Mumbai Pune Expressway in Monsoon

The Mumbai Pune Expressway, (officially known as the Yashwantrao Chavan Mumbai Pune Expressway) is India's first six-lane concrete, high-speed, access controlled tolled expressway. Below are some pictures of the same highway during monsoon season. A wonderful picture can also be found here.

    Another picture can be found here.

River Sarayan

River Sarayan in Sitapur. More about The natural beauty of rural countryside in Sitapur.

River Ghaghara

Ghaghara river eating away a 30 year old village - Angraura (District Sitapur)
River Ghaghara forms the Eastern border of the district Sitapur. The river is infamous for its annual floods that affect hundreds of villages on the either side of its course. Here in the picture above, the river is slowly consuming the site of village Angraura. I took picture while I was interacting with local people who were displaced by the river constantly moving towards the East - in other words it was eating away the land of the site where their village was located. They told me that the village was here at this site for last thirty years. People were demolishing their brick houses in order to collect them for future use. They wanted to save their properties as much as possible. Tractors could be seen with trolleys filled with bricks. To reach such a place was absolutely impossible until you had an SUV. I went there with a motorcycle and I had to deal with many slippery and muddy stretches on the way to this village. The village was never connected with any metalled road.  

Countryside in North India (Sitapur, Uttar Pradesh)

Countryside in North India (Sitapur, Uttar Pradesh)

Rural public health system in Sitapur, Uttar Pradesh - Experiences of a PhD student

The central government has been pumping in a lot of money into the health sector since last two decades. The National Rural Health Mission (NRHM), which has been mainly designed to help state governments to improve the situation of human resources and the infrastructure in government health facilities, has received a new lease of life with an extension of five years. Although many states have shown considerable improvement in the service delivery through enhancement in human resources, their training, and physical infrastructure, there are states like Uttar Pradesh (UP) where we rarely hear any inspiring story of success of transformation in the health system. Conversely, what we get to hear are stories such as the one published in the British Medical Journal and widely covered by the media in our country about the corruption in the implementation of NRHM. In fact, UP turned NRHM into a deadly web of graft and killings. A great chunk of the grant received by Uttar Pradesh was siphoned off by those in the bureaucracy and the government and the little that was left was not used properly. Given the sorry state of affairs, the centre reduced the aid under NRHM for a year. Now, when then NRHM has completed its first phase, it is important to review the progress made by Uttar Pradesh in these seven years. I have been visiting the health facilities of all three levels in the rural areas of district Sitapur since last many months. I am presenting here a snapshot of what the state’s rural health system actually is in the light of the norms laid under the Indian Public Health Standards, even after seven years of generous funding under NRHM.     

Almost 10 kilometres from the district headquarters, is a little bustling town called Ramkot. Like many other towns, it lacks basic civic services. Waterlogging, potholes, open sewage and dust along with vehicular and industrial pollution should not come as a surprise for you. The primary health centre (PHC) here is located about 700 meters away from the main town area. Before the new isolated building was constructed and unveiled in 2001, the PHC had only two rooms with a location in the heart of the town. Now, the number of rooms has increased and it can accommodate many people. The building is spacious and airy. However, the bigger size could only be possible when the location was shifted to outskirts of the town where for almost 200 meters around the PHC, nobody lives. The present location was the result of local politics. The government had no option other than to move the location of the new building to the outskirts of the town. Due to its location, which gives rise to serious security problems, doctors and other health workers do not want to stay on campus at night. The sweeper who also doubles as the watchman cannot do much. I was told that locals have damaged the property in the health centre. One or two families reside inside the boundary wall of the health centre. The health workers try to avoid them because they become furious and may cause physical injuries to them if they are told off. The boundary wall of the health centre remains half-constructed and the main gate is no longer at its place. The wall is broken at many places. The glass in many windows is broken.

Typical Health Sub-Centre - they are often located in the outskirts of the villages - and hence prone to theft, vandalism, misuse and destruction.

