Graft Poisons Uttar Pradesh's Health System in India
Daniel Etter for The New York Times
An effort to improve maternal health care in Uttar Pradesh, India's most populous state, has been plagued by a host of problems.
By LYDIA POLGREEN
Published: September 18, 2011
LUCKNOW, India - The first doctor to die, a senior government health administrator, was shot on his morning walk last October by two men on a motorbike. Six months later, his successor, a cardiologist, was shot to death while out on a predawn stroll. A third government doctor, accused of conspiring to murder the first two, was found dead in jail in June, lying in a pool of blood with deep cuts all over his body.
The one thing the doctors had in common? All three had at one point been in charge of spending this city's portion of the nearly $2 billion that has flowed to Uttar Pradesh, India's most populous state, as part of a nationwide push to improve the health of India's poorest citizens.
The state's health infrastructure remains abysmal, and officials say they now suspect that the murders resulted from a virulent combination of fast money, scant oversight and a notoriously graft-addled state political leadership. The last doctor to die, relatives say, was preparing to name names in a widening scandal. The central government has stepped in to investigate.
"When this much money is given to a government that is basically a criminal enterprise, violence cannot be ruled out," said Kamini Jaiswal, a prominent lawyer who has filed several lawsuits in the case.
The recent hunger strike by the social activist Anna Hazare has drawn attention to the everyday corruption that has infuriated India's middle class - the large and small bribes people must pay to evade the annoyances and harassments of an overbearing and inept state.
But in places like Uttar Pradesh, the price of corruption can be far higher, witnessed not just in the deaths of the doctors but in the toll it takes on the health of India's most vulnerable people.
Uttar Pradesh is by almost any measure one of the most corrupt states in the nation. It also has some of the worst health statistics anywhere, including rates of infant and child mortality and malnutrition to rival sub-Saharan Africa. If Uttar Pradesh were independent, its 200 million people would make it the world's fifth-largest nation, more populous than Brazil, a country with 35 times the land mass.
In 2005, the government, led by the Congress Party, created the National Rural Health Mission, which sought to overhaul the delivery of health care to the rural poor by building hundreds of thousands of new clinics and hiring millions of health workers.
Because of India's federal structure, most of the work was carried out by state governments like the one here, run by a lower-caste leader, Mayawati, who once accepted a garland of 1,000-rupee notes from supporters worth about $36,000. Not all of the states were prepared to handle it, and here, at least, much of the money never fulfilled its promise.
Some states fared much better, using the money effectively. Supporters of Mr. Hazare say that his demand for the creation of an ombudsman in every state could help stem corruption and protect whistle-blowers.
The central government handed over the cash to Uttar Pradesh with virtually no oversight.
Only after the doctors were killed did a review by the central government's investigators find that contracts worth millions of dollars were granted without competitive bidding, and millions more was paid in full to contractors who did not complete the work they were required to do, leaving health centers in ruins and without vital equipment. The government failed to make its investigative report public; The New York Times acquired a copy from The Indian Express, a leading newspaper that broke the story about the scandal.
Naseemuddin Siddiqui, Uttar Pradesh's health minister, said that the state had asked for the central government's inquiry. Asked for more details, he hung up the phone. Two state ministers have been forced to resign.
It is hard to see where the money went.
Two years ago state officials approved a plan to build a 30-bed health clinic in the village of Kurebhar, a three-hour drive from Lucknow. The new clinic would replace a four-bed site, which was straining to provide decent health services for 74 villages. More than $700,000 was budgeted for the project.
The building was supposed to be ready last December. Nearly eight months past that deadline, the health center was still a skeleton of red brick.
"We are trying to push them to do the work faster," said J. L. Mishra, the chief medical officer in the Sultanpur district. But the government had already paid all the construction fees in advance, leaving almost no leverage.
There is little evidence of the influx of cash in the health center. "We sometimes don't even have soap for our hands," said P. N. Tiwari, the center's vaccination officer. "Meanwhile, they are looting like monkeys," a reference, he said, to politicians, bureaucrats and contractors.
Half a dozen babies are born in the clinic daily, but the water tank is broken, so deliveries are performed without running water. The center has an ambulance, but it, too, is broken. Repairs would cost only about $30, but there is no cash to pay for it.
Crucial medical supplies, like oral rehydration salts for children with diarrhea, have been out of stock for months. Mr. Tiwari said that the money to fuel the generator ran out, leaving workers scrambling to keep vaccines cold.
Mr. Tiwari, a 30-year veteran of the government health system, said he was among those who believed that the vast increase in health funds with so little oversight had led to murder.
"Because of this money two doctors were killed," he said. "A huge amount of money is involved, so a huge amount of crime is taking place."
Doctors started dying in Lucknow last October. When the first to die, Vinod Kumar Arya, was shot, the case was treated as a puzzling mystery: why would anyone kill a mild-mannered government doctor?
The government did not immediately replace Dr. Arya, who had been the chief medical officer for the city, installing as interim chief a more junior officer, Dr. Y. S. Sachan. It was an important position that included responsibility for spending millions of dollars in rural health money from the central government.
In February, a cardiologist, B. P. Singh, was named chief medical officer. He had accepted the job in March under pressure, relatives said, and felt a great deal of strain in the post.
"He used to say there was a lot of corruption," said a cousin, Inder Pratap Singh, a lawyer at Lucknow's high court.
Dr. Singh had begun keeping a diary of improprieties, Mr. Singh said, and complained that he was being pressured to approve false expenditures worth hundreds of thousands of dollars.
On April 2, Dr. Singh was killed by two gunmen. A police investigation later concluded that the same weapon had been used in the killing of Dr. Arya.
Suspicion fell on Dr. Sachan, a politically connected bureaucrat who had worked in the city's health department for years.
He was an associate of the minister who managed the health funds, Babu Singh Kushwaha, a close ally of Ms. Mayawati, the state's chief minister. Dr. Sachan was arrested, but few people believed that a relatively junior bureaucrat would have carried out the murders on his own.
Dr. Sachan's wife, Malti, who is also a physician, said that her husband had been sacrificed to protect more powerful people.
"He told me, 'I am being framed in this case,' " she said.
Dr. Sachan had told his wife that he feared someone would kill him and felt safer in jail. He had decided to reveal who had directed him to steal money from the health department, relatives said, in a court appearance.
But the day before he was to appear he was found dead. Initially, officials ruled his death a suicide, but an autopsy revealed that he had bled to death from deep wounds that could not have been self-inflicted.
"The intention was very clear," said R. K. Sachan, Dr. Sachan's brother. "He was going to disclose the involvement of senior politicians in the scam. That is why he was silenced."
The families of the dead doctors hope for justice, but they have kept their expectations low.
"If he had been corrupt, he would have survived," said Mr. Singh, Dr. Singh's cousin. "Never will a senior bureaucrat or politician be convicted. Some small fish will suffer, but never the big ones."
Hari Kumar contributed reporting.