Archive for the ‘public policy’ Category

The Emperor’s New Clothes

“But he hasn’t got anything on” a little child said (Hans Christian Andersen)

 Three measures taken by the central government in recent years do not seem to be yielding dividends, at least in the short term. Demonetisation started off with the promise of unearthing black money, moved on to promising a cashless nirvana and has finally only succeeded in damaging growth prospects. The Goods and Services Tax (GST), after so many years in the making, was rushed through in a matter of months with inadequate software readiness and with poor education of the masses of small retailers and traders who, willy nilly, had to move overnight to online systems for which they were totally unprepared. The informal sector has been particularly hard hit by the speed of GST imposition. Implementation of Aadhaar was pushed through as a money bill. It is still facing civil society resistance in the Supreme Court, especially because of the stubborn bureaucratic insistence on treating it as a panacea for all of India’s ills, including tax leakages and terrorism, instead of first focusing on streamlining the process of beneficiary entitlements.

What has marked all these three “initiatives” has been the attempt by the political executive to display its so-called dynamism, consequences be damned. What has been even more noteworthy is the failure of the civil service, especially at the highest levels, to caution its political masters in rushing through with measures that affect the lives of large masses of people. Like the courtiers in Andersen’s fable, they are effusive in rushing to extol these policies, without sparing a thought for harsh realities. The same could be said for the inordinate haste of BJP state governments in pushing through legislation banning the sale and consumption of beef, which has jeopardised the livelihoods of large numbers, especially from the Muslim and Dalit communities, apart from rendering them vulnerable to vicious attacks by vigilante groups.

And now, the government has dropped a bombshell — it seems to want to tinker in a major way with the manner in which senior civil servants are allotted services after selection and the states to be allotted to those selected for the All-India Services. The only document available in the public domain is a letter from a Joint Secretary in the central government’s Department of Personnel to the Deputy Director General in the Department of Telecommunications. Ordinarily, such a letter would not even be deemed worthy of notice. What has set the cat among the pigeons is the mention in the letter that the measure is sought to be implemented from later this year, which means that the batch just selected (2019 batch) will serve as the guinea pigs. As a member of the 1980 civil service batch which served as guinea pigs for the last effort at civil service recruitment process reform, courtesy the Kothari Committee report, I am bemused that views of departments are being sought without any background paper or report serving as the basis for the thought process. It almost seems as though (à la demonetisation) the decision has already been taken and a perfunctory consultation process is being gone through before orders are issued.

Many of my colleagues in the civil services (all retired) have expressed themselves forcefully on this issue. While we are almost unanimous in our view that the civil service recruitment system is in need of reform, our apprehensions stem from the rather flimsy methodology suggested for the service/state cadre allocation, which would strike at the very roots of the concept of a competent, impartial civil service. The faculty at the Lal Bahadur Shastri National Academy of Administration, Mussoorie and at other institutes, where foundation courses are conducted, are hardly equipped to critically assess the capabilities of officers for deciding their suitability for different services. There are likely to be three deleterious implications if the proposed course of action is gone through in haste, without addressing fundamental issues of evolving a sound selection process.

Cronyism is the probable first evil that has to be factored in. India is still a country where regional, language and caste factors exercise a strong pull. Without disparaging my erstwhile colleagues from the northern states, it is a fact that, barring the Rajiv Gandhi era, there was a predominance of three or four states, especially Uttar Pradesh, in the senior echelons of administrative decision making at the centre, in the first fifty years after independence. While this phenomenon may be partly attributed to the reluctance of officers from the southern and western states to go on central deputation, it is also a fact that positions in key economic ministries were occupied by officers from the northern states or those who kept in close touch with the levers of power in Delhi. That the fulcrum has now moved to Gujarat is no cause for comfort: it only proves that bureaucrats most in sync with the political dispensation of the day at the centre rule the roost. But, at least, central deputation has finite time limits, till repatriation or retirement ends the bureaucrat’s tenure. The mind boggles, however, at the thought that a protégé can be given a lifetime job guarantee by a favourably disposed godparent at the time of service selection.

Corruption will inevitably follow any such non-transparent process, following Lord Acton’s dictum that “…absolute power corrupts absolutely”. In an ocean of corrupt State Public Service Commissions, the Union Public Service Commission maintained its reputation for integrity in the selection process for over six decades. While one may quibble over the manner of selection — bookish, elitist, etc. — there has never been a question of individuals (or coaching classes) using the lure of lucre to manipulate the selection process. I shudder at the prospect of the future of the country’s administration being subject to the possibility of temptations being dangled before faculty in training academies, who are called on to adjudicate between the relative merits of different candidates who qualify for the civil services, especially when one witnesses the debasement of so many institutions by the pernicious influence of money power.

Politicisation of the civil services will be the obvious corollary of any post-selection evaluation mechanism. The candidate who is smart enough to qualify for the foundation course will also be smart enough to realise that s(he) can use political strings to swing the desired service/state in his/her direction. The reign of different political dispensations every five years will only add masala to the selection process. And, heavens forbid, if the same party continues to rule at the centre for two or three decades, nothing stops it from packing the civil services with officers loyal to its ideology, fulfilling the Emergency dream of a “committed bureaucracy”. In a federal set up, where parties opposed to each other may be in power at the centre and in the states, nothing short of anarchy will reign when civil servants of the All-India Services assigned to different states are looked at with suspicion by state governments. We have already had a foretaste of this in Delhi because of no love lost between the Delhi government and the central government.