Electricity, water, and sanitation facilities are three most basic amenities and are a must in all the health centres. This health centre, surprisingly, did not have proper provision of any of the above. Electricity supply is very poor in this area. One can see a transformer sitting on the poles but wires are missing. The insides of the rooms at the PHC tell a similar story. Birds nest at places which should have held electrical equipments. None of the rooms have any ceiling fans. The tube lights are missing. The wiring at the main entrance of the main building is incomplete and wires are naked and open. Now, one can now imagine that how difficult it would be for a doctor or any health worker to work in the health facility in summers when the mercury goes as high as 47oC. Similarly, without electricity, it would be very difficult to stay in the health facility in the sultry monsoon season and chilling winters. The health centre has only one hand pump on campus. It is used by both the people illegally residing in the campus and the health workers. There is a water tank sitting high on an iron platform but it has never been used since there is no electricity. One old and unused plastic tank can be seen lying in the veranda of the main building. As far as toilets are concerned, nobody uses them because of lack of supply of water to the toilets.The room where dressing is done is a filthy place equipped with only one bed.
The narrative above is in complete contrast with the guidelines of the Indian Public Health Standards (IPHS). According to IPHS guideline published in 2012, a PHC “should be centrally located in an easily accessible area. The area chosen should have facilities for electricity, all-weather road communication, adequate water supply and telephone. PHC should be away from garbage collection, cattle shed, water logging area, etc. PHC shall have proper boundary wall and gate”. Apart from this, a “PHC should also have proper sign-age and an entrance with barrier free access”. The OPD must have separate wards for men and women. Although there is proper sign-age in the local language, there is no provision for entrance with barrier free access and separate wards for men and women. There must be one generator room and cold chain room. Since, there is no electricity in the campus; the cold chain room does not exist. In the absence of the cold chain in the PHC, the ANM has to go and pick up her vaccines from Barai, Jalalpur mother PHC which is about 25 kilometres from Ramkot. A round trip to the mother PHC would require more than 3 hours as public transport is very poor and causes delays. If she has to reach PHC on time with all the vaccines that she requires for the day, she will have leave her home as early as 6 O’ Clock in the morning. 
IPHS outlines many other facilities such as a computer with internet connection and a decent accommodation to be ‘essential’ at a PHC. The PHC in question unfortunatelyhas none of these two. None of the health workers stay at PHC in the night because the rooms for accommodation are devoid of essential amenities. Although a few rooms are now being constructed for medical officers, it is highly unlikely that they will ever be used as residence in the absence of electricity, water supply and security. Apart from this, as discussed above, the PHC does not have proper lighting, 24 hours electricity, water supply and functioning water storage facility. Despite this, PHC does not have any solar panels installed, although IPHS lists solar energy equipment under ‘desirable’ list. Another feature under desirable list is a lecture hall or a small auditorium for 30 peoplefor training purposes. However, there existed no such arrangement when I visited. 
This is just half of the story. Let us have look at the human resources available at the PHC. According to revised IPHS published in 2012, a PHC should have two medical officers – one MBBS and another from any AyUSH (Ayurvedic, Unani, Siddha, Homeopathy) stream. The PHC in question has only one MBBS medical officer. With only one doctor in position, it becomes very difficult to manage when he/she is on leave or on a tour for field supervision. In that case, the lab technician or the pharmacist writes the prescription which is nothing but playing with the life of the poor patients. Moreover, I witnessed the lab technician, who was writing prescription, advising people to buy medicines from the nearest medical stores in the town. This indicates that either the required medicines are not available with the pharmacist in the PHC or the technician/pharmacist has tie-ups with medical stores in the town market.
Although the number of lab assistants and pharmacists required at the PHC matches the IPHS norm, the PHC lacks required number of Nurses and Accountant cum Data Entry Operator. I have visited many other PHCs as well but I could never find these two cadres in position. Actually, health policies of the state do not envisage having nurses at PHC level. However, according to IPHS, there should be three nurses in position in a PHC. The lady health visitor and health assistant/worker (male), both stay at community health centre (CHC), although IPHS guidelines want them to stay at the PHCs. Two ward boys have been ‘prescribed’ to be in position at the PHC level but this PHC has only one in position. Three others, namely AyUSH pharmacist, health educator and cold chain & vaccine logistic assistant, have been envisaged as ‘desirable’ in IPHS guidelines. However, none of these ‘desirable’ health workers’ posts are sanctioned at the PHC. In such a situation, when the posts are not sanctioned by the government, what one can expect to exist is only a dysfunctional overburdened healthcare delivery system. 
It is not that this is the only story in this district; there are many others in different places. A small village/town called Manwa is about 40 kilometres from the state capital Lucknow and the district headquarters Sitapur. It is located just two kilometres off the national highway and well-connected by a good all-weather road. The PHC at Manwa is officially known as government women’s hospital (Rajkiya Mahila Chikitsalya). As far as the location is concerned, it is located just a few meters off the main road of the village. However, one cannot spot the building in the very first sight as it is painted with a different colour and its architecture is completely different from that of a normal PHC building.
One of the first things that you would notice is that the building is very old. Its inner walls have marks of rainwater leakages from past years. The plaster is broken and coming off the walls. The bricks can be easily seen in many places. There is only one room for two female doctors posted. The ceiling of the room leaks heavily whenever it rains therefore a yellow plastic cover has been placed under the ceiling. There is a rusty, old-looking, green one-and-a-half meter tall almirah for all the medicines and equipment. Imagine, how big would be the stock of medicines contained in it! There is an old wooden table in the centre of the room with two plastic chairs and iron stool around it. The floor of the room is broken and has tiny puddles. The walls of the room are no different from the ones that I have described above. I was told that both female doctors sit in the same room. There is only iron bench available for patients. The bench can accommodate only three adults. I could not find any fan or cooler even in the month of June when the temperatures go as high as 46oC. There is no lighting either.

