By Deepti Priya Mehrotra

A study on corruption across India reveals that approximately 50 million BPL households paid as much as Rs 8,830 million in bribes in one year to access 11 selected public services. Highest on the corruption list is the police

The benefits of planned economic growth are supposed, at some point of time, to reach the poor. Despite 60 years of independence, not only has this ‘trickle down’ failed to materialise, there actually seems to be a ‘trickle up’: bribes paid by the poorest households to government functionaries for accessing public services. While corruption exists in all strata, it hurts the most when it affects those already living on the brink.

A recent study, designed and conducted by the Centre for Media Studies (CMS) in collaboration with Transparency International India (TII), reveals that the approximately 50 million BPL (below the poverty line) households in India paid as much as Rs 8,830 million in bribes, within one year, to access 11 selected public services. This colossal amount, extracted from the poor, indicates a ruthless cynicism at work within the innards of the State.

The stranglehold of corruption exists across all 31 states and union territories of India. The TII-CMS India Corruption Study-2007 found that in order to avail of the 11 public services studied, approximately one-third of the total number of BPL households had to pay bribes.

The worst service, in terms of corruption, turns out to be the police. This is hardly surprising, yet it does provide occasion to pause and question the credibility of a law-and-order system that harasses the most powerless and vulnerable. Across the country, around 10% (5.6 million) BPL households interacted with the police during one year; of them, 2.5 million had to pay bribes to police functionaries. The total amount in bribes paid by these households to police personnel is estimated to be a whopping Rs 2,148.2 million. Around half of the households had no option but to pay a bribe at the very first step — the point of registering their complaint.

Six of the 11 public services covered in the study are ‘need-based’ — police, banking, housing, forests, the National Rural Employment Guarantee Scheme (NREGS), and land records/registration. The rest are ‘basic services’ — the Public Distribution System (PDS), health, school education, electricity, and water supply. The 11 services can be ranked as follows, in terms of their corruption count: police (1), land records/registration (2), housing (3), water supply (4), NREGS (5), forests (6), electricity (7), health (8), PDS (9), banking (10), and school education (11). Need-based services, being monopolistic and/or involving asset-creation, rank relatively high on the corruption scale compared to basic services.

Land records/registration and housing emerged as the most corrupt service, after the police. At issue is people’s fundamental right to shelter and livelihood. Nearly 18% of BPL households interacted with the land records/registration department, of which one-tenth reported paying a bribe, amounting to an estimated Rs 1,234 million. Nearly one-fourth of bribes were extracted simply for the provision of land records. Over half of the households visited the concerned offices three or more times to access routine services.

Alok Srivastava, Research Director, CMS, notes: “The government claims computerisation of land records helps reduce corruption — but our study disproves this.” As regards housing, 78% of BPL households that interacted with the housing department experienced difficulties; one out of two said ‘corrupt staff’ was the main source of their difficulties. With two out of every five (a total of approximately 1.5 million) households paying a bribe or using contacts to avail of housing services, an estimated Rs 1,566 million was pocketed, largely by departmental staff. Around 45% of households found corruption had increased during the past year.

To avail of water supply, an essential service, BPL households paid Rs 239 million in bribes. Occasions for bribery were installation/maintenance of handpumps, meter installation, pipe repair, supply of irrigation water, etc. The NREGS, a scheme meant to provide relief to households suffering chronic unemployment, has become another site for harassment. Around 0.96 million rural BPL households paid bribes to avail of NREGS benefits, to the tune of Rs 71.5 million in the course of one year! Around 47% of rural BPL households that interacted with the NREGS found officials/staff corrupt. Half the households that paid bribes did so to get registered for work under the scheme.

Around 20% of BPL households interacted with the forest services. These largely tribal households, whose livelihoods depend on the forests, paid bribes to the tune of Rs 240 million, in one year, to obtain permission to collect fuel wood and gather saplings, etc. Most paid bribes directly to the concerned staff and officials.