Merit is likely to be a casualty of the proposed changes. But the issue of choice also rises. Young Indians spend the best part of their productive years attempting to seize the holy grail of the civil services. Now, when the grail seems to be within reach, it could be snatched away by the whims of a few instructors or the machinations of colleagues, aided and abetted by unscrupulous elements. When certain services continue to exercise an allurement for prospective civil servants similar to that of the songs of the Sirens for sailors in Greek mythology, introducing an element of uncertainty for a further period of six months to one year after selection could lead to one of two consequences: (a) it could discourage bright young women and men from seeking to join the civil services, or (b) more damagingly, it could encourage the entry of elements who seek to obtain their desired service/state through any means, mostly foul. If you doubt me, just see the type of candidates who are standing for elections to legislatures and Parliament. Gresham’s law of the civil services will then operate with a vengeance.

Let me hasten to add that I, and most of my retired friends in the civil services, are strongly in favour of reforms in the processes of selection to the civil services as well as subsequent career advancement. We recognise that there has been considerable heartburning over the fact that a single examination decides the future life trajectory of an individual. You could argue that so does an IIT or IIM selection process, but then these are not lifetime guarantees. The IIT/IIM graduate still has to compete with others for entry into a particular line of employment. At the same time, given that there is so much hype to get a “prestigious” civil service job, the selection process has to be insulated from pressures and influences. In an earlier blog (Reshaping India’s bureaucracy – a blueprint for action), I had proposed wide ranging changes in the structure of the civil services, including the abolition of the All-India Services and making all appointments contractual, to meet the administrative challenges of the coming decades. While I am sure that there will be plenty of views on (and criticism of) my suggestions, I strongly feel that cosmetic changes are no solution to a bureaucratic system that is perceived by the mass of the people of India as unresponsive, lethargic and tyrannical. It is possible that some variant of what I have proposed could be devised, with implementation in stages. But unless the issue is addressed at all levels of government — central, state and local — and efficiency and accountability are introduced in governance, the Indian public will continue to be shortchanged in service delivery and India’s long-term growth and development prospects will be affected.

The need of the hour is a close, hard look at what is wrong with our governance systems and how to improve these. Merely toying with service allotment or state allocation is no solution: if anything, these will worsen the situation and lay the government of the day open to the charge of changing the system to suit its political requirements. It would indeed be ironical if a government that swears by Sardar Patel were to demolish the edifice of the civil services built up by him, without developing a viable long-term alternative. Were this to occur, we can only take refuge in the words of the late Jayaprakash Narayan “विनाशकालेविपरीतबुद्धि”(when one’s doom approaches, one’s intelligence works perversely).

No Shades Of Grey for India

I am not, as you might think, advocating the banning of the erotic book and film which have titles similar to the headline of this blog. But I am getting increasingly convinced that operating in grey areas is something Indians revel in. The new millennium has offered adequate proof that Indians abhor convention and thrive on discretion. While departing from the former allows for abominable behaviour even in the temples of Indian democracy, adhering like blood-sucking leeches to the latter enables the growth of the rent-seeking economy and polity. Where laws exist, bend them to suit oneself and one’s clan (even if discreetly) and, where they are silent, may the devil take the hindmost, decencies be damned.

Let us start with the legislatures, the roots of democracy in India. Over the last decade, we have seen the top two legislative organs of the country, the Lok Sabha and the Rajya Sabha, apart from a number of state assemblies, being held hostage by elected representatives. Rushing to the well of the House, disrupting legislative business, indulging in fisticuffs and even grabbing the Speaker’s mace have been par for the course. A very far cry from the conventions in the British Houses of Parliament, where the Speaker’s word is law and where, once the Speaker has risen from her chair, all members on their feet must resume their seats. Of course, the farce commences even before the assembly commences its first sitting. Karnataka 2018 is its latest and most dramatic example. After a rather dubious decision by the Governor, the Supreme Court (SC) stepped in to order an immediate trust vote on the floor of the House. Flouting established convention, the Governor departed from the established procedure of appointing as pro tem Speaker the senior most elected member, generally from the opposition, to conduct the proceedings prior to election of the regular Speaker. This was obviously done to smoothen somewhat the winning of the trust vote by the newly sworn in Chief Minister (CM). Unfortunately, for the BJP, the SC fettered the discretion of the pro tem Speaker such that the CM had to resign within thirty-six hours of being sworn in.

But conventions have died a painful death in India over the years, assisted by constitutional functionaries. At the behest of whichever party is ruling at the centre, Governors of states have twisted the provisions of the Constitution of India, notably Article 356A, to help dismiss elected governments of a political hue different from the centre. As India steps squarely into the era of hung Parliaments/Assemblies and coalition governments, Karnataka and, before it, Goa, Manipur and many other instances represent the जिसकी लाठी उसकी भैंस (he who holds the stick controls the buffalo) mentality that dominates the Indian psyche. “Show me the Governor and I’ll show you the government” seems to be the prevailing motto. This blog does not have the space to go into the Sarkaria Commission recommendations on government formation in the states or the SC rulings in the SR Bommai and Rameshwar Prasad cases. But common sense would dictate that, after a tiring, costly election process, that government is sworn in which has the best chance of lasting the next five years. When the largest party falls well short of a majority and there are not enough independents and members of other small parties to help it cross the half-way mark, the logical course of action would be to invite post-poll coalitions of other parties, which have affirmed their joint intention of government formation, and give them a chance to prove their majority on the floor of the House. The Governor does have discretion but, as a functionary who has sworn to uphold the Constitution, (s)he is duty bound to act in a manner which does not reek of political partisanship.

Governments of all political persuasions have never been respecters of conventions. Recently, the Income Tax (IT) department raided the Badami (Karnataka) resort owned by an MLA-hopeful of the Congress during the election process. Nothing wrong in this, except the timing! Did the raids by the IT department and the subsequent attention supposedly lavished on him by the Enforcement Directorate have anything to do with his recent switch of loyalties from the BJP to the Congress? This worthy, after many twists and turns in the saga, appears to be as yet with the Congress, but who knows what the morrow brings? There were also disquieting media reports that loyalty of some MLAs was sought to be bought by promising leniency in investigation of economic offences in which they were allegedly involved. With the reputation of central investigative agencies already at an all-time low, efforts at their subornation are a cause for worry.

