ध कड़ी से कड़ी कार्यवाई हो | इसके बाद जिला परियोजना अधिकारी ने ब्लॉक शिक्षा अधिकारी को भी इसकी सूचना दी | इस बात को बीते हुए आज 4 महीने से अधिक हो चुके हैं तो आप लोग जरा सोचिये कि अब आगे क्या हुआ होगा? सोचिये?

आगे यह हुआ कि 4 महीने बीत जाने के बाद अब मुख्य शिक्षिका वरिष्ठता के आधार पर पदोन्नत हो गई हैं और केंद्र संकुल समन्वयक (CHT) भी बन चुकी हैं | जी हाँ, आपने बिलकुल सही सुना | हिमाचल प्रदेश में शिक्षा विभाग दो भागों में कार्य करता है – पहला शिक्षा विभाग का स्थायी ढांचा जिसे सभी प्रकार की प्रशासनिक शक्तियां प्राप्त हैं और दूसरी तरफ सर्व शिक्षा अभियान के रूप में अस्थाई सोसाइटी | हिमाचल में शिक्षकों की पदोन्नति वरिष्ठता के आधार पर शिक्षा विभाग के स्थाई ढांचे द्वारा की जाती है | वहीं सर्व शिक्षा अभियान के अंतर्गत आने वाले अधिकारीयों के पास वास्तव में किसी शिक्षक को हटाने एवं पदोन्नत करने की कोई शक्ति ही नहीं होती|

एक तरफ सर्व शिक्षा अभियान के जिला परियोजना अधिकारी ने मुख्य शिक्षिका के काम को देखते हुए उनके ऊपर एक्शन लेने की हिम्मत दिखाई | वहीं दूसरी तरफ रुढ़िवादी ढांचे की वजह से वरिष्ठता के आधार पर मुख्य शिक्षिका के ऊपर कार्यवाई होने के बजाय उसकी पदोन्नति हुई | इससे ये कहना गलत नहीं होगा कि ऐसे अधिकारी सिस्टम की जटिलताओं के ढांचे की ओट में  छिप जाते हैं | क्यों इस तरह के सिस्टम तैयार किये जाते हैं जिसमें सरकार खुद ही उलझ कर रह जाती है और फायदा ले जाते हैं तो केवल कुछ मौकापरस्त अधिकारी?

पिछले अध्ययनों और अनुभवों के आधार पर शायद मुझे यह कहने में मुझे कतई गुरेज नहीं है कि यदि वह निरिक्षण अधिकारी शिक्षा विभाग के स्थाई ढांचे यानी लाइन डिपार्टमेंट से होता तो थोड़ी बहुत कार्यवाही शायद देखने को मिल भी जाती |

यह समस्या केवल शिक्षा विभाग की ही नहीं है बल्कि यह बात सभी विभागों के ऊपर लागु होती है जो सेवा वितरण में अपनी अहम् भूमिका निभातें हैं | ऐसे कितने ही रोजमर्रा में इस तरह के अधिकारी होते हैं, जिनके खिलाफ लोग अपनी आवाज तो उठाते हैं परन्तु सिस्टम की जटिलता या कभी लापरवाही की वजह से ऐसे लोग पाक साफ़ निकल जाते हैं | जरुरी है कि सरकार ऐसा सिस्टम तैयार करे जो ऐसे लोगों के खिलाफ पूरी पारदर्शिता से जांच करे और उनकी जवाबदेही सुनिश्चित करते हुए अपना निष्पक्ष निर्णय सुनाये | इसी से एक बेहतर सेवा वितरण के सिस्टम का निर्माण हो पायेगा |

#1 Walking the Tightrope: the future of the IAS

As the Indian bureaucracy completes over 160 years in 2018, former Indian Administrative Service (IAS) officer T.R. Raghunanandan reflects on the decisions being taken by the government to reform the IAS and the impact these are likely to have. 