In a country where food security is still a pipedream and millions suffer from malnutrition, health and PDS department personnel have not spared people. Health services interfaced with four-fifth of BPL households, of whom over half faced difficulties and 15% paid bribes or used contacts. Another 2% were denied health services because they could not pay a bribe. Around Rs 87.0 million was paid in bribes during the course of a year. However, nearly one-fourth of households felt that grievance redressal mechanisms were improving. As for the PDS, more than half of the 47.23 million households that interacted with service-providers had no doubt that corruption existed in the department. Around one-third felt corruption had increased during the year. Around 10% paid bribes or used a contact — the majority to get a new ration card or take home their quota of rations. Three out of four households that paid bribes did so directly to the concerned staff/officials. Bribes were paid to the tune of Rs 458 million.

Expansion of school education is being promoted with much fanfare, yet some 3.1% BPL households reported paying bribes — the majority for new admissions, issuance of certificates, and promotions. The amount paid in bribes is estimated at Rs 120 million. Srivastava says: “The major share is in the higher classes — Classes 9 to 12. Most bribes were demanded by school officials or staff, and were paid directly to them.” One can only wonder about the kind of ‘education’ being imparted by adults themselves mired in corruption.

Dr N Bhaskara Rao, Chairperson, CMS, says that previous CMS studies on corruption (2003 and 2005) showed that corruption involving citizens had declined, albeit marginally, in certain public services. This improvement may be partly due to specific measures like the Right to Information (RTI) Act, citizens’ charters, and social audit. Yet, levels of corruption remain unacceptably high, particularly in the context of BPL households. The ultimate proof of ‘inclusive growth’ would be to ensure that basic services actually accrue to the poor. The TII-CMS study should be viewed, in this context, as “a tool to sensitise the larger public and concerned stakeholders, and prompt governments and civil society groups to take locally relevant initiatives”.

Srivastava explains that a vast network of experienced investigators and field workers carried out the survey, covering 22,728 randomly selected BPL households. The field work took place between November 2007 and January 2008.

The findings emphasise the fact that no state is near the ‘zero corruption’ mark. However, the level is relatively moderate in some states including Himachal Pradesh, Andhra Pradesh, Maharashtra, Uttarakhand, Chandigarh and Tripura. It’s high in others such as Gujarat, Jharkhand, Kerala, Delhi, Orissa and Manipur, very high in states like Rajasthan, Karnataka and Meghalaya, and highest (to the extent of being ‘alarming’) in Assam, Bihar, Jammu and Kashmir, Uttar Pradesh and Goa.

This nationwide survey suggests an agenda; it is up to civil society and politicians to respond. The direction is clear: urgent measures are needed to curb corruption, particularly as it affects those living at the margins. There is need for widespread awareness, vigilance, and committed efforts to improve governance and check dishonest practices at every level. It must be recognised that public services are entitlements, not charity to be provided or denied according to whim. States that are worst affected obviously need to devise strategies to deal with what is, in effect, not only a crisis of governance but also an ethical crisis.

CMS and TII have already held a series of meetings with various government departments to discuss the relevant findings and suggest possible strategies. They understand that it is important to work with policymakers as well as with people at the grassroots. Seeing the research as only Phase I, R H Tahiliani, Chairperson, TII, describes plans on the anvil for advocacy: “Phase II and Phase III of this endeavour would include training of grassroots-level workers and activists and arming them with information about the extent of the corruption in different areas, and use of the Right to Information Act to empower the poorest to stand their ground and not pay bribes while demanding and accessing the services they are entitled to.” TII hopes to provide each BPL household in the country with a passbook of entitlements and keep them updated periodically so as to fight poverty and improve the lot of the poorest of the poor.

(Deepti Priya Mehrotra is a Delhi-based writer)

InfoChange News & Features, August 2008

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By G Ananthakrishnan

In the absence of a robust state-funded health infrastructure providing free care, citizens have no option but to seek out private facilities. As a result, we have a burgeoning private healthcare sector, unregulated and often exploitative

A single episode of major illness is enough to eat away the life-savings of most individuals in India . In fact, there is data to suggest that such illnesses push several families below the poverty line. The World Bank reported in 2002 that irrespective of income class, one episode of hospitalisation is estimated to account for 58% of per capita annual expenditure, pushing 2.2% of the population below the poverty line. Even more disconcerting is the fact that 40% of those hospitalised had to borrow money or sell off assets. During 1986-96, the number of people who could not access healthcare because of financial reasons doubled over the baseline.