In the prevailing gloom over the functioning of the legislature and the executive, the performances of the Election Commission of India (ECI) and the SC give cause for cheer. In what was a bruising election, the ECI ensured the free exercise of franchise, though the role of muscle and money power in influencing voters is still a disease that requires remedy. The SC moved swiftly to check efforts to influence legislators and its eagle eye ensured that no attempts were made to monkey around with the trust vote process.

In the final analysis, however, it is the moral fibre of individuals that will determine the development of healthy practices in a democracy. We had the newly sworn in BJP CM of Karnataka announcing a farm loan waiver, transferring key police officials and seeking to augment his party’s strength in the trial of strength by nominating a legislator from the Anglo-Indian community (until restrained by the SC). We had the top legal functionary of the Central Government, the Attorney-General, foregoing his beauty sleep to appear in the predawn SC hearing and advancing ludicrous arguments that effectively encouraged horse-trading (man-trading??). We had the newly-elected MLAs apparently so vulnerable to inducements and threats that they had to be shepherded like preschool children, with no guarantee that they will not play truant in the coming months. To this date, government formation by the JD(S)-Congress combine has been bedeviled by the chase after lucrative portfolios. We had electronic media representatives treating this entire episode as a chess game and speculating on who will bring money and muscle to bear on government formation. And, finally, there is the ordinary citizen, inured to the reality that, to get ahead in life, you need to jump the red signal, help your wards cheat in examinations and part with mamool to grease your way through government. Where is the sense of shame and probity in all these individuals, and countless others? One senses no sadness or weariness in witnessing the repeated drama, just another Roman circus for the masses.

At least for the near future, we seem to be in a situation where it may be necessary to codify important conventions to get over the Indian aversion to following commonly accepted norms. There is already a code of conduct for elections. Similar codes need to be evolved for, among other things, procedures of government formation at the centre and in the states, conduct of legislative business, appointment of governors, powers of investigative agencies once elections have been announced and conduct of private activities of legislators that conflict with their public roles. These codes need to be implemented rigorously with salutary penalties for their infringement which could range from public shaming to loss of office.

However, nothing will really change until the educated thinking classes assume the responsibility for setting our derailed democracy back on the rails. Let us not forget that a diverse group of thinking Indians, seventy years ago, drafted one of the most glorious modern-day Constitutions. Keeping it alive, and enriching it further, is, alas, a task our present generation has failed in miserably. Karnataka is the latest manifestation of the terminal disease afflicting our democracy, which needs skilful doctors, not butchers. We ignore this at our own peril.

 

Reducing Child Malnutrition – Action Backed By Data

After many stops and starts, the National Nutrition Mission (NNM) is being launched by the Prime Minister on 8 March (International Women’s Day) at Jhunjhunu in Rajasthan. I have heard some rumblings about the NNM’s excessive focus on data monitoring and the lack of a specific programmatic focus. This is but to be expected from the Indian intelligentsia, which always looks upwards for policy and programme inspiration. In the last fifteen years, we have been snowed under with programmes designed to improve access to healthcare, employment and food. Most of these programmes have not fitted in with the lumbering public service delivery mechanisms that are a characteristic of most Indian state governments. Additionally, their implementation has been bedeviled by inadequate budgetary provisions. It is time that we move from policy obsession to action focus, as admirably enunciated by my friend Sanjeev Ahluwalia in his recent article (Junk Policy for Action). Hence, my two bits on what needs to be done in the sphere of reducing child malnutrition.

For a start, with the Fourteenth Finance Commission mandating an increased devolution of central financial resources to the states from 32% to 42%, the time has come for state governments to stop crying that they are being deprived of “mother’s milk” by the centre. Along with such budgetary provisions as accrue to them from the centre, state governments need to responsibly start making significant budget provisions for the nutrition, health and education sectors, which will contribute most to reducing the incidence of child malnutrition and mortality. States also need to take a hard look at their policies for supplementary nutrition provision to mothers and children under the Integrated Child Development Services (ICDS) programme. This area that has seen phenomenal corruption enriching contractors, politicians and bureaucrats and has drawn the ire of even the Supreme Court but has not altered politico-bureaucratic behaviour in the least, except the search for more ingenious methods to pull wool over the eyes of the Court. Schemes like the Karnataka Mathru Poorna programme, which provides a hot midday meal to pregnant and nursing mothers, need to be replicated, with close social monitoring to minimise leakages. Supplementary nutrition to children in anganwadis (and, where they are under-3, at home) needs to rely on local food preparation by mothers’ and self-help groups.

At the same time, the central government can help matters by acting as a funnel for data dissemination and technical advice. A huge volume of data relating to maternal and child health and nutrition process and outcome indicators flows into the central government data servers every month. The ICDS monthly progress report is supposed to be sent online every month by all state governments to the Ministry of Women & Child Development, Government of India (MWCD). Even if it is sent (itself a matter for investigation), no one looks at it, let alone sends analysed data back to the state government for remedial action. The Mother and Child Tracking System (MCTS) was introduced by the Ministry of Health & Family Welfare, Government of India (MOHFW) with much fanfare in 2011 to track the health and nutrition status of mothers and children from conception through delivery to the time the child reaches the age of 5 years. Not a byte of this voluminous data collected over the past seven years has been made available to, or has been used by, state government health and nutrition machineries to improve their capabilities to better serve mothers and children. If the NITI Aayog, MWCD and MOHFW work together to make all this extremely useful field-level data available to state government formations right down to the anganwadi and health sub-centre levels, they will have contributed more to reducing child malnutrition and mortality than all the central government efforts over the past forty years.

