Little tragedies
The state's tall claim of double digit economic growth is belied by the high number of infants who do not live beyond their first year.
Labour started for Shivrani, 20, without warning. Night had fallen in Jirahua, a village tucked in Madhya Pradesh's Rewa district, its 323 households lit by a thousand stars, and a few kerosene lamps. Her labourer husband away on work in neighbouring Uttar Pradesh, Shivrani's father Mugul Kishore hired a tempo-much beyond the means of landless Kol tribals-to take her to the nearest primary health centre (PHC), 5 km away at Dabhaura. At 11 pm, Shivrani gave birth to a baby girl, her first child. But instead of crying, the newborn started gasping for air. With no emergency resuscitation in place at the PHC, a desperate Kishore hired another tempo to take mother and child to a paediatrician in Sirmaur, 39 km away. Halfway through the journey, the baby died. No explanations offered, nor any compensation. Just another little life lost before time, in the worst place to be born in India.
It's a blot that refuses to go away. For the past 12 years, Madhya Pradesh has carried the dubious distinction of being the state with the highest infant mortality rate (IMR), worse than some parts of sub-Saharan Africa. And like scars one learns to live with, the MP government seems to have accepted and is doing little in this regard. IMR, an indicator of a community's health status, is also symptomatic of a state's overall socio-economic status. The poor IMR in MP thus belies the state's tall claims of over 10 per cent GDP growth and an agricultural growth rate of almost 21 per cent.
The Sample Registration System (SRS) 2016-based on 2014-15 data-pegs IMR in MP at 52, the highest for any state in the country. Assam and Odisha follow at 49 and Uttar Pradesh at 48. In SRS 2015, MP and Assam both had the highest IMRs at 54 in the country. IMR in India in 2015, as per a World Bank report, stands at 38. To be fair, MP has shown consistent improvement in IMR figures over the years, but is it good enough? Apparently not.
NUMBERS THAT MATTER
The statistical breakdown tells its own story: that health amenities are yet to penetrate the depths of MP. The state health department, especially in rural areas where IMR is more acute (57 in rural areas, 35 in urban), also happens to be understaffed and grossly under-equipped. The state has 51 district hospitals, 66 sub-district hospitals, 334 community health centres (CHC), 1,171 PHCs and 9,192 sub-centres for its estimated population of 7.64 crore. Sanctioned rural infrastructure is woefully short. The average population that government-provided health infrastructure serves in Madhya Pradesh is far higher than in many states. In MP, a sub-centre serves 5,000-7,000, a PHC 40,000-100,000 and a CHC 1-3 lakh.
Thirty states and union territories in India have PHCs serving an average population less than MP; 25 states and UTs have a better average for sub-centres and 24 states and UTs in CHCs. Clearly, MP is at the bottom of the heap. So while in Lakshadweep, a CHC serves 4,714 people on an average, in MP, a CHC serves an average population of 157,357. In Arunachal Pradesh, if a PHC serves an average population of 9,114, a PHC in MP serves 44,882. Even in bigger states like Rajasthan, a sub-centre serves 3,574, while in MP a sub-centre serves 5,718. The difference is drastic. Worse, the CHCs, PHCs and sub-centres in MP are understaffed. According to the statistics division of the Union ministry for health, a total of 3,436 posts of male health workers (HW) are lying vacant In rural MP, besides 207 posts for women at PHCs and sub-centres. Specialists such as obstetricians and gynaecologists or paediatricians-crucial for safe birth and neonatal care-are also short.
The shortage of doctors is compounded by callousness in most hospitals. Two months back, two kids, aged a year-and a-half and five years old died at the Paediatric Intensive Care Unit (PICU) of the government run-Maharaja Yashwantrao (MY) Hospital in Indore after they were administered nitrous oxide instead of oxygen during medical procedures. "Both kids were from very poor families and came to MY Hospital because their families had no money to go elsewhere," says Shanno Khan, advocate for the kids' families. The hospital staff allegedly confused the supply lines. While their death will not contribute to IMR statistics, the callousness of the staff is telling of the larger state of affairs.
BRIBE THE BABUS
The state health department, which has primarily been tasked with the reduction of IMR, is a picture of rampant leakages and inefficiency, the corruption in its corridors legendary. Three former directors of the department-Dr Yogiraj Sharma, Dr Ashok Sharma and Dr A.N. Mittal-are facing probes. Even the income tax department, that usually steers clear of those in government, raided officials of the health department because they were found to be "high net worth" individuals. While I-T officials raided Dr Yogiraj and Dr Ashok in 2007 and 2008 respectively, the then health director Dr A.N. Mittal was covered in a search by the Lokayukta in May 2012, throwing up Rs 38 lakh in cash besides Rs 72 lakh worth of jewellery, land ownership documents and foreign currency.