This obviously suggests a greater role for the public sector in healthcare. Yet, several studies have recorded the growing role of the private sector in the provision of healthcare in India . In a study of World Bank projects operating in India , Kamran Abbasi makes it clear that lack of funding in the public healthcare sector translates into inadequate quality of service, which forces “the poor to turn towards the private sector, which in turn exploits clients by using expensive inappropriate technologies and overprescribing”.

Writing on the role of private practitioners in tuberculosis control, Mukund Uplekar et al note in The Lancet that 80% of households prefer to use private sector treatment in India for minor illnesses, and 75% of households prefer to go to the private sector for major illnesses. An examination of healthcare access patterns for the population leads to the startling revelation that the vast majority of people have been forced to rely on private facilities because there is an absence of state-funded alternatives.

According to figures from the National Sample Survey Organisation for 1998, quoted in a study by V R Muraleedharan and Sunil Nandraj, there was a 7% increase in the number of outpatients patronising rural private sector facilities, from 74% in 1986-87 to 81% in 1995-96. In urban areas, this rise was about 8%, from 72% to 80% during the same period. In the case of in-patients, the rise was sharper, from 40% to 56% in the case of rural and 40% to 57% in urban areas.

A snapshot of the private healthcare sector in India emerging from the study by Muraleedharan and Nandraj shows that in absolute terms, the size of the health infrastructure is significant, but its distribution is lopsided and urban-centric. There is one qualified doctor for 802 people and one hospital for 11,744 people, besides one bed for 693 people. But there are serious imbalances in the distribution of these facilities. In Tamil Nadu, at least 70% of 37,733 allopathic physicians are in the private sector while 10,000 are in government service. There are nearly 10,000 doctors in and around Chennai. Therefore, the ratio of doctors to population changes from 1:800 for Chennai to 1:1,590 for the state average.

The National Council for Applied Economic Research reported in 1992 that a study of household surveys showed over 55% of illness episodes being cared for by private facilities, and 33% to 39% by the public sector. PHCs and sub-centres catered to only 8.2% of cases in rural areas.

Why do so many patients seek private doctors?

In some settings, private practitioners are perceived as providing better care because they include injections as part of every treatment, and are willing to make house visits, which are convenient. In contrast, government services are not popular because of long waiting periods, the arrogant attitude of staff and non-availability of medicines.

In the absence of a robust state-funded health infrastructure providing free care, citizens must seek out private facilities. Based on a study of the weaknesses in the tuberculosis control programme, The Lancet reported that among 22 countries with the highest prevalence of TB, private health expenditure as a percentage of the total was among the highest in India , at 87%. The number of patients incurring ‘out-of-pocket’ expenditure as a percentage of total spending was also unconscionably high at 84.6%.

Acknowledging the rise in patronage of private healthcare in many poor nations, the British Medical Journal traced the phenomenon to greater flexibility of access, shorter waiting time, greater confidentiality, and sensitivity to user needs. However, there cannot be an unreserved commendation of any measure to expand the private sphere without an overarching concern for a state-funded care system. The debate on the debilitating impact of a policy that is guided by private care imperatives has dominated proposals to revamp the National Health Service (NHS) in the United Kingdom , with suggestions that the discourse on expansion is actually driven by a desire to pave the way for the entry of private care providers from the United States and elsewhere. Thus, tax funds would indirectly lead to an expansion of the private healthcare sector at the cost of the public system.

This issue is of particular concern to India , as the private sector has not met its obligations of providing free care to a particular percentage of poor patients as required by law. Citing this little-known and poorly-enforced provision, Members of Parliament Ram Kripal Yadav and Daroga Prasad Saroj wanted to know, in the Lok Sabha, the steps taken by the Centre to ensure that private hospitals provide 30% of their patients free treatment. Union Minister of State for Health and Family Welfare Panabaka Lakshmi replied on July 21, 2004 : “Health being a state subject, it is for the respective state governments to formulate conditions and norms for setting up of private hospitals… (and) with regard to the treatment of poor patients and also to ensure that the conditions and norms are followed by private hospitals.”

