Aaditya Singh
Making maternity safer and affordable
This article originally appeared in centreright.in. CRI content has now been subsumed in swarajyamag.com. The views expressed here are personal and do not necessarily reflect those of the editors of swarajyamag.com

In a recent interview published in e-Gov magazine on Tuesday, October 01, 2013, the Mission Director, National Rural Health Mission (NRHM) said:

“Janani Suraksha Yojana (JSY) has seen a phenomenal increase from 7 lakh beneficiaries in 2005 to more than 1 crore a year 2010 onwards… Building on JSY,another major initiative ‘Janani Shishu Suraksha Karyakram’ was launched in June, 2011 to eliminate out of pocket expenditure for pregnant women and sick neonates. The initiative entitles every woman delivering in a public health institution to free drugs, diagnostics, diet besides to and fro transport. Free entitlements have now been expanded to cover antenatal and postnatal complications and sick infants up to one year of age.”

Indeed, while the past few years have seen widespread attempts to revamp the state of health provisioning, on-the-ground evaluation of health care system reveals a huge gap between intention and implementation.

In Sitapur, one of the backward districts in Uttar Pradesh, Kaushlya Devi (name changed), delivers a baby in a 24X7 Primary Health Centre (PHC) located on a brand-new four-lane National Highway-24,which connects Lucknow to Delhi. As per the JSY scheme, not only all the pregnancy-related costs are to be borne by the Government, Kaushlya is also entitled to free transport and food. However, after her delivery in the night, a nurse (Auxiliary Nurse and Midwife) comes and asks for money in exchange for her services. Kaushlya was asked to pay Rs. 320.

Hamari ‘baksheesh’, the nurse demanded. Kaushlya told the nurse about her poor financial condition and expressed her inability to pay the baksheesh. Kaushlya was, in turn, told by the PHC staff that she will not discharged from the hospital until she pays the baksheeh. Kaushlya had no cash money to give, neither at the hospital nor home. But left with no option, she had to mortgage her gold nosepin at the local goldsmith in exchange for some cash to pay to be discharged and be able to go home.

While Kaushlya’s case highlights the problems in the operation of much praised JSY, a conditional cash transfer program which promotes institutional delivery by the means of cash incentives with the overall objective of reducing maternal and child mortality; it is emblematic of the dismal state of health care provisioning in the north Indian state of Uttar Pradesh. Indeed, following the implementation of JSY the percentage of institutional delivery has increased quite remarkably, drawing praise at national and international forums for making safe delivery a reality for the poorest of poor mothers in India. Drawing from the 6-month-long (March-September 2013) field research in the district of Sitapur, Uttar Pradesh, it seems, however that the success of JSY is limited largely to the increasing proportion of institutional deliveries and programme aims of quality of care, reducing out-of-pocket health expenditure on maternity care remain unfulfilled.

Overburdened health system

The current number of health facilities in the district is nowhere near the norms set by the Indian Public Health Standards (IPHS). A district teeming with 4.3 million rural people would need another 17 CHCs, 82 PHCs and almost 400 SCs to cover its total population (IPHS recommends a SC per 5000, a PHC per 30000 and a CHC per 120000 people). Apart from shortage of health facilities, the quality of existing infrastructure is poor with no basic amenities like electricity or water supply. Only 19 CHCs, 2 PHCs and one SC provide delivery care facilities in the district of 4.5 million people. The number of nursing staff in the CHCs is 33 nurses as against IPHS norm of 190 nurses (IPHS recommends 10 nurses per CHC). If current population is taken into consideration, the total number of required nurse goes up to 360 which is 10 times the current number of nurses in the district. Moreover, there are many CHCs running without a nurse. ANMs in such cases have to assume nurse’s responsibility.

Overburdened ASHAs
During my field research, I interacted with a number of officials at the various layers of health system, from ASHAs to district level officials. ASHAs are local women trained to act as health educators and promoters in their communities.They are considered to be the mainstay of JSY as they are responsible for motivating women to give birth in hospitals.

As of 2013, there are 3008 ASHAs in the district. However, looking at the population norm, the district needs another 1300 ASHAs. Currently, on an average, one ASHA takes care of about 1500 people. It must be noted here that a considerable number of AHSAs actually do not work.

There are a number of reasons behind such retraction. Contractual nature of the job, no guarantee of fixed income and undue delays in paying ASHAs their due, are some of the reasons why they leave the system. It is also important to note that while there is an increase in the demand for health care services, since 2008 there have been no new recruitments of ASHAs. This has resulted into higher work pressure on existing staff, which is reflected in the poor health service delivery. The shortage of staff notwithstanding, ASHAs have been successful in bringing pregnant mothers, especially the poorest of poor, under the radar of public health system.

Lack of basic amenities

Once you reach the CHC, the tall claims about the health system reforms made by many international and national organisations and the governments both at the Centre and the State, fall flat. Let us take a look at how the lack of basic amenities and infrastructure makes a delivery at CHCs a horrible experience not only for pregnant mothers but also for her family and relatives.

Out of nineteen, only five CHCs in the district, have 24 hours electricity. It must be noted here that two of them are designated as First Referral Unit (24X7 CHC with facilities for obstetric surgery, blood transfusion, anaesthesia, specialist paediatric care, operation theatre and required equipment) and remaining three are located on four-lane National Highway-24 connecting the district headquarters to Lucknow. Some of them do have old electricity generators running on diesel but they are rarely used for lighting purposes.

