A C-section delivery, as opposed to a normal vaginal delivery, requires incisions in the abdomen and uterus and is viewed as a life-saving procedure for the mother and the child in case of certain complications. These include clinical emergencies that may affect the pregnancy or labour– foetal distress, prolonged labour, excessive bleeding and high-risk pregnancies with a history of diabetes or HIV.

The Lancet report flags the proliferation of C-sections in private hospitals as the prime driver of this trend. In doing so, it questions the rise in unnecessary C-sections, conducted even when pregnancies are low-risk. Annually, 50% of the 6.4 million unnecessary C-sections around the world were located in Brazil and China.

Avoidable surgical procedures act as long-term impediments to the health of the mother and child and could end in death or disability, WHO had warned in this 2015 statement. An often ignored fact is also the relatively slower process of recovery post a C-section delivery and the trauma it can cause. It also increases the expense burden on the patient and her family.

“The bills went up to more than Rs 1 lakh and now that’s something that we’ll have to consider in case we decide to have a second child,” said Apoorva Panwar(23), who gave birth to her daughter through a C-section in April, 2018.

A first child delivered through a C-section procedure also increases for a woman the likelihood of complications in the next pregnancy, as per a 2014 Lancet report.

In Chandigarh, 98% deliveries through C-section
Is there an acceptable percentage of C-section deliveries? In 1985, WHO had advocated that 10%-15% of deliveries in a country could be through C-section procedures. But in a 2015 statement it clarified that it should be provided to any woman in need. As a country’s C-section rate rose towards 10%, there was a corresponding decline in child and maternal mortality, it said. But there was no evidence of it making an impact on child and maternal mortality after the rate crossed 10%.

If more than 10%-15% of deliveries are conducted through C-section it means overuse and misuse of the procedure, The Lancet report said.

In India, C-section rates vary widely — it is 6% in Nagaland and Bihar and 58% in Telangana, showed National Family Health Survey-4 (NFHS-4) data. “C-section rates crossing 50% is simply unacceptable,” said Arun Gadre, a Pune-based gynaecologist and senior coordinator for Support for Advocacy and Training for Health Initiatives (SATHI).

The highest number of C sections in the country was reported from Chandigarh (98%), way beyond what Gadre considers acceptable. For every one child born through normal delivery, 60 children were delivered via C-section. In Delhi, the percentage stood at 67.83%.
At 6.1%, south Asia has witnessed the fastest increase in caesarean rates in the last fifteen years, as per the Lancet report.

However, in the sub-continent, India has lower rates than Bangladesh (30.7%) and Sri Lanka (30.5%), but higher rates than Nepal (9.6%) and Pakistan (15.9%).

Private facilities conduct more C-sections: 45% in cities, 38% in villages
Health activists believe that the private section is fuelling the boom in C-sections. “The declining face of public healthcare and the aspiration for better services push families into choosing the private sector,” said Gadre. “This is the basic pathology of Indian healthcare. In the last 14 years, nothing has been done to been done to hold the private sector accountable and unregulated c-section run amok. The private sector is categorically profiteering through C-sections.”

In India, 45% of Caesareans were conducted in urban, private facilities and 38% in rural private facilities. And 56% deliveries in private hospitals empanelled under the Central Government Health Scheme (CGHS) were Caesarean procedures, as per a 2017 reply by JP Nadda, union health minister. Data collected from 20 out of 31 cities (64.5%) with private hospitals empanelled under CGHS were disproportionately inclined towards Caesarean deliveries.

A C-section delivery seems to be the new “normal”, new mothers living in urban India told IndiaSpend. Most women in her office had undergone a C-section, said Reshma Kuckyan (29), who birthed via a C-section when it was found that her baby’s growth was lagging. “My colleagues kept telling me that I would be fine, and since 90% of them had a C-section, I was prepared to have one myself.”

Among cities, Pune recorded the least number of C-sections at 38%, still above the acceptable limit.

C-section deliveries have moved upwards from 28% to 41% in private hospitals between 2005-2006 and 2015-2016. Public facilities, on the other hand, have recorded a decline, as per data in NFHS-4.

Women in wealthiest quintile seek more C-sections
Why are C-sections more common today? Changing dietary habits, late pregnancies and the fear of labour pain are some of the reasons, said doctors.