The issue becomes clearer in the answer of Health Minister A R Antulay to a question in the Rajya Sabha in 1995. The minister said: “The 4th Joint Conference of Council of Health and Family Welfare held in October 1995 also recommended that the private sector which benefits from concessions should provide a minimum of 30% beds and 40% outpatient/diagnostic services free for treatment of the poor. In the past, private hospitals/nursing homes were allowed to import medical equipment at concessional rates of duty subject to the condition that a certain percentage of free treatment would be provided in OPD/IPD to poor patients. The state governments are required to check whether these conditions are being met by private hospitals/nursing homes.”

Regulation and the lack of it

There is a complex set of factors that have rendered regulation of medical care practically meaningless in India . Muraleedharan and Nandraj report that the major problems include lack of monitoring by statutory bodies, outdated and inadequate legislation, and inability of the government to enforce even the available regulatory laws.

One of the earliest laws in force is the Delhi Nursing Homes Registration Act 1953, which requires that all private nursing homes satisfy a set of criteria and register themselves. However, a survey reported in 1994 found that there were 1,600 unregistered nursing homes functioning in the national capital, despite the law, indicating that it was not being enforced even in the city where national laws are made.

On the question of costs associated with private care, V R Muraleedharan points out that there is inadequate information on in-patient care to come up with a sound analysis on whether the costs are justified. The lack of sustained data collection was confirmed by the then minister of state for health and family welfare, in answer to a question in Parliament: “Health being a state subject, the details of hospitals run by state governments in the country are not maintained centrally.”

There is thus considerable evidence to conclude that the poor are unable to access quality healthcare in India due to inequities prevailing in the system. Health insurance, either taken individually or provided as group cover, is helping some sections, though this remains a minority phenomenon in the overall scheme. The imperatives for policy therefore are to bring about greater budgetary expenditure on public health, institute monitoring mechanisms involving transparent and professionally audited procedures both in the public and private sectors, and ensure that the private sector, which has a legal commitment to share its facilities with the poor, is compelled to do so.

(G Ananthakrishnan, a Chennai-based journalist, follows development issues primarily in the areas of sustainability, equity, the environment, education and health. Email: ganant@vsnl.comThis e-mail address is being protected from spam bots, you need JavaScript enabled to view it )

References

NSSO 1998, Sujatha Rao, ‘Health Insurance, Concepts, Issues and Challenges’, Economic and Political Weekly , August 21, 2004
Kamran Abbasi, ‘The World Bank and World Health, Focus on South Asia II – India and Pakistan ‘, British Medical Journal , Vol 318, 1999, pp 1132-1135
Private Practitioners and Public Health, weak links in tuberculosis control’, The Lancet , Mukund Uplekar et al, Vol 358, 2001, pp 912
‘Private healthcare sector in India and options for partnership: Policy challenges’, V R Muraleedharan and Sunil Nandraj. http://lnweb18.worldbank.org/sar/sa.nsf/Attachments/chapt9/$File/09_Yazbeckfinal.pdf
Ibid
‘Factors affecting health seeking, utilization of curative health care’, Chirmulay D, BAIF Development and Research Foundation, 1997
‘Private practitioners and public health: weak links in tuberculosis control’, The Lancet , Vol 358, Sept 15, 2001
Private health care in developing countries’, Anthony B Zwi et al, British Medical Journal , Sept 1, 2001
Rajya Sabha, Unstarred Question No 1128, 07.12.1995
Delhi houses 1,600 unregistered nursing homes: survey, http://www.expresshealthcaremgmt.com/20040315/cover02.shtml
Private Hospital Sector in Madras City : Some Preliminary Observations’, V R Muraleedharan

In view of the strenuous and demanding nature of the medical profession atleast some efforts should be made on the part of the government to make this profession more productive with respect to both doctor and his performance towards the patients.The work culture especially in postgraduate courses leads to an early exhaustion of both mental and physical resources of a doctor’s body (a Homo Sapiens by species) and gives rise to a sense of hatred for the system and the patients which is a product of the sustained pressure both from the hospital administration and the familial responsibilities of economic and personal nature.