The last three months of staying away from blogging – my longest absence so far from this site – has not been without event. From the unique experience of witnessing a state’s elections from up close as the election agent of a candidate, one argued and bantered on issues concerning the bureaucracy; an eternal favourite subject of discussion on social media.

Three events have shaken the Indian Administrative Service to its very foundations in the meanwhile. The first is a letter from a Joint Secretary of the Union Government, which suggested that selection of officers into the various civil services and – in the case of the All India Services – their allocation to various states, will depend upon the final ranking of the candidate after he or she has attended the Common Foundation Course at the Lal Bahadur Shastri National Academy of Administration. The second is an advertisement issued by the Union Government, seeking for open selection to the positions of the Joint Secretaries in selected key ministries of the Union Government. The third is the acrimonious showdown between the elected government of the Union Territory of Delhi and the civil servants working with it, which hopefully has now been resolved and a working arrangement of sorts restored.

On each of these issues, discussions within the tribe – I still continue to be a member of it, in spite of my voluntary retirement – have been full of clashing opinions. While officers who continue to serve in office have generally been quiet, or at most, are cautious in their comments, those who have retired have not held back from voicing their concerns. Most comments on these developments have been adverse, though some are optimistic that the changes rung in with the first two decisions will be for the better. Yet, there is unanimity – a rare thing when IAS officers discuss anything – that these events have irreversibly changed the character and the ethos of the service.

Let me say what I think is right, or wrong about these matters. The first issue is whether the final selection of officers into their respective services should depend upon the performance of the officer trainees in the Common Foundation Course.

The Civil Services examination is a trial by fire. There are three levels that have to be cleared till one finds one’s name on the merit list. At each level there is a carnage; a ruthless exclusion of those considered unfit. The first is an objective test that screens participants for the main examination. Nearly a million candidates appear for this examination and not more than ten thousand clear it; that is a selection rate of one candidate per hundred aspirants. Then, these ten thousand or so appear for a written examination comprising several papers, after which about two thousand are selected for face to face interviews. Following the interviews, nearly a thousand are finally selected into a basket of various services. Considered to be at the top; though technically, there is no such hierarchy, is the Indian Administrative Service, to which roughly one hundred and fifty candidates are selected. Then come the Indian Police Service, the Foreign Service, the Revenue Service, the Audits and Accounts Service and so on, again in no particular order of hierarchy, to make up the list of selected candidates.

Given the intensity of the competition, there is very little to distinguish one successful candidate from the other. While some of the top performers are prodigiously brilliant and their final marks are way beyond those obtained by their fellow competitors, as one goes down the merit list, the bunching of successful candidates who have obtained the same number of marks, becomes more and more pronounced. It is not unusual that what separates an individual who makes it into the IAS from one who does not, may be a fraction of a percentage point of marks obtained. Also given that the optional subjects that may be offered by candidates for the written examination ranges from medicine, to engineering, to law and to Chinese, the comparisons of skill and intelligence levels of different candidates is like comparing the proverbial apple with the proverbial orange.

In such circumstances, the successful candidate is bathed in relief and happiness when the results are announced. Since society makes much of them, many succumb to the belief that they are individuals with extraordinary intelligence. But some are intelligent enough to understand that they were lucky to be faced with questions that played to their strengths. It was their good day when they took the examination, and they aced it.

From what I remember, the Common Foundation Course was an endless lark. Nobody, except those officer trainees who were genetically wired to be diligent and sincere – read that as ‘humourless and dour’ – took the Common Foundation Course seriously. The government is being very unfair now, to reduce this celebration of success into another grind, where officers are closely scrutinised, before their fate for the next three decades is decided.

On a more serious note, will this idea of testing the officers during the Foundation course have the effect of improving the quality of the civil services, or is it another extension of the torture of the civil services examination? I will continue this exploration in my next blog. 

#2 WALKING THE TIGHTROPE: THE FUTURE OF THE IAS

As the Indian bureaucracy completes over 160 years, former Indian Administrative Service (IAS) officer T.R. Raghunanandan reflects on the decisions being taken by the government to reform the IAS and the impact these are likely to have. The first part of this blog can be found here.  