But having all the data is not enough; using it judiciously is even more crucial to successful outcomes. Since the Prime Minister is launching the NNM in Rajasthan, an example from that state will highlight what I mean. May I refer you to a report in the Hindustan Times of 27 February 2018 (Programme to address all malnutrition causes). This piece details the programme to tackle severe wasting or severe acute malnutrition (SAM) through community involvement, known in nutrition circles as Community Management of Acute Malnutrition (CMAM). The first phase of the CMAM initiative was undertaken in 2015-16 in 41 blocks in 13 districts of Rajasthan. That over 2.25 lakh under-5 children were screened and nearly 10,000 children were enrolled in the programme, of whom over 90% are reported to have recovered from SAM is good news. At the same time, this is still touching only the tip of the iceberg. These 13 districts are home to over 24.50 lakh under-5 children, of whom, if one goes by the latest National Family Health Survey (NFHS-4) figures, over 2.50 lakh children fall in the SAM category. Even if one takes just a cross-section of blocks in these 13 districts, the CMAM screening of 2015-16 ought to have uncovered a far greater number of SAM children than 10,000. Screening of entire child populations in selected areas was probably the reason for the lower number of SAM children identified, since the ICDS-health machinery would have been able to reach only a limited number of children with the resources available. Since the ICDS is supposed to record weights of all under-5 children monthly, it would have been a far more effective strategy to identify severely underweight (SUW) children (those with weights less than three standard deviations below normal) and then record the heights of these SUW children to arrive at an accurate assessment of the number of severely wasted children.

The news report states that the Mission Director of the National Health Mission, Rajasthan claims success for the CMAM exercise. Apart from the low numbers of SAM children reached, there is no supporting evidence to show the extent of non-relapse into SAM of the over 9000 children who are supposed to have moved out of SAM. I would be rather sceptical of a CMAM programme which does not give specific data on the same children one year after their release from the facility where they underwent treatment. The Rajasthan government now plans to expand the programme of Integrated Management of Acute Malnutrition (IMAM) to 50 blocks in 20 districts (which include the original 13 districts) of the state. IMAM is a programme developed in geographical contexts where civil strife and ethnic unrest lead to worsening of children’s nutrition status. It has to be applied cautiously in settings where child malnutrition is a chronic condition rather than an emergency situation. Rather than getting caught up in acronyms, it is desirable to focus on the fundamentals. The 20 chosen districts have an under-5 child population of over 45 lakhs, with a reasonable estimate (based on NFHS-4 data) of about 5 lakh SAM children. To avoid spreading resources (financial and manpower) too thin and to get the maximum mileage for the money spent, it would be advisable to track the weight of every child in every anganwadi in these districts and to identify the anganwadis with the maximum burden of SAM children. The heights of children falling in the SUW category could be recorded by a health functionary, who would also assess any prevalence of disease in the child requiring treatment. These SAM children could then be treated under the prescribed SAM protocols, with the highest-incidence anganwadis being taken up first, and other lesser-incidence anganwadis being taken up subsequently, depending on the financial and organisational capacity to treat the children. The condition of these children should be followed up for a year subsequently by the three As, the Auxiliary Nurse Midwife (ANM), the Accredited Social Health Activist (ASHA) and the Anganwadi Worker (AWW).

I am not discounting the importance of an integrated approach to treating child malnutrition, covering behavioural changes in families and communities and the need to focus on policy interventions in nutrition-sensitive sectors like drinking water, sanitation, hygiene and livelihoods. What I am worried about is that in the enthusiasm to do too many things, the central issue of tackling the immediate problem of SAM will be lost sight of. This is the reason why the Rajmata Jijau Mother-Child Health and Nutrition Mission of Maharashtra, the first of its kind in the country, focused on specific action areas in a sequential order, with fairly gratifying outcomes. Unless we adopt the same talisman that Gandhiji adopted, substituting the “most malnourished child” for the “poorest and weakest man”, we are unlikely to remove what has been, and continues to be, a blot on India’s development story.

Child malnutrition: Using data more effectively

The National Nutrition Strategy (NNS), released by the NITI Aayog in September 2017, is an important milestone in India’s long fight against child malnutrition. And not just because it points to a welcome focus on child malnutrition at the highest levels of the Central government. It is in the wake of the release of this strategy that, perhaps for the first time, we are seeing a clear focus on data related to child nutrition.

Soon after the NNS was released, the Ministry of Women & Child Development (MWCD) held a national-level workshop with top policy makers, health and nutrition experts, and district collectors from over a hundred districts in the country. It was here that the spotlight was turned on child nutrition data, with the MWCD highlighting the performance of states in improving child nutrition indicators between the 2005 and 2015 National Family Health Surveys (NFHS-3 and NFHS-4, respectively).

It went on to commend three states—Chhattisgarh, Arunachal Pradesh and Gujarat, in that order—for performing the best in reducing under-5 child stunting over the 10-year period. However, the selection of these three states seems incongruent with NFHS-3 and -4 data, which shows Arunachal Pradesh, Tripura and Himachal Pradesh as having the greatest percentage declines in stunting between 2005 and 2015. Chhattisgarh and Gujarat, in contrast, came in only sixth and eleventh, respectively, in the state rankings (highlighted in the table below).

Ramani table

Why the discrepancy when the data was available?

The criterion for selecting states was based on the absolute percentage reduction in stunting between 2005 and 2015. This method was flawed (and embarrassing) on two counts.
First, it failed to follow an accepted statistical principle: when computing reductions in any variable, the percentage fall relates to the reduction in value in relation to the previous base value. Second, it disregarded the NNS data, which had already highlighted reductions in stunting rates across different states over the 10-year period, rightly based on percentage reductions over the NFHS-3 percentages.

