Recently, the government announced that it plans to transfer benefits under various schemes directly into the bank accounts of individual beneficiaries.  Benefits can be the Mahatma Gandhi National Rural Employment Guarantee Scheme (MNREGS) wages, scholarships, pensions and health benefits.  Beneficiaries shall be identified through the Aadhaar number (Aadhaar is an individual identification number linked to a person’s demographic and biometric information).  The direct cash transfer (DCT) system is going to be rolled out in 51 districts, starting January 1, 2013.  It will later be extended to 18 states by April 1, 2013 and the rest by April 1, 2014 (or earlier).  Presently, 34 schemes have been identified in 43 districts to implement the DCT programme. Currently, the government subsidises certain products (food grains, fertilizers, water, electricity) and services (education, healthcare) by providing them at a lower than market price to the beneficiaries.  This has led to problems such as high fiscal deficit, waste of scarce resources and operational inefficiencies.  The government is considering replacing this with an Aadhaar enabled DCT system.  It has claimed that the new system would ensure timely payment directly to intended beneficiaries, reduce transaction costs and leakages.  However, many experts have criticised both the concept of cash transfer as well as Aadhaar (see here, here, here and here). In this blog, we provide some background information about cash transfer, explain the concept of Aadhaar and examine the pros and cons of an Aadhaar enabled direct cash transfer system. Background on cash transfer Under the direct cash transfer (DCT) scheme, government subsidies will be given directly to the beneficiaries in the form of cash rather than goods.  DCTs can either be unconditional or conditional.  Under unconditional schemes, cash is directly transferred to eligible households with no conditions. For example, pension schemes.  Conditional cash transfers provide cash directly to poor households in response to the fulfillment of certain conditions such as minimum attendance of children in schools.  DCTs provide poor families the choice of using the cash as they wish.  Having access to cash also relieves some of their financial constraints.  Also, DCTs are simpler in design than other subsidy schemes.  Even though cash transfer schemes have a high fixed cost of administration when the programme is set up, running costs are far lower (see here, here and here). Presently, the government operates a number of DCT schemes.  For example, Janani Suraksha Yojana, Indira Awas Yojana and Dhanalaksmi scheme. In his 2011-12 Budget speech, the then Finance Minister, Pranab Mukherjee, had stated that the government plans to move towards direct transfer of cash subsidy for kerosene, Liquified Petroleum Gas (LPG), and fertilizers.  A task force headed by Nandan Nilekani was set up to work out the modalities of operationalising DCT for these items.  This task force submitted its report in February 2012. The National Food Security Bill, 2011, pending in Parliament, includes cash transfer and food coupons as possible alternative mechanisms to the Public Distribution System. Key features of Aadhaar The office of Unique Identification Authority of India (UIDAI) was set up in 2009 within the Planning Commission.  In 2010, the government later introduced the National Identification Authority of India Bill in Parliament to give statutory status to this office.

  • The Aadhaar number is a unique identification number that every resident of India (regardless of citizenship) is entitled to get after he furnishes his demographic and biometric information.  Demographic information shall include the name, age, gender and address.  Biometric information shall include some biological attributes of the individual (such as fingerprints and iris scan).  Collection of information pertaining to race, religion, caste, language, income or health is specifically prohibited.
  • The Aadhaar number shall serve as proof of identity, subject to authentication.  However, it should not be construed as proof of citizenship or domicile.
  • Process of issuing and authenticating Aadhaar number: First, information for each person shall be collected and verified after which an Aadhaar number shall be allotted.  Second, the collected information shall be stored in a database called the Central Identities Data Repository.  Finally, this repository shall be used to provide authentication services to service providers.

