Authored by Anil Nair and CV Madhukar PRS just concluded a workshop for MLAs from 50+ from more than a dozen states.  What an AMAZING experience this was, even though this is the sixth such workshop we have held in this past year! This three day workshop on 'Mastering the Budget' was designed to help MLAs understand how to work with budget documents and numbers, find trends, understand the most critical macro numbers to track, etc. The second day of the workshop was tailored to reflect on the big thematic issues that have an impact on state finances. The Fiscal Responsibility and Budget Management Act, the Goods and Services Tax, the pattern of quantum of funds flow from the Centre to the state and local governments, the 13th Finance Commission, etc. The final day was devoted to doing an inter-state comparison of states on important budget parameters, and gleaning lessons from them. The idea for this budget workshop germinated at a previous workshop held at IIM Bangalore. The participating MLAs requested PRS to organise a special session on 'Mastering the Budget'. So this workshop was being organised as a result of their feedback. The choice of location was easy -- this was held at the National Institute for Public Finance and Policy in Delhi, which is amongst India's foremost institutions working on state budgets and public finance issues. Invitations were sent out to MLAs in several states. Responses started coming in within a few days, with about 70 confirmations. But there is always an uncertainty on the participation until the very last minute because elected politicians have immense demands on their time, at least some of which are unpredictable. So it was heartening to see that more than 50 MLAs came to the workshop representing 15 states -- Bihar, Rajasthan, Odisha, Uttar Pradesh, Assam, Kerala, West Bengal, Andhra Pradesh, Meghalaya, Tamil Nadu, Madhya Pradesh, Himachal Pradesh, Gujarat, Haryana, Manipur. The participants ranged from first time MLAs (about 50%), to a sitting Minister, a sitting Speaker, former Ministers, and senior leaders of political parties from some states. But the best part about the interaction in this workshop was that even on seemingly complex issues being discussed in the classroom, the MLAs were not mere recipients of 'gyan' that was being dished out. They had important questions to raise, and well articulated points of disagreement with the faculty, and brought in practical perspectives that might not have otherwise come up in the discussions. They went beyond the scope of the workshop to engage the economists on discussions on subjects like FDI in retail, state of India’s economy… Based on our experience of several workshops with MLAs, we want to share some observations about the participating MLAs: -         There are MLAs in every state who want to understand substantive policy issues, and are willing to invest time and energy to do so. -         When the MLAs participate in these workshops, they choose to do so on their own, and are not compelled by anyone to do so. -         The sessions almost always begin and end on time, even in the freezing cold mornings in the Delhi winter. -         The MLAs are very engaged in the discussions, ask questions, and bring in their experiences into the classroom discussions. -         They keep partylines completely out of the substantive classroom discussions, and in the rare event that some new participant mentions anything partisan, other participants quickly ask him to avoid making any such mentions. In 2011, we have engaged with over 250 MLAs through these workshops and more. These workshops are just a starting point of what we hope will develop into a sustained, longer term engagement with MLAs on policy issues coming up in their states. In an important partnership with the Indian School of Business, Hyderabad, PRS has already conducted two workshops  at the world class facilities at the ISB campus, and is planning to hold more in 2012. Just as PRS engages with about 300 MPs in Parliament, the hope is that more MLAs will be able to derive value from the work of PRS in the years to come, thereby making their decisions better informed. Some feedback from MLAs from our earlier workshops can be seen here: http://www.youtube.com/watch?v=9XlgKCp2bvs or http://www.youtube.com/watch?v=01kLLTVtJOU&feature=related or http://www.youtube.com/watch?v=WA4NZqCj2xk&feature=related  

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).