Once Officer Trainees are selected, they are all directed to join the Common Foundation Course, an orientation programme that usually starts in the  August of every year.  Since more than 500 individuals now get selected, there is not enough accommodation in the Lal Bahadur Shastri National Academy of Administration, Mussoorie; so a parallel Common Foundation Course is held in the National Academy of Direct Taxes, Nagpur.

The Common Foundation Course is considered a big milestone; not in terms of the training content imparted, but simply because it is the professional gateway to what is a lifetime of service in the government, for most participants. The academic content comprises hardly anything worth remembering. Once one clears the entrance exam into the civil services, the classes on subjects such as Constitutional law or public administration does not hold one’s attention. The Foundation Course therefore relies on four kinds of activities to keep the participants active and interested.

The first are the classroom sessions where the resource persons are invited experts in their respective fields, or are civil servants with relevant experience. Usually, instead of regular lectures, panel discussions are organised, which stoke the exchange of several perspectives. These give newly recruited officers a preview into life in the government. The second are the after office hours activities. Life is an active social whirl, with plenty of societies formed by the officer trainees, say, for example, in music, theatre, quizzing and suchlike, which conduct competitions and discover that talents of the Officer Trainees go well beyond the ability to pass a tough examination. The third are group activities that involve traveling and immersion into various situations, known as ‘attachments’. Officer trainees, usually in small groups, are attached to various agencies or offices for this immersion. There is a village attachment and a tribal one, as also attachments with prominent NGOs, agricultural universities, Public Sector Undertakings and so on. Officers are attached to units of the armed forces as well. Some of these are undertaken in the Common Foundation Course while others are spread over a two year probationary period. The last are tests and project reports, in which officers, either individually or collectively, reflect upon their experiences, do a modicum of academic study and submit a final report on a chosen subject.

There have been suggestions in the air for more than thirty years that the marks obtained, both in the examinations conducted in the Academy for all participants in the Common Foundation Course, as also the internal assessments based on an assessment of the academic and non academic performance of each candidate, ought to be reckoned for the allocation of services and inter-se ranking. The Kothari Committee on reforms to the selection process for the Civil Services was the first to make this suggestion. However, the government did not accept this recommendation, stating that the assessment process conducted by the Academy was prone to be distorted due to political or other pressures. The government has recently again reopened this issue and asked the suggestion of states on what they thought off the idea.

Will this idea of testing the officers during the Foundation course have the effect of improving the quality of the civil services, or is it another extension of the torture of the civil services examination?

Personally, I think it is a tiresome idea, for several reasons. First, officers who finally make the grade have undergone one of the toughest examination processes, which has screened them from thousand others who did not make it. It just is not fair if a fourth layer of high stakes examinations are going to be held, in order to determine where the officer would be finally slotted. Second, a lot of officers selected for the Foundation Course don’t attend it, as they are again appearing for the civil services examination. How they will be assessed is not known. Third, the UPSC has been a bulwark of impartiality and credibility, when it comes to the selection of civil servants. The Constitution does not envisage that any part of the selection process would be undertaken by a body other than the UPSC. It would be a dilution of this approach if the government wants to conduct another final screening examination before assigning the state in which the officer will serve.

I would let the Foundation Course be. It is meant to be a lark. It is meant to build a sense of unity between people from diverse professions and interest. It is meant to develop social skills, particularly in those who have become mindless recluses because of repeatedly writing the civil services examination. Adding one layer more to the three stage recruitment process is not worth the trouble; it only vitiates the celebratory and cheerful atmosphere of the Academy and replaces it with grim faced examination fever. It would not allow any time for cathartic celebration. I think everybody who writes the civil services exam and succeeds at it, deserves a little bit of time to luxuriate in the feeling of success.

The Challenges of Building State Capability in India

In the latest Harvard Center for International Development Speaker Series podcast, Centre for Policy Research President and CEO Yamini Aiyar discusses the challenges of building state capability in India and the functioning of the bureaucracy.