For a PRS analysis of the Bill, see here. Aadhaar enabled direct cash transfers Advantages Identification through Aadhaar number: Currently, the recipient has to establish his identity and eligibility many times by producing multiple documents for verification.  The verification of such documents is done by multiple authorities.  An Aadhaar enabled bank account can be used by the beneficiary to receive multiple welfare payments as opposed to the one scheme, one bank approach, followed by a number of state governments. Elimination of middlemen: The scheme reduces chances of rent-seeking by middlemen who siphon off part of the subsidy.  In the new system, the cash shall be transferred directly to individual bank accounts and the beneficiaries shall be identified through Aadhaar. Reduction in duplicate and ghost beneficiaries: The Aadhaar number is likely to help eliminate duplicate cards and cards for non-existent persons or ghost beneficiaries in schemes such as the PDS and MNREGS.     Disadvantages Lack of clarity on whether Aadhaar is mandatory:  According to UIDAI, it is not mandatory for individuals to get an Aadhaar number.  However, it does not prevent any service provider from prescribing Aadhaar as a mandatory requirement for availing services.  Therefore, beneficiaries may be denied a service if he does not have the Aadhaar number.  It is noteworthy that the new direct cash transfer policy requires beneficiaries to have an Aadhaar number and a bank account.  However, many beneficiaries do not yet have either.  (Presently, there are 229 million Aadhaar number holders and 147 million bank accounts). Targeting and identification of beneficiaries:  According to the government, one of the key reasons for changing to DCT system is to ensure better targeting of subsidies.  However, the success of Aadhaar in weeding out ‘ghost’ beneficiaries depends on mandatory enrollment.  If enrollment is not mandatory, both authentication systems (identity card based and Aadhaar based) must coexist.  In such a scenario, ‘ghost’ beneficiaries and people with multiple cards will choose to opt out of the Aadhaar system.  Furthermore, key schemes such as PDS suffer from large inclusion and exclusion errors.  However, Aadhaar cannot address errors in targeting of BPL families.  Also, it cannot address problems of MNREGS such as incorrect measurement of work and payment delays. Safeguard for maintaining privacy: Information collected when issuing Aadhaar may be misused if safeguards to maintain privacy are inadequate.  Though the Supreme Court has included privacy as part of the Right to Life, India does not have a specific law governing issues related to privacy.  Also, the authority is required to maintain details of every request for authentication and the response provided.  However, maximum duration for which such data has to be stored is not specified.  Authentication data provides insights into usage patterns of an Aadhaar number holder.  Data that has been recorded over a long duration of time may be misused for activities such as profiling an individual’s behaviour.

Recently, the Standing Committee on Health and Family Welfare submitted its report to the Parliament on the National Commission for Human Resource for Health Bill, 2011.  The objective of the Bill is to “ensure adequate availability of human resources in the health sector in all states”.  It seeks to set up the National Commission for Human Resources for Health (NCHRH), National Board for Health Education (NBHE), and the National Evaluation and Assessment Council (NEAC) in order to determine and regulate standards of health education in the country.  It separates regulation of the education sector from that of professions such as law, medicine and nursing, and establishes professional councils at the national and state levels to regulate the professions. See here for PRS Bill Summary. The Standing Committee recommended that this Bill be withdrawn and a revised Bill be introduced in Parliament after consulting stakeholders.  It felt that concerns of the professional councils such as the Medical Council of India and the Dental Council of India were not adequately addressed.  Also, it noted that the powers and functions of the NCHRH and the National Commission on Higher Education and Research (to be established under the Higher Education and Research Bill, 2011 to regulate the higher education sector in the country) were overlapping in many areas.  Finally, it also expressed concern over the acute shortage of qualified health workers in the country as well as variations among states and rural and urban areas.  As per the 2001 Census, the estimated density of all health workers (qualified and unqualified) is about 20% less than the World Health Organisation’s norm of 2.5 health workers per 1000 population. See here for PRS Standing Committee Summary. Shortfall of health workers in rural areas Public health care in rural areas is provided through a multi-tier network.  At the lowest level, there are sub health-centres for every population of 5,000 in the plains and 3,000 in hilly areas.  The next level consists of Primary Health Centres (PHCs) for every population of 30,000 in the plains and 20,000 in the hills.  Generally, each PHC caters to a cluster of Gram Panchayats.  PHCs are required to have one medical officer and 14 other staff, including one Auxiliary Nurse Midwife (ANM).  There are Community Health Centres (CHCs) for every population of 1,20,000 in the plains and 80,000 in hilly areas.  These sub health centres, PHCs and CHCs are linked to district hospitals.  As on March 2011, there are 14,8124 sub health centres, 23,887 PHCs and 4809 CHCs in the country.[i]  Sub-Health Centres and Primary Health Centres

  • § Among the states, Chhattisgarh has the highest vacancy of doctors at 71%, followed byWest Bengal(44%),Maharashtra(37%), and Uttar Pradesh (36%). On the other hand, Rajasthan (0.4%), Andhra Pradesh (3%) and Kerala (7%) have the lowest vacancies in PHCs.
  • § Nine states do not have any doctor vacancies at all at the PHC level. These states includeBihar, Jharkhand andPunjab.
  • § Ten states have vacancy in case of ANMs.  These are: Manipur, Uttar Pradesh, Chhattisgarh,Gujarat,Goa, Himachal Pradesh, Tamil Nadu, Haryana, Kerala and Andhra Pradesh.
  • § The overall vacancy for ANMs in the country is 5% while for doctors it is 24%.

