N C Saxena, Distinguished Fellow, Skoch Development Foundation

In the last decade, the Government of India (GoI) has launched several flagship programmes in the social sector, presenting a unique opportunity to accelerate social development and to cover the gap between the desired Millennium Development Goals (MDGs) and their present levels, but unless constraints impeding programme delivery at the state and cutting edge level are identified and remedial action taken, attaining the Goals by 2015 is unlikely. The problem has been compounded by the fact that GOI has adopted more ambitious targets than the MDGs, as the X and XI Plan documents strive to achieve the same targets by 2012, that is, three years before the suggested date.

It is obvious that these ambitious targets cannot be achieved through a ‘business as usual’ approach, as the past performance has not been fast enough to give us hope that we would reach the desired goals within the stipulated timeframe. Impact studies of some of the important flagship programmes clearly establish poor delivery and leakages, leading to tardy progress on the desired social outcomes.

Targeted Public Distribution System (TPDS)

A Planning Commission study (2005) found that about 58 per cent of the subsidised foodgrain issued from the Central Pool does not reach the BPL families because of identification errors, non-transparent operation and corrupt practices in the implementation of TPDS. Over 36 per cent of the budgetary subsidy on food meant for BPL households is siphoned off the supply chain and another 21 per cent reaches APL households. Only about 42 per cent of subsidised grain issued from the Central Pool reaches the target group.

An assessment study was carried out in 2008 of 162 Gram Panchayats awarded the Nirmal Gram Puraskar for reporting hundred percent use of toilets across six states i.e. Andhra Pradesh, Chhattisgarh, Maharashtra, Tamil Nadu, Uttar Pradesh and West Bengal. It was found that only 63 per cent households had a functional toilet.

An All-India study (Samuel 2004) carried out by a renowned agency, Public Affairs Committee (Bangalore), showed that although the percentage of households reporting the use of ration cards is high, only one-fourth of the rural and one-fifth of the urban households reported the regular availability of staple foodgrains at the ration shop. Regular availability is reported by more than half of all rural households in the four southern states, viz. Andhra Pradesh, Karnataka, Kerala and Tamil Nadu, but only by 2 per cent (or less) of the users in the states of Bihar, Haryana, Punjab and Uttar Pradesh. According to a World Bank study (2007) household access to PDS in some statesmost notably Bihar, UP, Rajasthan, and MPhas remained consistently very low to a point where it cannot be considered a significant programme in household welfare terms in these poor states.

Integrated Child Development Services (ICDS)

Despite a massive increase in the budget and physical expansion of the programme in the last 10 years (there are now 1.5 centres per revenue village) the NFHS-3 findings show that a mere 32.9 per cent of children who live in an area covered by an ICDS centre had utilised any service from the centre in the 12 months preceding the survey. The programme on paper provides for supplementary feeding for children below the age of six and pregnant and nursing mothers for 300 days in a year, but it could reach just 26.5 per cent of children, and what is worse is that only 12 per cent children reported getting it regularly. The picture is the same for women, as only 21 per cent of pregnant women and 17 per cent of lactating mothers were provided supplementary food. The utilisation of other components of the programme is equally dismal. In a critical area like immunisation, only 20 per cent of children reported getting any immunisation from the AWC. 82 per cent children never received any health checkup from the centre.

The net outcome is that malnutrition in the age group 0 to 3 years has declined only by one percentage point in the last eight years from 47 to 46 percent, and continues to be one of the highest in the world, even worse than Sub-Saharan Africa. More than half of India’s women and three-quarters of children are anaemic with no decline in the last eight years.

National Rural Health Mission (NRHM)

In health, the MDG target of reducing infant mortality rate to 27 per 1000 births by 2012 and even by 2015 will surely be missed if the present slow rate of decline from 60 in 2002 to 54 in 2007 continues. The progress on immunisation has been equally dismal, as it has improved only by one percentage point to 44 per cent in the last eight years, which is far behind the desired goal of 90 per cent to be achieved by 2012-2015. Internationally, India is shown to be suffering from alarming hunger, ranking 66 out of the 88 developing countries studied (IFPRI 2008).

Why does India continue to have poor health indicators? There are several reasons. Rural health care in most states is marked by unfilled staff vacancies, absenteeism of doctors/health providers, low levels of skills, shortage of medicines, poor management, inadequate supervision/monitoring, and callous attitudes. There are neither rewards for service providers nor punishments for defaulters.

The Planning Commission recently (2009) evaluated quantity and quality of service delivery in rural public health facilities under NRHM in four states-UP, Bihar, Rajasthan, and AP. Its finding was that the human resource gap remains the single most important challenge in strengthening the public health system and meeting the NRHM goals.

The Planning Commission recently (2009) evaluated quantity and quality of service delivery in rural public health facilities under NRHM in four states-UP, Bihar, Rajasthan, and AP. Its finding was that the human resource gap remains the single most important challenge in strengthening the public health system and meeting the NRHM goals. Medical professionals available in the country, especially specialists, are not joining the public services. Some specialities, such as anaesthesia and psychiatry, have very few professionals being produced in the country. Nursing colleges are far short of requirements, and ANM Training Centres have been non-functional for about a decade in several states, leading to nonavailability of staff nurses and ANMs for recruitment. Paramedical personnel such as Laboratory Technicians are again too few, or not trained and registered as per standards. Few of the cadres have an orientation or training in public health planning and management.