“I have had mothers with unrealistic expectations insisting on having babies at a specific time,” said Suchitra Pandit, director and consultant obstetrician at Surya group of hospitals, Mumbai. “One patient who was in labour said she wanted to have her baby only at 5pm.”
When she was warned about the dangers of delaying her delivery her family said they were willing to put down the specification in writing.

Among women in the wealthiest quintile (top 20% of the population by income), the choice of undergoing C-sections has gone up from 10% to 30% in the 20 years upto 2014, reported IndiaSpend in 2017.

The increased rate of C-section deliveries also reflects of medical advances that allow detection of emergencies that necessitate it, said doctors. Colour doppler ultrasounds and neonatal intensive care units (NICU) have made it easier for doctors to assess the risks attached to a foetus’ growth.

“The presence of high-capacity NICU in tertiary settings can save the life of many premature babies. If we can salvage a life in times of complications, then we have no choice but do a C-section,” said Pandit.

At 3.5 million, India has the most number of preterm babies in the world, according to WHO.

Keeping a check on numbers
WHO recommends Robson classification, a checklist of 10 obstetric parameters  to determine the need for a Caesarean. These include factors such as the history of a pregnancy and gestational age.

In 2017, an online petition signed by more than 1 00,000 people had raised attention to India’s tryst with continually rising rates. The ministry of women and child development pushed for the display of Caesarean numbers by private hospitals, reported The Hindu on July 4, 2017.
“You tend to lose count of the number of deliveries and surgeries you conduct. But when you see the numbers, it acts as a check,” said Seema Jain, a Delhi-based gynaecologist.

(Chhetri is a graduate of Lady Shri Ram College for women.)

Courtesy: India Spend
 

The post Caesarean Deliveries More Expensive, Can Imperil Children, But They Have Doubled In India, Mostly In Urban Private Hospitals appeared first on SabrangIndia.

These are some of the findings of a new survey report, the Teen Age Girls report (or the TAG report), released by Nanhi Kali, a project by the Naandi Foundation, which works with adolescent girls.

Even as the aspirations of teenage girls soar–seven in 10 teenage Indian girls want to finish graduation, three in four have a specific career path in mind, and nearly three in four do not want to marry before the age of 21, as we reported in the first part of this series–their current status in society and at home has not significantly changed and most struggle with a variety of what the survey calls “new age skills”, such as travelling alone, using a smartphone, typing out a document on a computer in English and asking for directions.

The survey asked girls aged 13-19 years questions on nine topics including educational and health status, basic life skills, agency and empowerment within and outside the home and aspirations.

In the second of this three-part series, we explore how their educational status, attitudes on empowerment and gender norms and new age skills play out against  these aspirations. This is significant, at a time when 63.2 million of them are set to be first-time voters in 2019. The third part explains how their access to healthcare and sanitation is crucial in a country where every second teenage girl is anaemic.

1 in 5 teenage Indian girls not currently studying, dropouts increase with age
Teenage girls make up 6.6% (80 million) of India’s populace–equivalent to the population of Turkey–and education helps them find employment, achieve aspirations, be healthier and reduce poverty.

Yet, as more girls strive for better opportunities, they are challenged by lagging gender parity and the inability to complete secondary education.

One in five teenage Indian girls, as we said, is not currently studying, the data show.

Among the states, Andhra Pradesh, Kerala, Telangana and West Bengal recorded the highest percentage of girls currently studying at 100% each. Madhya Pradesh and Uttar Pradesh, with only 64% girls currently studying, have fared the worst.

While 92.3% girls aged 13 are currently studying, this drops to 65.5% by age 19, the survey showed.

Source: Teen Age Girls Report, Naandi Foundation

Investing in girls–a society-based solution
“We’re working around the fact that investing in the girls is a good idea,” said Rohini Mukherjee, chief policy officer at Naandi Foundation.

An investment in attainment of quality education levels and development of ‘new age skills’–which the survey defines as skills important for efficient functioning in a deeply technology-oriented and fast-paced landscape–has far-reaching, long term benefits, the report noted.

The focus on girls in this age group is based on two implications: The potential of productivity held by an individual girl in contributing to the labour force, and the development of the children she might birth.

Girls who study up to 12 or more years, till the age of 18, are less likely to have teenage pregnancies, less likely to have a shorter interval between children, and less likely to have more than two children during her lifetime, as IndiaSpend reported on January 22, 2018.

This delay in childbearing will significantly reduce India’s projected 2050 population of 1.7 billion by more than a quarter, as IndiaSpend reported on January 12, 2018.