Further, departing from the NNS figures and rewarding states for good performance unnecessarily raises questions as to whether the Central government wished to name certain states because their political affiliations coincided with those of the party ruling at the Centre.

What the numbers don’t tell us

It is significant to note that the largest decreases have been recorded in the less populated states (under 25 million people). Larger states, with their high population densities (often in congested urban sprawls), their geographical diversity and greater administrative challenges, are often likely to find the issue of stunting reduction more difficult to tackle.

Also important to recognise is that states like Goa, Kerala and Tamil Nadu—already well ahead in indicators like stunting rates—would never win any national prize for reducing child stunting. This is because their base is already low and the scope for further improvement is, therefore, circumscribed. This may well demotivate the ICDS machinery in such states.

Since the NITI Aayog and the MWCD are going to use a new Nutrition Monitoring System (NMS) to identify states/districts/blocks that are performing well and those that are lagging, it is even more critical to employ a rational methodology in order to get a true picture of the progress registered in any area.

What we can do to get the numbers right

There are a few steps that can help present a more accurate picture for policy making.

Categorisation of states
A three-tier state structure could be developed to assess performance between successive surveys of malnutrition, whether of stunting, underweight or wasting. For instance, in the case of stunting rates, states could be classified into three categories, as detailed in the tables below.

Ramani table 2

Increase frequency of district-level surveys
With NFHS-4 releasing district surveys along with the state surveys, for the first time we have a picture of the districts’ performance in different states and the worst indicators in respect of the three parameters of stunting, under weight and wasting. We need national surveys to be carried out more often so our attention remains focused on the problem.

Regular monitoring and use of critical data
We need greater commitment from the state and Central governments to develop systems for regular collection, monitoring and use of data on child growth. For instance, child growth monitoring has been highlighted as an important component of the ICDS for many years, but has largely been ignored in practice.

While all states are required to send monthly weight data of all children in all ICDS projects to the centre, the MWCD and the states have paid no attention to this data till date. States (barring Maharashtra) do not publish this data on their websites either, although the Right to Information Act mandates placing all such information in the public domain. The result is the extremely dubious quality of data.

Specific focus on indicators and districts with poor progress
NFHS-4 lists the top 100 districts with the highest underweight rates as well as the top 100 with the highest stunting rates. While as many as 55 districts overlap across both these lists, 32 belong to just three states: Bihar, Madhya Pradesh and Uttar Pradesh.

Interestingly, the NFHS-4 data shows a prevalence of high wasting rates in most states, including those that have performed better in reducing child and infant mortality rates in the past decade.
In general, while reduction in stunting percentage rates has been reasonable to very good in many states, reduction in percentages of underweight children has not been so encouraging.

With wasting remaining alarmingly high in many districts, taking up programmes to reduce severe or moderate acute malnutrition through state and community efforts will have to be one of the major focus areas of governments in different states.

Going forward, the MWCD and NITI Aayog will be faced with the onerous job of working with different states, especially Category A states, in devising practical, workable plans and programmes to make a significant impact on child malnutrition.

The first steps have been taken, with the NNS publication and the decision to set up the National Nutrition Mission. However, unless these are backed up by enlightened leadership at the Central and state levels, with a dedicated resolve to reduce the incidence of child malnutrition in all three aspects, India will continue to be an underperformer in an area that is key to the future of its population.

This article was originally published on India Development Review (IDR), the country’s first independent online media platform for leaders in the development community. You can access the article here

The commercialisation of nutrition – Maharashtra comes full circle

The flip-flops in India’s child nutrition policies are nowhere better exemplified than in the recent decision of the Maharashtra government to issue a tender for the supply of fortified ready-to-cook pre-mixes for feeding children, aged three to six years, in rural anganwadis.

Maharashtra has, for many years now, outsourced the supply of take home rations (THR) for mothers and children below the age of three years to so-called Mahila Sansthas that in turn have subcontracted this work to private manufacturers in the state and outside.

With the tendering for ready to cook pre-mixes, Maharashtra is turning the clock back on the important Supreme Court (SC) decision of 2004 that mandated state governments to serve hot cooked meals prepared by women self-help groups, or similar locally based women’s organisations, to children attending anganwadis.

What does this imply for the ICDS* supplementary nutrition programme and what are its likely ramifications?

Quality of food supply is the first and most important concern.
It is difficult to take at face value the tender stipulations that quality checks will be carried out by the supplier organisation at in-house laboratories. Nor can one take comfort from the provision for quality checks at independent laboratories ordered by the ICDS Commissioner. Public laboratories in India are notorious for delays in furnishing reports, enabling defaulters to get away.

The 2012 report of the SC Right to Food Commissioners to the SC highlighted the poor quality of THR supplies in Maharashtra. However, despite complaints about poor THR quality, no action has ever been taken in the past against politically powerful suppliers, either in Maharashtra or other states. In any case, public laboratories in India are notorious for delays in furnishing reports, enabling defaulters to get away.

There is also the issue of whether pre-mixes supplied to children will be as nutritious as hot cooked meals, apart from the question of palatability. Even adults who use pre-mixes to quickly rustle up upmaor sheera at home will testify that the pre-mixes’ taste is nowhere close to that of items prepared from fresh natural ingredients.

With a provision of only INR 6 per child per day, there is also the very real apprehension that the suppliers will be tempted to compromise on quality to maintain their profit margins.

Quantities of pre-mixes supplied to anganwadis, and used for meal preparation, will be the next issue.
At one time, probably about four decades ago, states such as Maharashtra and Gujarat set the standard for efficient, responsive administration. Unfortunately, these states too have degenerated in administrative efficiency and probity to the levels of their counterparts in northern and eastern India. The travesty that represents ICDS nutrition supplies in Uttar Pradesh has been well documented.