Table 1: State-wise comparison of vacancy in PHCs

 

Doctors at PHCs

ANM at PHCs and Sub-Centres

State Sanctioned post Vacancy % of vacancy Sanctioned post Vacancy % of vacancy
 Chhattisgarh 1482 1058 71 6394 964 15
 West Bengal 1807 801 44 10,356 NA 0
 Maharashtra 3618 1326 37 21,122 0 0
 Uttar Pradesh 4509 1648 36 25,190 2726 11
 Mizoram 57 20 35 388 0 0
 Madhya Pradesh 1238 424 34 11,904 0 0
 Gujarat 1123 345 31 7248 817 11
 Andaman & Nicobar Isld 40 12 30 214 0 0
 Odisha 725 200 28 7442 0 0
 Tamil Nadu 2326 622 27 9910 136 1
 Himachal Pradesh 582 131 22 2213 528 24
 Uttarakhand 299 65 22 2077 0 0
 Manipur 240 48 20 984 323 33
 Haryana 651 121 19 5420 386 7
 Sikkim 48 9 19 219 0 0
 Meghalaya 127 23 18 667 0 0
 Delhi 22 3 14 43 0 0
 Goa 46 5 11 260 20 8
 Karnataka 2310 221 10 11,180 0 0
 Kerala 1204 82 7 4232 59 1
 Andhra Pradesh 2424 76 3 24,523 2876 12
 Rajasthan 1478 6 0.4 14,348 0 0
 Arunachal Pradesh  NA  NA NA NA NA 0
 Assam  NA  NA NA NA NA 0
 Bihar 2078  0 NA NA NA 0
 Chandigarh 0 0 NA 17 0 0
 Dadra & Nagar Haveli 6 0 NA 40 0 0
 Daman & Diu 3  0 NA 26 0 0
 Jammu & Kashmir 750  0 NA 2282 0 0
 Jharkhand 330  0 NA 4288 0 0
 Lakshadweep 4  0 NA NA NA 0
 Nagaland  NA  NA NA NA NA 0
 Puducherry 37 0 NA 72 0 0
 Punjab 487 0 NA 4044 0 0
 Tripura  NA  NA NA NA NA 0
 India 30,051 7,246 24 1,77,103 8,835 5
Sources: National Rural Health Mission (available here), PRS.Note: The data for all states is as of March 2011 except for some states where data is as of 2010.  For doctors, these states are Bihar, UP, Mizoram and Delhi.  For ANMs, these states are Odisha and Uttar Pradesh.

 

Community Health Centres

  • § A CHC is required to be manned by four medical specialists (surgeon, physician, gynaecologist and paediatrician) and 21 paramedical and other staff.
  • § As of March 2011, overall there is a 39% vacancy of medical specialists in CHCs.  Out of the sanctioned posts, 56% of surgeons, 47% of gynaecologists, 59% of physicians and 49% of paediatricians were vacant.
  • States such as Chhattisgarh, Manipur and Haryana have a high rate of vacancies at the CHC level.

Table 2: Vacancies in CHCs of medical specialists

  Surgeons Gynaecologists Physicians Paediatricians
State

% of vacancy

 Andaman & NicobarIsland 100 100 100 100
 Andhra Pradesh 74 0 45 3
 Arunachal Pradesh NA NA NA NA
 Assam NA NA NA NA
 Bihar 41 44 60 38
 Chandigarh 50 40 50 100
 Chhattisgarh 85 85 90 84
 Dadra & Nagar Haveli 0 0 0 0
 Daman & Diu 0 100 0 100
 Delhi 0 0 0 0
 Goa 20 20 67 66
 Gujarat 77 73 0 91
 Haryana 71 80 94 85
 Himachal Pradesh NA NA NA NA
 Jammu & Kashmir 34 34 53 63
 Jharkhand 45 0 81 61
 Karnataka 33 NA NA NA
 Kerala NA NA NA NA
 Lakshadweep 0 0 100 0
 Madhya Pradesh 78 69 76 58
 Maharashtra 21 0 34 0
 Manipur 100 94 94 87
 Meghalaya 50 NA 100 50
 Mizoram NA NA NA NA
 Nagaland NA NA NA NA
 Odisha 44 45 62 41
 Puducherry 0 0 100 NA
 Punjab 16 36 40 48
 Rajasthan 57% 46 49 24
 Sikkim NA NA NA NA
 Tamil Nadu 0 0 0 0
 Tripura NA NA NA NA
 Uttar Pradesh NA NA NA NA
 Uttarakhand 69 63 74 40
 West Bengal 0 57 0 78
 India 56 47 59 49
Sources: National Rural Health Mission (available here), PRS.

[i].  “Rural Healthcare System in India”, National Rural Health Mission (available here).