Childbearing runs parallel with early marriage–which was noted as one of the prime reasons for girls dropping out from their schools–according to a 2017 study by International Centre for Research on Women (ICRW), a US-based non-profit organisation.  

In all, 96% teenage Indian girls are unmarried, the survey showed. About 73% girls said they would prefer to get married at or after 21 years of age, complementing the aspiration of the 70% who wish to graduate or sit for competitive exams.

“Every extra year spent in school increases the income earned by a girl by no less than 10%-20%,” said the TAG report. “The returns are higher, upto 15%-25%, on secondary education.”

Women were also seen to reinvest 90% of their income in their families. Hence, increasing incomes of women have also proven to lift entire families and communities out of poverty, the report said.

Higher levels of education also foster higher expectations of standards of living. Self-sufficiency, or the ability of providing for oneself, is higher after a secondary or tertiary-level (college) because the income earned increases.

Food security then posits itself as an offshoot as women with a secondary and tertiary level education are less likely to say that they don’t have enough money to buy food versus women with primary education or less, according to this July 2018 World Bank report.

The same report also points to an increase in the knowledge and conversation surrounding AIDS and HIV and the decision-making ability about one’s own healthcare by one-fifth, nationally.

Women’s knowledge of HIV/AIDS grew from the level of 8% with no schooling to 39% with twelve or more years of schooling, as per data in the National Family Health Survey, 2015-16.

The gender norms and perception battle: 45% teenage Indian girls said boys have better opportunities
Gender norms appear to play a role in the dropouts: About 45% teenage Indian girls said they believe that boys in their community get more opportunities to pursue education and employment than they do; only 20% thought men/boys in their community can do as much as housework as they do, data show.

The figures were slightly better in urban areas compared to rural areas.

While 46.5% girls in rural areas said boys in their community have better opportunities to pursue education, 41.9% said so in urban areas.

Source: Teen Age Girls Report, Naandi Foundation

A similar pattern of responses was noted when 45.5% girls in rural areas said boys get more opportunities to do jobs than women did. Among their urban counterparts, 43% indicated the same.  

Source: Teen Age Girls Report, Naandi Foundation

While 18.6% girls in rural areas said boys in their community can do as much household work as they did, 23.8% girls urban areas said so.
Source: Teen Age Girls Report, Naandi Foundation
New age skills for a new age woman
Keeping in mind the evolving lifestyles and the demand for a skill-set that helps execute both professional and personal goals of security, independence and self-reliability, the survey envisioned 10 new age skills.

As many as 91% girls can receive and make calls using a mobile phone, the survey found.

About half the girls surveyed (48%) said they can go to a police station and file a complaint, similar to the percentage of girls (52%) who said they can travel alone for a journey for four or more hours.

Digital literacy in English (the ability to make a document on laptop/computer) at 23% as well as access to social media (27%) and internet (30%) fared the lowest among the ten skills.

Digital access and connectivity have been touted to be a ‘gamechanger’ in helping the marginalised break intergenerational cycles of poverty, according to this 2017 report by United Nations Children’s Fund (UNICEF).

However, digital access was seen to be a dividing line as millions in need are actually unable to access it. Referencing the presence of a gender gap in digital access, the UNICEF report said that less than one-third of internet users in India are women.

Among the girls surveyed, 59.6% said they had between up to five new age skills, with a higher percentage among 13- to 15-year olds (66.4%). Meanwhile, 40.4% girls said they had six or more new age skills–though this was to be seen mostly among 16- to 19-year olds (46.9%).

This is the second of a three-part series on India’s teenage girls. You can read the first part here.

Next: Why Health & Sanitation Are Crucial To Teenage Indian Girls Realising Their Aspirations

(Chhetri, a graduate of Lady Shri Ram College for women, is an intern with IndiaSpend.)

Courtesy: India Spend
 

The post Gender Norms, Lack Of New Age Skills Threaten To Derail Teenage Indian Girls’ Aspirations appeared first on SabrangIndia.