The main purpose of having a generator is to maintain the cold-chain (the place where vaccines are kept).Non-existent seating arrangement in most of the CHCs forces people to retire and sleep on unhygienic floors. Lack of electricity, fans, heaters, chairs, water coolers etc. makes visiting CHCs a horrible experience. Some CHCs become inaccessible during monsoons because they are located off the main road and not connected by a metaled road.

Poor quality of care
ASHAs reveal the real story of quality of care poor rural women receive when they deliver in so-called rural hospitals i.e. CHCs. Since, most of the CHCs have only one or two labour tables, sometimes mothers have to deliver on unsantized floors. Given the fact that electricity is supplied only for 6 hours a day, deliveries during night time are often conducted using light from torch, mobile handset, wax-candles and local kerosene lamps.ASHA is supposed to manage kerosene oil, lamps, candles and even matchboxes before leaving for CHC.

Running water inside labour rooms is a rare luxury in CHCs. There are washbasins stuck in the wall though. Water is generally carried from a hand pump by the family members or relatives of the patient in a bucket. The horror of delivering a baby in a CHC does not end here. Toilets in most of the CHCs are without any running water. One has to carry water of his/her own, from the only hand pump in the campus. It should come as no surprise if they remain untidy all the time.

Dais conduct deliveries
Lack of nurses and ANMs in the state health system still forces UP to take help from traditional birth attendants. Moreover, nurses and ANMs in UP still consider delivery to be a dirty ‘task to be performed only by ‘dais‘ (local midwife)’. Hence, they rarely involve themselves in labour process. CHCs have to hire private dais (midwives) who conduct deliveries to earn (Rs.50-100 per delivery) their bread. The role of a staff nurse or ANM at CHCis currently restricted only to “‘monitoring’ the process of delivery, intervening only when necessary and administering necessary injections”.

Safe maternity still requires money
ASHAs reveal that after delivery, it is usual to administer some injections like Methergine and provide essential medicines to mother. These medicines are generally not available in the hospital dispensary and need to be bought from private drug stores located just outside CHC. The expenditure on these medicines is actually an out-of-pocket expenditure which Janani Shishu Suraksha Karyakram launched in 2011 aims to eliminate.

Normally, the total expenditure varies between Rs.100 to Rs.200. However, after dark, the drug stores usually take advantage of the fact that there are no other shops around and charge the poor patients more than the maximum retail price.When either the government ambulance is being used for other emergencies or the driver is not available, it is not possible to drop the patient home after delivery. In this situation, patients sometimes have to pay up to Rs.500 to hire a private vehicle such as a taxi or a jeep/van, especially during night time.

Pay ‘mandatory’ bribes and ‘baksheesh’, get JSY money
After delivery, the nurse processes necessary documents and distributes cheques to patients. In some CHCs, especially poorly accessible ones located in Eastern part of the district, it is mandatory to pay Rs.320 after delivery regardless of who you are – a poor peasant or a rich landlord. There is no receipt given for this payment. ASHAs revealed that this money (Rs.320) is distributed among nurse, dai, and sweeper-cum-watchman at the spot. The patient has to pay another Rs.20 to receive her cheque. North India is known for its son preference. Therefore, whenever the baby is a boy, nurses, dais and others in the CHC usually ask for a monetary gift from the family members of the patient. The amount varies from as little as Rs.100 if the patient belongs to a poor family to as high as Rs.2000 plus gifts if the patient belongs to a rich family.

ASHAs do not receive what they are entitled to
ASHAs are supposed to receive an amount of Rs.600 per institutional delivery. However, from this money, they also have to pay Rs.120 to CHC staff in order to get the payment sanctioned and thus, their actual payment is Rs.480 per case. This amount of Rs.120 is distributed among the Superintendent and the accountant/clerk (Rs.100 for the Superintendent+ Rs.20 for accountant). ASHAs receive an honorarium of Rs.150 for each regular immunization (RI) drive and thus, they are paid Rs.3000 every four months for these RIs. However, the money reaches their bank account only when they pay Rs.1500 in advance to the account manager at CHC and too without a receipt. They further revealed that a part of money actually goes to Chief Medical Officer. It is also possible that the chain goes on even further.

Final words
What government has been successful in is that it has been able to provide delivery care in rural hospitals (CHCs). However, low quality of care and financial burden is still a problem. Although the money under JSY attracts women to deliver in a health facility, a lot of JSY money is actually being squandered on bribes to health workers. Apart from that patients have to spend on necessary medicines and injections and sometimes on transport as well. On the other hand, whatever money government pays to ASHAs for their services, one-fifth of that goes to the pockets of accountants/clerks and superintendents. This is a sheer wastage of taxpayer’s money.

The infusion of money into the system will not do any wonders until it is ensured that it reaches the right person at the right time and place. Therefore, the major challenges is to ensure accountability and transparency in the implementation of JSY. Apart from that health system in UP needs a revamp in terms of physical infrastructure and human resource without which we cannot expect any scheme to perform well. NRHM has been extended till 2017 and may prove another opportunity for UP to make much needed “architectural corrections” in its health system. However, any hope for rapid change in the health system of UP would be a fallacy until health as an issue remains at the bottom of the agendas of political parties in the state.