As Assembly elections in Uttar Pradesh draw closer, the outgoing Bharatiya Janata Party (BJP) government is stepping up its election promises. There have also been several recent claims that point to Uttar Pradesh as a model state, which has effectively handled the COVID-19 crisis.
However, if we look at the situation on the ground, we see that the health system in UP is sick. In a previous report, we looked at just how faltering UP’s health infrastructure is. In this report, we examine the state of the health workforce at the primary health care level in UP.
Dilapidated health infrastructure and inadequate and weak health personnel lead to poor delivery of care to the population, clearly visible during the COVID-19 pandemic, especially in the second wave of 2021. As many news reports have revealed, UP’s health system has collapsed – the government tried to hide the true death toll, but floating corpses, unmarked graves on river banks and overflowing crematoriums and cemeteries exposed the crisis .
As we show below, UP has huge gaps in the numbers required in various health staff positions. Some of these positions, such as civil servants in Anganwadi and health workers in sub-centres and primary and community health centres, are crucial in reducing the number of preventable maternal and child deaths. There is no doubt that UP has some of the worst indicators among the various states in the country – the second highest infant and maternal mortality rates.
Anganwadi Officials – False Statements by UP Government
In recent rallies and public speeches, the UP Chief Minister hailed the efforts of Anganwadi workers during the COVID-19 pandemic and announced the distribution of smartphones.
However, the government has taken no concrete steps to improve their conditions. For all categories of civil servants in Anganwadi services, there is a significant percentage of vacant sanctioned posts. What is more concerning is that vacancies have increased over the years since 2018 when the current government came to power.
As shown in Figure 1, for the Child Development Project Officer (CDPO) position, 42% of sanctioned positions were vacant in 2018, rising to 57% in 2021 – an increase from 378 CDPO vacancies to 514 vacancies against a requirement of 897 civil servants. CDPOs are key officers at the district level in the Integrated Child Development Services Department (ICDS) – a crucial program for children 0-6 years old, pregnant women and nursing mothers to ensure nutrition and early childhood care and development.
For supervisors, 43% of sanctioned positions were vacant in 2018, rising to 57% in 2021, going from 2,890 vacant positions to 3,815 vacant positions against a need for 6,718 supervisors. Similarly, the proportion of vacant sanctioned positions for Anganwadi workers and helpers has increased over the past four years. There were 16,762 vacancies for Anganwadi workers in 2018, which in 2021 increased to 19,252 vacancies. For Anganwadi helpers, the current number of vacancies is 27,089.
Vacancies of civil servants in Anganwadi Services – 2018 to 2021 (in %
These shortages have put undue pressure on existing civil servants, especially with the increased workload during the pandemic. The increased workload did not result in a commensurate increase in compensation. Dozens of Anganwadi workers staged protests, demanding an increase in monthly pay. In September 2021, the UP government claimed to have increased monthly fees for Anganwadi workers and assistants. However, the workers exposed the government’s claim because the meager increase announced was in fact part of the performance-related incentive scheme and was not added to the monthly fee.
In 2017, the BJP manifesto promised a fair fee increase based on a freshly constituted committee report. However, there was no such increase; the monthly fee for an Anganwadi worker remains at Rs 5,500 in main Anganwadis, Rs 4,500 in mini Anganwadis, and the assistant earns Rs 2,750 per month.
Continuing shortages of healthcare workers in CSPs and CSPs
Anganwadi service officials are not the only category of primary health workers to suffer. Health worker shortages persist at all levels of care in rural UP. Community Health Centers (CHCs) were designed to provide a secondary level of health care to referral cases from the primary level and cases requiring specialist care. In some of the CSC’s critical positions, shortages exceed 70% of the required manpower.
Figure 2 shows a shortfall of almost 77% for obstetricians and gynecologists compared to the number required in rural UP CHCs – because, against a requirement of 711, only 161 are in place. On top of that, surgeons are also 77% short of the required number – just 166 in place against a requirement of 711 surgeons. Only 180 pediatricians are in place against 711 required, i.e. a shortfall of 75% compared to the required staff. Similarly, CHC radiographers and physicians are shortfalls by 73% and 57%, respectively. Compared to the requirement of approximately 2,844 specialists (including obstetricians and gynecologists, paediatricians, doctors and surgeons) in CHCs, there are only 816 in place, a deficit of 71% .
Shortage of healthcare workers in CHCs (as of March 31, 2020) (in %)
Primary Health Centers (PHCs) were envisioned as “the first point of access to a qualified public sector doctor in rural areas for the sick and those reporting directly or referring sub-centres for health care curative, preventive and promotional”. Subcentres (SC) are the most peripheral and first point of contact between the primary health care system and the community. The latest figures for PHC and SC in UP show huge gaps for some of the important categories of healthcare workers at this level of care.
In the CSPs of the UP, there is a shortage of nursing staff by around 44% – 1,613 are in post, while the number required is 2,880. For laboratory technicians, this percentage reaches 65%. For another crucial position of health assistant (male and female) in primary health centers, the shortage reaches 92%! Only 475 health auxiliaries are in place against a need of 5760.
At the CS level, the shortage of health workers (men) reaches 91%, i.e. a shortage of 18,877 positions against a need of 20,778.
Shortage of healthcare workers in CSPs (as of March 31, 2020) (in %)
These huge shortages for key rural health worker positions at the primary level translate into poor health care delivery or even non-existent health services. Most of these services, as under the ICDS, are crucial for the health of pregnant women, nursing mothers and very young children. These shortages of health workers would impact the incidence of malnutrition in the state.
Whatever the publicity of the UP government claiming that the UP is making significant progress in providing health care to the people, the reality on the ground turns out to be the opposite. The fact is that the delivery of health services is far from satisfactory. Moreover, the UP government has also failed its health workers. While health workers, especially frontline workers such as Anganwadi workers, continue to provide services even in such difficult situations as the pandemic, the government has failed to provide them with decent pay or employment by providing a large number of vacancies.