If the Medical Officer in Charge is not present at the Community Health Centre (CHC) to monitor the attendance of those operating under him/her in public health facilities (including not just paramedical staff but also technicians and pharmacists), it is more likely that they too will abscond from their duties altogether.

Sanitation

The Total Sanitation Campaign (TSC) was launched in 1985 by the Centre to cover all households with sanitation facilities and promote hygiene for overall improvement of health of the rural population. In 2004 a new scheme, Nirmal Gram Puraskar (NGP) was introduced to give innovative financial incentives to panchayats for promoting rural sanitation on a mass scale, so that Panchayati Raj Institutions shift their priorities from hardware to ensuring sustainability of toilet use on a continued basis.

An assessment study was carried out by GOI (2008) of 162 NGP Gram Panchayats who were awarded for reporting hundred percent use of toilets (the study included all the 37 NGP awarded GPs in 2004-05 and 125 NGPs awarded GPs in 2005-06) across six states i.e. Andhra Pradesh, Chhattisgarh, Maharashtra, Tamil Nadu, Uttar Pradesh and West Bengal. It was found that even in the NGP villages, only 63 per cent households had a functional toilet. Among the reasons provided by households where toilets are not being used, poor or unfinished installation account for 31 per cent followed by lack of behaviour change (18 per cent) and no superstructure (14 per cent). Blockage of pan and pipes also account for another 26 per cent of the reasons.

Some MDG indicators for India and other poor countries

	India	Bangladesh	Myanmar	Vietnam	Bhutan
Infant Mortality Rate 1990	83	105	91	40	91
Infant Mortality Rate 2007	54	47	74	13	56
Underweight children under 5	43	41	32	20	14
Immunized against measles	67	88	81	83	95
Rural population with adequate sanitation	26	35	72	50	70
Attendance ratio of girls to boys in primary school (net) (%)	88	106	102	100	91

Out of 162 GPs studied, there is no open defecation only in 6 GPs. In another 64 GPs open defecation was less than 20 per cent. This is followed by 39 GPs where up to 40 per cent people do open defecation, and in 29 GPs where up to 60 per cent people resort to open defecation, and alarmingly 24 GPs report more than 60 per cent people still practise open defecation. The situation was relatively better in case of Andhra Pradesh, Maharashtra and West Bengal and bad in case of Chhattisgarh where more than 60 per cent GPs reported that more than 60 per cent people were going for open defecation. In UP, in 45 per cent cases, toilets were found to be non-existent or left incomplete, though it was certified by the district authorities that not only the toilets existed but these were being used too!

Excluded groups

It is well known that economic and social progress in India has generally bypassed the dalits, Scheduled Tribes, women, and people living in remote areas, who have remained voiceless and ignored. The crux of their hopeless situation lies in their inability to access and retain their rightful entitlements to public goods and services due to institutionalised structures and processes of exploitation.

There are also serious problems in identification of the poor. For instance, despite three BPL surveys (1992, 1997 and 2002) the errors of exclusion and inclusion in the list remain above acceptable limits. Errors of exclusion are those that misclassify the poor in the non-poor category, while errors of inclusion include the non-poor in the poor category. These errors can be calculated using the 61st round (2004-05) of consumer expenditure data of the National Sample Survey Organisation.

Thus more than half of the poor either have no card or have been given APL cards, and are thus excluded from the BPL benefits. These must be presumably the most poor tribal groups, women headed households, and people living in remote hamlets where administration does not reach. Thus, the people most deserving of government help are deprived of such assistance. On the other hand, 25 per cent of the households belonging to the non-poor category possess BPL or Antyodaya cards.

It is a matter of concern that India’s pace of improving social indicators seems to be much slower than countries poorer than India, such as Bangladesh, Vietnam, Myanmar, and Bhutan.

Gender

The gender gap in school attendance continues with 82 per cent of boys attending school compared to 72 per cent of girls at the primary stage. India’s maternal mortality ratio (MMR) in 2007 of 256 deaths per 100,000 live births is unacceptably high. It is almost fifty times higher than in many developed countries; and also significantly higher than the MMR reported by Thailand (36), China (41) and Sri Lanka (43).

More than one-third (36 per cent) of Indian women have a Body Mass Index (BMI) of less than 18.5 kg/m2 indicating a high level of nutritional deficiency. This leads to a serious inter-generational transfer of malnutrition to babies and also points to the neglect of women’s health.

Extremely low share in land ownership and property, and the decline in the juvenile sex ratio over the last decade, visible in the data from Census 2001, is an indication that the Constitutional assurance of freedom and equality for women is still far from being fulfilled.

It is a matter of concern that India’s pace of improving social indicators seems to be much slower than countries poorer than India, such as Bangladesh, Vietnam, Myanmar, and Bhutan (see table).

It is not the size of allocations on propoor services alone that matters. The Government of India transferred billions of rupees in 2008-09 to the states. If even half of it what GoI transferred to states was to be sent to the sixty million poor families (at 28 per cent as the cutoff line for poverty, 300 Million poor would be equivalent to roughly sixty million households) directly by money order, they would receive more than Rs 80 a day! It proves that public expenditure needs to be effectively translated into public goods and services that reach the poor for it to have an impact on poverty and social outcomes.