When the then Minister for Women & Child Development, Government of India pushed for commercial supply of food items in the ICDS in 2008, it did not meet with the approval of the Cabinet Committee on Economic Affairs (because it would open the doors to large-scale corruption).

The apprehensions of poor programme delivery are amplified by the top-down approach adopted in this tendering system. There is no mention anywhere in the tender document of social accountability through monitoring of supplies and service delivery by village level institutions like the gram panchayats, their health and nutrition committees and mothers’ groups, let alone their involvement in the process of meal preparation.

As one who was involved with the ICDS in Maharashtra through the first decade of this millennium, I can vouchsafe for the beneficial multiplier effects of involving local bodies from the Zilla Parishad to the Gram Panchayat, as well as local communities, in the management of child nutrition. In the present scenario, the pre-mix will be distributed from the project to the anganwadi, with no check on whether the right quantities are reaching the anganwadi.

Stipulations within the tender raise questions around corruption and the concentration of production among a handful of large players.
What is disturbing about the tender are the numerous conditions which straight away disqualify smaller groups from participating in the supply of nutrition to children. Although the tender document specifies that only women self-help groups, Mahila Mandals, Mahila Sansthas and village communities are eligible to bid, the requirements to be fulfilled by the successful bidder rule out the possibility of the tender being awarded to any small group.

There are onerous conditions regarding the high annual turnover needed to qualify, the need for a functional and operative licensed manufacturing unit and an in-house testing facility to test the quality of the premix. The three Mahila Sansthas that were awarded the THR contract had leased facilities for THR production from private agro-companies; ownership and operational control of the Sansthas as well as the companies were vested in the same family.

With the present tender also permitting the participation of Mahila Sansthas, there is ample scope for the same stratagem being employed to circumvent the SC rulings on contractors and private suppliers.

From an equity viewpoint too, the concentration of production in a few organisations denies economic benefits to a very large number of rural women’s groups, which earn their daily bread through the preparation of meals for children.

Ultimately, the issue boils down to whether government programme funds of about INR 2,500 crores should be channelled to a few organisations with, if previous experience is any guide, links to private producers.

Other states are adopting more equitable and empowering solutions
The move of Maharashtra to premix supplies comes at a time when other states are innovatively experimenting with public systems to improve nutrition supplies to mothers and children.

Karnataka has introduced eggs and milk in the daily diet for 3-6 years children, Orissa is promoting the cultivation of local millets and Chhattisgarh has improved its public distribution system to ensure regular food grain supplies to families.

As the foregoing discussion brings out, this policy serves neither the ends of efficiency (given the scope for possible quality and quantity aberrations), nor those of equity (concentration of supply in a few hands) or empowerment (with no role for participation of local governments and communities). Whether such a policy behoves a land that is the karmabhumi of Shahu Maharaj, Jyotiba Phule and Babasaheb Ambedkar is the question that ought to concern us today.

*ICDS (Integrated Child Development Services) is the largest programme in the world devoted to the care of pregnant and nursing mothers and children under six years of age.

This article was originally published on India Development Review (IDR), the country’s first independent online media platform for leaders in the development community. You can access the article here 

What trips street-level bureaucracy?

“There’s many a slip ‘twixt the cup and the lip.”  Nowhere is this proverb truer than in the government machinery of India that is tasked with the staggering responsibility of delivering various crucial services to the 1.3 billion inhabitants of this country.

Whether it is the police guaranteeing the security of the common citizen, the doctor attending to patients at the public health facility or the teacher imparting basic education to children in schools in remote areas, it is glaringly evident that citizens of India are being seriously short-changed in availing public services that are their inalienable right.

We in India, especially the middle class, are quick to blame the street-level bureaucracy (SLB) for faulty implementation of what we consider to be impeccably-designed policies.

Where does the truth really lie? An examination of the functioning of SLBs, covering anganwadi workers and their immediate supervisors in the Integrated Child Development Services (ICDS)*, reveals some home truths on where things are going wrong.

I. Policy vs implementation

The first unpleasant truth is that programmes as packaged in statutes and administrative regulations are not quite what the SLB implements on the ground. There are quite a few reasons for this:

Focus on a limited set of activities
While the ICDS manual prescribes several duties for the anganwadi worker, the ICDS machinery focuses only on supplementary nutrition provision to mothers and children. It excludes activities such as monitoring the growth of children, counselling of caregivers on health and nutrition, and early childhood education.

Food supply is the only concern of the officials of ICDS directorates and the departments at the state level. As a result, the anganwadi worker is considered to have done her duty if she has distributed take home rations (THR) to mothers and children aged under three, and handled cooked meals for children in the 3-6 age group.

Emphasis on paperwork versus outcomes
The anganwadi worker is also required to complete a huge load of paperwork on the supply of food and on the nutrition status of children, to be sent to her superiors every month. If these duties are completed and reports sent to the state and central governments regularly, there is no accountability for outcomes. For example, the nutrition status of children—as revealed by their height and weight measurements, which are critical for determining and addressing stunting and wasting in children below five years—is never addressed in a systematic manner.

II. Leakage in programme implementation

The second shocking fact lies in the subversion of the supplementary nutrition programme by the contractor-politician-bureaucrat nexus. An average Indian state has around 75 lakh children aged below six. With a provision of supplementary nutrition at a rate of INR 6 per day to each child, the annual bill works out to approximately INR 1,350 crore. This huge budget lends itself to manipulation by vested interests.

A recent LANSA study documents the systematic siphoning of public money in Uttar Pradesh through this programme. While a few packets of the THR (daliya) are distributed to families, the bulk of the supplies are sold as cattle feed, giving additional illegal income to the anganwadi worker. Silence is bought through the complicity of all those who are part of the supply chain.