A lesser known part of the health insurance programme, also called Modicare, comprise health and wellness centres that will have a critical role in controlling the growing burden of non-communicable diseases in India. They will also offer maternal and child health services.
The problem is that sub-centres, run by a team of an auxiliary nurse midwife, a male multi-skilled health worker and health assistants, are short of staff while primary health centres do not have enough doctors:
 

• Of the 156,231 sub-centres in India, 78,569 were without male health workers, 6,371 without auxiliary nurse midwives and 4,263 without either, according to Rural Health Statistics, 2017.
• PHCs require 25,650 doctors across India to tend to a minimum of 40 patients per doctor per day for outpatient care, as per Indian Public Health Standards (IPHS). If these standards are met, 1 million patients could be benefit everyday. But with a shortage of 3,027 doctors, 1,974 PHCs are without doctors. This means that 12%, or 121,080 patients, go without access to primary health care every day.

Healthcare in India’s villages is a three-tiered structure under the National Rural Health Mission (NRHM)–sub-centres, primary health centres and community health centres.

Sub-centres are at the forefront, covering 5,000 people in the plains and 3,000 in hill or tribal areas. PHCs are equally important for the Ayushman Bharat Yojana to succeed because they are the first link to a consultation with a medical doctor and act as referral points for specialist consultations at community health centres.

Strengthening both the PHCs and sub-centres will ease the burden on secondary (district hospitals and block community health centres) and tertiary health institutions (specialist and super-specialist services in hospitals-cum-medical colleges). Failure to find enough doctors will also set back universal health coverage as envisioned by the successive National Health Policies in 2002 and 2017.

Distribution of health professionals skewed in favour of cities
Seventy percent of India’s population lives in villages and 30% in urban areas. But the distribution of health workers leaves rural India with little access to healthcare–60% of the country’s 2-million strong health workforce caters to urban India, only the remaining 40% services villages, as per data from a 2016 World Health Organization (WHO) report.

There is another issue the proposed centres will have to deal with: Health-workers practising in both urban and rural areas of India are not adequately qualified, as per the WHO study. Among urban and rural allopathic doctors, only 58% and 19% doctors, respectively, were medically qualified. As for nurses and midwives practising in rural areas, only 33% have studied beyond secondary school and 11% have medical qualification, the report estimated.

A perception survey of patients who visited healthcare facilities more than once showed that 43% patients, on average, across four states were not satisfied with the medical treatment provided by the health facilities. Of the patients surveyed, 34% complained of staff absenteeism, 32% of shortage of medicines 13% of long waits; 3% said centres were shut, 2% claimed that there were no facilities at all and the remaining 5% alleged different acts of corruption, according to the 2011 report by the High Level Expert Group on Universal Health Coverage.

Low access to public healthcare means reliance on private practitioners
A potential area of concern for the new wellness centres could be the reliance of rural patients on non-degree allopathic practitioners (NDAPs)–practitioners without an MBBS–according to a study carried out in Uttar Pradesh and Bihar.

Studies in rural Karnataka, Andhra Pradesh and Odisha have shown reliance on private practitioners for multiple reasons. The biggest of these is the lack of easy access to public health facilities: 73% sub-centres were more than 3 km from patients, 28% sub-centres and 20% PHCs were not accessible by public transport, concluded an IndiaSpend analysis of a Comptroller and Auditor General report.

The easy availability and proximity of an NDAP allowed for faster consultation, according to this 2014 study carried out in north India. “Embedded in the community, the NDAPs have adapted their services to people’s needs, preferences and economic capabilities”, making them the preferred resource for “all-in-one” services, the study said.

Why qualified medical professionals avoid rural India
Retention of doctors in rural areas is a major challenge which Ayushman Bharat is yet to confront: A 2011 study funded by the World Bank and the UK department of international development found that 39% medical providers in PHCs in 19 major states were counted “absent”.
Poor living and working conditions, irregular drug supply, weak infrastructure, professional isolation and the burden of administrative work–these are some of the challenges faced by doctors on rural postings, stated a 2017 study by the Public Health Foundation of India.

As of 2018, India has 497 medical colleges registered with the Medical Council of India that together offer an intake capacity of 60,680 seats for MBBS. Trends in India, as well as other BRICS nations such as South Africa, suggest that most doctors prefer to sign up for hospital-based specialisations in urban areas than get into general practice at PHCs, a 2015 study published in Human Resources for Health observed.

To address this, policy frameworks in several states have mandated compulsory rural service of 1-5 years during postgraduate medical studies. Further, some states require medical officers to practise medicine in rural areas for a particular period after postgraduate studies.

Mid-level health providers are ideal for wellness campaign: Experts
Mid-level health providers could be the solution to the shortage of doctors in rural areas, according to this report of a national consultation on strengthening rural healthcare, 2018.  