Purchases are an important source of bribes. Being flush with funds, bureaucrats consider the health department a prime posting while for ministers it is an in-demand portfolio. "Former health minister Ajay Vishnoi's brother who was an engineer with the state electricity board was brought in on deputation with a body that used to float tenders for procurement of medicines," alleges Congress spokesperson Pankaj Chaturvedi. The budgetary allocation for the health department in 2016-17 stands at Rs 6,693.55 crore, a large part of which is for purchase of medicine and equipment.
The National Family Health Survey 4 points out that, on an average, a resident of urban MP going to a government hospital for a delivery incurs Rs 1,746 and a rural resident Rs 1,259 as 'out of pocket expenditure'. This is just the amount given as bribes to ward boys and other staff. At the policy level, promotion of institutional deliveries was seen as the panacea for maternity and childbirth issues. However, while institutional deliveries have ensured a decline in Maternal Mortality Rate (MMR) from 498 per lakh deliveries in 2000 to 221 per lakh deliveries now, similar reduction is not for IMR.
LONE RANGERS ALL
Experts suggest that the absence of multi-sector convergence renders reduction in IMR a distant dream. It's not just the health department that's failed to curb the high IMR-though it does have a primary role in it-the woman and child development (WCD) department and the rural development department (RDD) are also to blame. WCD is supposed to monitor the health of girl infants while RDD is responsible for ensuring employment resulting in financial independence among women. Presently, each department has a lone ranger approach and coordination is missing.
"What is required is the Life Cycle Approach, which focuses on the health of the girl child, because it is she who eventually becomes a mother," says nutrition expert and advisor to the Supreme Court appointed-Commissioner in the Right to Food Campaign, Sachin Jain. "Unless the mother is healthy, the chances of survival of children cannot be bright." There is also a lack of outreach programmes. "Women have been treated a certain way through centuries and this cannot change overnight or merely by pumping in money," he says. Under the National Food Security Act, 2013, women are entitled to maternity benefits but are not getting them.
THE MEDICAL MACHINE
Jain explains why Madhya Pradesh has been able to reduce IMR over the years but continues to have the worst index for the past 12 years. "Rapid intervention by the government through allocation of funds and schemes ensured that the low-hanging fruit was plucked. What remains now are the harder targets. It's an uphill climb from here," he says. "Madhya Pradesh also needs to focus on safe delivery, quality of maternal and newborn care-from hospital to home, feeding practices, immunisation, control of pneumonia and diarrhoea," says Dr Vandana Bhatia, health specialist at UNICEF, Madhya Pradesh.
The state's health minister Rustam Singh agrees that there is a shortage of doctors, especially specialists, in MP. "We realise there is a problem and have been trying to find a solution," he says. A state government proposal for training graduate doctors from an institute in Maharashtra that would bring the doctors at par with specialists awaits cabinet approval. On corruption in the health department, the former IPS officer says that it was a problem but leakages have been controlled now.
Officials put forward another set of reasons for the consistently high IMR. "MP's demographics are different from other states and are partly responsible for the high IMR statistics," says principal secretary, WCD, J.N. Kansotia. MP has about 1.5 crore tribals and 1.1 crore SCs, he points out, and both communities have low socio-economic indicators besides low overall health status, he explains. Areawise, MP is a vast state with swathes of forest cover beyond the scope of outreach programmes. Even areas traditionally under feudal control, mainly districts of Bundelkhand and Baghelkhand that border UP, are worse off than territories formerly under British rule. As per the Annual Health Survey 2012-13, the worst districts in MP in terms of IMR are Panna (85), Satna (83) and Guna (75). It's pertinent that these areas were under princely rule prior to independence. "Interventions such as the Sabla scheme that aims at improving the health status of adolescent girls and nutrition for pregnant women under ICDS are showing results," he says.
Despite the awareness of the extent of the problem, there seems no solution on the anvil. Schemes and programmes aimed at improving rural health statistics have been around for a decade. The state government is still relying on the National Rural Health Mission and aanganwadi workers to improve its IMR numbers in the next SRS. Will Madhya Pradesh be 13th time lucky?