The situation is not much better in respect of hot, cooked meals, where the proceeds of funds received (even if irregularly) are distributed among all stakeholders, including the anganwadi worker and the ICDS supervisor, with very little reaching children in the form of improved nutrition.

III. Socio-cultural barriers

Traditional social prejudices and behavioural patterns also adversely impact the messages being understood and acted upon. Two examples come to mind. Promoting early breastfeeding within an hour of birth has been recommended for a variety of reasons. However, social practices have often militated against this, with the belief that the child must be fed specific fluids before breastfeeding is initiated.

In the area of sanitation, proper hygiene practices and the absence of open defecation are known to promote the healthy growth of children. A recent study by Diane Coffey and Dean Spears has attributed the failure in restricting open defecation in India to social and cultural forces unique to the country. These are centred around religious practices of purity and pollution and the consequent reluctance to locate toilets in proximity to the house.

While these instances reflect the demand factor impacting the efficacy of public services, there are also supply aspects that affect client response to public services.

IV. Inadequate infrastructure

Irregularly functioning Primary Health Centres, which are often closed when the citizen has spent time and money to make her way there, act as a disincentive to use public health facilities. The problem is compounded when the health provider behaves indifferently, and/or demands illegal payments. Such experiences discourage citizens from using the facility and force many to shift to private doctors, sometimes of very dubious quality.

What is being done to address this?

India’s policy mandarins are frustrated by this lack of success at translating significant budgetary allocations and governmental effort into improved outcomes in different social sectors. They are, thus, increasingly seduced by direct cash transfers to clients and privatisation of health, education and corrective services.

However, this approach still begs the question: are citizens guaranteed access to improved services? There will still be need for regulatory agencies that monitor how private agencies function, including the quality and pricing of their services. Poor governance in direct management of public service delivery systems can easily transfer to equally poor oversight of private providers.

Take the case of the Universal Basic Income (UBI), which has caught the fancy of academics and policymakers in India. Apart from the vital issue of who will be entitled to UBI, and its fiscal implications, the question of fair and equal access to services critical to human health and development is still a moot point.

Is there a solution?

The few short-lived successes in child nutrition programmes in certain states have been the result of inspiring bureaucratic leadership, backed by political commitment. Unfortunately, results show only as long as the bureaucratic champion is around.

But long-term success in reducing key indicators of malnutrition, such as stunting and wasting, require sustained efforts to put in place functional systems that can operate irrespective of personalities and governments. These include:

  1. Evidence-based, nutrition-specific and nutrition-sensitive interventions, backed by committed government budgets and active participation of different government departments and agencies.
  2. Health and nutrition protocols that are scrupulously followed, with rigorous monitoring of child nutrition outcomes to ensure accountability.
  3. Empowering local governments and frontline workers and supervisors with financial and administrative authority to deliver meaningful outcomes.

Above all, the political and bureaucratic leadership in the various states must provide a conducive and supportive environment for the effective functioning of SLBs, something that has been sorely lacking till now.

*ICDS is the largest programme in the world devoted to the care of pregnant and nursing mothers and children under 6 years of age.

This article was originally published on India Development Review (IDR), the country’s first independent online media platform for leaders in the development community. You can access the article here

Himalayan Blunders in Healthcare – Gorakhpur and Beyond

This article was originally published on Indus Dictum, a site where thought leaders from diverse fields, spanning business and technology to politics and modern law, contribute unique insights and experiences. You can access the article at https://indusdictum.com/2017/08/17/himalayan-blunders-in-healthcare-gorakhpur-and-beyond/

In a country which is seemingly inured to bad news, the news of the deaths of a large number of children, infants and adults in a major hospital in Gorakhpur, Uttar Pradesh (UP) was like an atom bomb being dropped. Predictably, the blame game started immediately, with every opposition party and every media hack trying to pin the blame on someone, preferably the head honcho of the state. The previous Chief Minister was loudest in his criticism, forgetting that he had presided over the destinies of the state (and its health systems) till just a few months ago. In this atmosphere of cynicism and one upmanship, we are in danger of losing sight of the disease and focusing merely on the symptoms.

Let us start with some visuals, which convey the bald facts about the state of amenities in the Paediatric and Neonatal Intensive Care Units (PICU and NICU) of the hospital in question, the Baba Raghav Das (B.R.D.) Medical College and Hospital, the major tertiary health facility in the city of Gorakhpur, the bastion of the present Chief Minister of UP. These are reproduced from a tweet from Rahul Verma (@rahulverma08) based on the replies to a Right To Information (RTI) query of 2011.


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Reply from the office of the Principal, B.R.D. Medical College, to an RTI application.


The RTI reply of early 2012 gives telling evidence about the lack of facilities in the hospital (in particular, the non-functioning of critical life-saving equipment because of poor maintenance) and the significant staff shortages in both medical and nursing staff. Although this is a slightly dated reply, there is little reason to suppose that matters have greatly improved in 2017, given the disclosure that lack of oxygen supply to children and neonates could possibly have been a prime cause of the large number of deaths.


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Staffing shortages in medical and nursing personnel (Jan 2012)


The reply, which is signed by the Head of the Department of Paediatrics of the hospital, shows that 50% of the qualified medical posts are unmanned and 40% of the nursing posts are not filled in. Even more disheartening is the state of affairs in respect of critical equipment in the ICUs. The incubators, pulse oximeters and infant ventilators are not working, while 16% of the cardiorespiratory monitors are non-functional.