“A key challenge that India faces is that even after diagnosis, people continue to use health care services in secondary and tertiary settings, for conditions which can be managed at the primary care level,” said Chandrakant Lahariya, the national professional officer, Universal Health Coverage, WHO. “Mid-level service providers could here help in promoting and continuing to provide primary health care.”

The proposed health and wellness centres, under Ayushman Bharat, will have teams led by mid-level health providers. These could be nurse practitioners, auxiliary nurse midwives or physicians with a short period of training who can aid doctors.

However, this has been a continual site for debate. Upon the release of the National Medical Commission Bill, which sought to introduce a bridge course for AYUSH practitioners so they could practise modern medicine, the Indian Medical Association expressed its reservations about under-qualified practitioners of three kinds. These were those “with no qualification whatsoever, practitioners of Indian medicine (Ayurvedic, Sidha, Tibb, Unani), homeopathy, naturopathy, commonly called AYUSH, who are not qualified to practice modern medicine (allopathy) but are practicing modern medicine; practitioners of so called integrated medicine, alternative system of medicine, electro-homeopathy, indo-allopathy etc. terms which do not exist in any Act”.

But a 2010 study conducted by the Public Health Foundation of India, National Health Systems Resource Centre and State Health Resource Centre of Chhattisgarh was more optimistic about the potential role for mid-level practitioners.  

In Chhattisgarh, rural medical assistants (RMAs), a special cadre of health providers trained for three-and-a-half years and equipped with one year of internship, were inducted into the state’s health workforce to fill the gaps created by vacancies for medical officers in PHCs. In 2017, there was a shortfall of 43% doctors (444 doctors in position of a required 785 doctors in PHCs) in Chhattisgarh.

A medical officer with an MBBS and an RMA with a three-year diploma were seen to be equally competent in providing primary health care, the study observed.

In fact, RMAs performed the best in terms of prescribing drugs. The largest proportion of “effective” prescriptions for malaria were written by RMAs (64%); AYUSH doctors (57%) and RMAs (10%) also wrote “better” prescriptions than medical officers for diarrhoea.
Overall, average perceived quality scores were highest for RMAs (85%), followed by medical officers (84%), AYUSH medical officers (80%) and paramedicals (73%).

“Mid-level healthcare providers (MLHPs) are extremely helpful in delivering a range of identified health services, especially preventive and promotive services,” said Lahariya. “India contributes to more than two-thirds of the global burden of non-communicable diseases. Here, the role of the MLHPs becomes even more important.”
Only complications arising from health conditions such as hypertension and diabetes that affect a large number of Indians need specialist care, he pointed out. “Mid-level service providers could be involved in the delivery of preventive and promotive health services and controlling the epidemic of diabetes and hypertension and saving the cost in future from related complications,” he said. “Many African countries have mid-level service providers who impart basic prescriptions and are the standards of care.”

Doctors trained in generalist practice might be better equipped for public healthcare
Another way to increase the presence of doctors in rural India could be to train them in generalist environments, said this report by Academy of Family Physicians of India and World Organisation of Family doctors (WONCA).   

“Ninety percent of common problems that affect the community can be handled by a family physician,” said Raman Kumar, president of the Academy of Family Physicians of India. “With medical advancement and a shift towards a privatised medical industry in cities, hospitals are visited for specialised consultations even for smaller reasons like a headache and running nose. Waiting time for a consultation increases and since these services are expensive, people often don’t get access to healthcare and then refer to pharmacies for self-medication or non-degree allopathic practitioners.”

The reliance on pharmacies makes a big dent in family budgets in India. Pharmacies accounted for 52% of the out-of-pocket expenses incurred for buying medicines: Eighteen times more than the expenses incurred in general government hospitals (3%), more than two times the expenses in private general hospitals (22%), as per the household health expenditures in India report released in 2016.

General practice is a specialisation in developed countries like the US and UK, Kumar pointed out. “In India, most graduates are taught in hospital-based, specialist settings and then we expect them to work in a community,” he said. “There will have to be separate departments of family medicine in medical colleges for students and professionals to be introduced to a generalist approach.”

By 2030, India will need to create 15,000 seats for family medicine practitioners, according to a need-assessment report on tertiary care institutions.

(Chhetri, a graduate of Lady Shri Ram College for women, is an intern with IndiaSpend.)