Only a detailed enquiry will (hopefully) establish the truth of the allegation that one of the primary causes for the deaths was, apart from encephalitis, the shortage of oxygen supply in the paediatric and neonatal wards. I am not too sanguine about the truth in this regard coming out given the conflicting statements from politicians, doctors and bureaucrats on when payments were released to the oxygen supplier and on whether oxygen shortage was in fact responsible for the deaths.


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Status of equipment and machinery in PICU and NICU.


But the issue goes far deeper than that of lack of oxygen supply alone. It is a pointer to the systemic rot in UP’s public institutions and in its systems of governance, a malaise that can be seen across institutional structures in different Indian states. Nowhere is this better exemplified than in the condition of India’s health systems.

UP’s public health care systems do not reach many of its citizens, especially the most vulnerable. This is partly due to the low percentage of public expenditure on health systems, as reflected in a 33% to 40% shortfall of over 31,000 health sub-centres, over 5000 primary health centres and 1300 community health centres in the state (as reported in the Financial Express). On top of this is the abysmal functioning of even such public health care institutions as do exist at the primary and secondary levels and the resultant lack of confidence of the public in these facilities. With primary and secondary public healthcare services not adequately available in Gorakhpur and its neighbouring districts, Sant Kabir NagarSiddharth NagarMaharajganjKushinagar and Deoria, the public is forced to come to a tertiary care facility even for ailments that can be treated at lower levels. A large hospital that already suffers from shortage of funds and skilled manpower, poor management, and corruption, is thereby further overburdened. The National Family Health Survey of 2015 (NFHS-4) data reveals the poor quality of health services that mothers and children receive. While 5% to 10% of mothers receive full antenatal care, medical check-up of neonates in the first two days after birth ranges from 9% to 25%. About 66% of children in the 12-23 month age group are fully immunised in Gorakhpur and Deoria districts, with the percentage falling to just over 40% in the other four districts.

Not surprisingly, then, rates of child undernutrition, morbidity and mortality, as well as maternal mortality rates (MMR), are high in this region. Mortality rates of under-5 children vary from 76 to 116 per 1000 live births and of infants (0-1 year) from 62 to 87 per 1000 live births, with 80% of the infant mortality rate being accounted for in the first 28 days after birth. Stunting and underweight rates in under-5 children exceed 40% and 32%, with well over 10% of children falling in the wasting category. MMR in the Basti and Gorakhpur mandals, where these districts are located are 304 and 302 respectively per 100,000 live births (all mortality figures are taken from the Annual Health Survey 2012-13 of Uttar Pradesh, conducted by the Census Commissioner of India and undernutrition figures from the NFHS-4 data). All these figures are distressingly high and place many of UP’s districts in the same league as war-torn states of Africa in health and nutrition indicators.


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The underlying morbidity and mortality proneness of the population in this region, especially its children, is exacerbated by the surrounding external environment. In their recently published book, Where India Goes: Abandoned Toilets, Stunted Development and the Costs of Caste, Diane Coffey and Dean Spears have highlighted the contribution of the practice of open defecation to high stunting rates in children. Open defecation has persisted despite the Swachh Bharat Abhiyan, because of the notions of pollution associated with latrines in the house and the reluctance to empty the pit latrines. The Japanese Encephalitis (JE) virus, to which a large number of the present deaths are attributed, is spread by the Culex mosquito breeding in the swampy paddy fields which are a feature of eastern UP. With traditional immunisation rates themselves being low in this region, it should be self-evident that the two doses of the JE virus immunisation are also not covering a significant portion of children. Insanitary conditions coupled with poor immunisation rates and failure to reach health care early to affected persons – especially children – constitute a lethal combination that contributes significantly to high mortality rates.

This deadly cocktail of factors is aggravated by the endemic corruption in the health and nutrition sectors in UP. The scam in the National Rural Health Mission in UP has been facilitated by politicians and highly placed bureaucrats, including some from my former service, the IAS. Fictitious purchases of medicines for which payments were made were facilitated by doctors and officers of the health department in collusion with suppliers. This disease is by no means confined to UP: nearly every state in India is prone to this syndrome, given the centralisation of purchase powers in the state secretariats. In fact, the purchase of medicines is mostly made keeping in mind the interests of politically-linked powerful suppliers, with no analysis of the disease and illness pattern in different areas of the state, which would enable a scientific assessment of the type and quantum of medical supplies required. States are loath to adopt the pattern of Tamil Nadu, which set up the Tamil Nadu Medical Services Corporation over two decades ago to streamline the procedure for procurement, storage and distribution of essential drugs and medicines to government medical institutions throughout the state. UP has a similar scam operating in the ICDS sector, which is meant to provide wholesome take home rations to mothers and under-3 children, and hot cooked meals to children in the 3-6 year age bracket. A recent LANSA study details the systematic misappropriation of huge sums from the ICDS budget for lining the pockets of the politician-bureaucrat-contractor nexus.

Once again, in the ritual breast-beating that is going on in the media, there is the real danger that we will revert to the “business as usual” approach after a short hiatus. The Harvard economist, Lant Pritchett, characterised India as a “flailing state”, not quite failed like many of its Asian and African confrères but where accountability is extremely weak and where there is little control of the head over the limbs of the state. Even this is a very charitable interpretation given that, in the Indian context, the limbs behave just as the head dictates. What I wish to highlight is the need to focus on systemic processes and institutions rather than personalities and political formations. As the preceding paragraphs seek to establish, a combination of factors – man-made and natural – have contributed to the ongoing crisis in India’s health systems. Rather than looking for temporary scapegoats, the need for an overhaul of the system is overdue (one possible solution is outlined by the Foundation for Democratic Reforms). The acid test for the new government in Uttar Pradesh has arrived, whether it will tread the same beaten track of its predecessors or chart a new path to governance and the arrival of achhe din in UP. Else, we will be left to exclaim “Even you, Brutus?”