Courtesy: India Spend

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“A poor country with weak state capacity like India, when confronted with the pressure to redistribute, had necessarily to redistribute inefficiently, using blunt and leaky instruments,” said the Economic Survey of 2016-17. State capacity refers to the government’s ability to utilise resources to deliver essential services, such as education and health.
 
Concerns regarding the quality of government services being affected due to understaffing were raised in the 2015 report of the Seventh Central Pay Commission, the committee to review and revise central government employee pay packages. For every 100,000 people, India had 139 central government employees, compared to the US, which had 668, the report said.
 
Understaffing is frequently manifest in protests and inefficiency.
 
Overworked doctors at the Centre-run Safdarjung Hospital demanded an increase in staff to extend out-patient department (OPD) hours, the Hindu reported on July 14, 2018. Similarly, the quality of teaching and research in central universities was affected because a third of teaching posts were vacant, IndiaSpend reported on August 16, 2018.
 
The central government has spent Rs 11 lakh crore ($160 billion), nearly twice Sri Lanka’s gross domestic product (GDP) in 2017 ($87 billion), on 3.2 million employees in 10 years to 2016-17; the expense rose 340%, from Rs 41,676 crore in 2006-07 to Rs 182,513 crore in 2016-17.
 

 
There were, on average, 500,000 vacancies in central government jobs over 10 years.
 
In 2006, of 3.5 million sanctioned posts, only 88% or 3.1 million positions were filled, a gap of 417,495 employees, the data show. In 2016, 89% or 3.2 million of 3.6 million were filled, a vacancy of around 412,752 employees.

 
 
Most vacancies were in group C (clerks and office aides) jobs, the data show. Of 3.2 million sanctioned posts in group C in 2016-17, 87% or 2.8 million were filled.
 
Vacancies of around 300,000-320,000 posts in group C alone are about three times the employees added (111,909) over 10 years.
 
Increase in employee pay scale, increase in expenditure
 
“To keep the salary structure of the employees viable, it has become necessary to improve the pay structure of their employees so that better, more competent and talented people could be attracted for governance,” said the report of the Seventh Central Pay Commission, which said government-employee salaries should be competitive with the private sector.
 
The expenditure on base pay increased 331%, from Rs 27,834 crore to Rs 120,002 crore, over a decade to 2017. Employees received 157% more in-hand cash, after the Seventh Central Pay Commission report and the hike in minimum wages (Rs 7,000 to Rs 18,000).
 
Dearness allowance (DA)–additional compensation to cover cost-of-living increases–accounted for a larger share of the pay structure (42%) than basic pay (36%) between 2011-12 and 2015-16. The trend changed in 2016-17, after the revisions recommended by the Seventh Central Pay Commission.
 
In 2016-17, basic salary formed 66% of central-government salaries, followed by DA (16%). House rent and other allowances made up the remaining 4% and 14%, respectively, according to the report on Pay and Allowance 2016-17.
 

Source: Final report of the 7th Pay Commission 2015; Annual Report on Pay and Allowances of Central Government Civilian Employees 2016-2017*
 
The department of science and technology, which funds research and development of science and technology associated with water, energy, health, environment, climate, agriculture and food, is running at less than half its capacity, from 37% vacancy in 2014 to 55% posts vacant in 2016.
 
Up to 49% posts are vacant in the civil aviation ministry, followed by the corporate affairs ministry with 44%.
 
The defence ministry had the most vacancies in 2016 with 187,054 posts (31%).
 
Overall, there appears to be a shortage of 25%-35% staff, on average, across 51 ministries, the data show.
 
To fill some vacancies, the central government is planning to employ professionals in senior management posts, such as joint secretaries, on contract across 10 areas.
 
Although there are no data on the number of contract employees, according to this November 2016 reply to the Lok Sabha (lower house of Parliament) by labour minister Bandaru Dattatreya, the central government was a major employer of contract workers, according to data released by the Seventh Central Pay Commission. The Centre spent over Rs 300 crore on contractual manpower in 2012-13.
 
As many as 43% of government employees held temporary jobs, according to the 2014 report by the Indian Staffing Federation, an organisation that covers regulations related to outsourcing of skills.
 
(Chhetri, a graduate of Lady Shri Ram College for Women, is an intern with IndiaSpend.)
 
We welcome feedback. Please write to respond@indiaspend.org. We reserve the right to edit responses for language and grammar.
 

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