Typical labour room at a Health Sub-Centre - unused and vandalised

Such dysfunctional hand pumps are commonplace. 

Filthy toilets - Lack of water discourages their use  

There was another room which was closed when I asked them to show me the room. An old rusty bed is lying unused in the room. The room was not even cleaned properly. There is no electricity connection. The power supply in the village itself is erratic. The PHC does not own a generator either. In such a situation, one cannot expect computers, internet and other operation-theatre related equipment to be there in the facility. One should also not expect the existence of an overhead tank, piped supply of water and functional toilets as prescribed in IPHS guidelines. In the absence of electricity supply, the solar cells can be an alternative for regular supply of electricity but the PHC rooftop is barren. The PHC does not have its boundary wall and hence, no main entrance. The building is not at all sufficient to call it a PHC. There are no separate rooms for lab technician, pharmacists, ANM etc. There is no cold chain available here as well. In fact, there is no way a normal or caesarean delivery can take place in the hospital without endangering the life of the mother and the child.

This Health Sub-Centre is located in wilderness. Do you think an ANM can stay alone in this building in the night?

PHC Shahpur makes use of its resources in this way
As far human resources are concerned, there are two medical officers available at the centre which means the IPHS norms about the number of doctors are being fully complied with. However, lab technician, nurses, accountant-cum-data entry-operator and ward boys are not in position. Not even a single ANM has been positioned here to help the medical officers/doctors. In this situation, one cannot expect to get proper care and services. There is a sweeper at the PHC who lives in the nearby quarters constructed for the support health worker and ANM positioned at HSC. LHV and health worker/assistant (male) stay at the community health centre while as per IPHS guidelines they actually should be the part of the PHC staff. As far as health educator is concerned, he is only found at CHC that is at the block level. The government in Uttar Pradesh has not been able to deploy health educators at all the PHCs.
Let us have a look at what happens in the health sub centres (HSC) which are the first contact point between common masses and the public health care system. The sub centre (SC) I visited is located (exactly fifteen kilometres towards the west from the district headquarters on the national highway 24) just 100 meters off the highway. At the very first sight, what I could see was a thick wall of shrubs and bushes along the walls of the sub centre. The building of the sub centre has been constructed a few years ago. However, the layers of the plaster on the boundary wall have started coming off the wall and bricks can be easily seen. The main gate of the building remains open 24X7. Let us have a glimpse of amenities provided at the SC for health workers. Since there is no electricity connection, we cannot expect the standard electric items. No electricity automatically translates into no running water. There is a hand pump but it takes ages to get water from it. The toilet is not used because of the absence of running water in it. The premises are not kept clean as there is no support worker at the HSC. Although, the ANM does hire a person to clean it occasionally, she complains that villagers make it dirty in various ways including open defecation by small children. The HSC has been looted twice.

Unused resources

In the absence of any amenities and security, the ANM does not stay at the health centre and comes to the health centre twice a week from the nearest town. As per IPHS, HSC should have an ANM residence with all the facilities and she should stay at SC. IPHS guidelines also state that apart from ANM, there should be an additional ANM and a male health worker (MHW) at the HSC. However, none of the HSCs in the district have any additional ANM or MHW. The lack of these two health worker and the support worker overburdens ANM. She does most of the things alone or with the accredited social health worker (ASHA) working in her area. 
Such a grim situation prevails even though the above mentioned HSC and PHCs are have better access (compared to the others in the district) to the headquarters and the capital city and well-connected with the national and state highways. Now, one can imagine what could be the situation in the interiors especially those located on the eastern border of the district. This part of the district faces devastating floods every year posing tremendous challenges to the health department. In the interiors, where road connectivity is poor, no health worker wants to stay for long.They get ‘attached’ (that is they are posted at location ‘A’ but work at location ‘B’. How does it happen is a serious question) to the health centres nearest to their village or home town. The consequence of such practices is a serious distributional inequality of human resources among the health facilities. Apart from this, severe shortages (unfilled positions) also plague the health system. For example, the government records at the chief medical officer’s office at the headquarters show that the community health centres (CHCs) located in the two eastern towns of the district have no specialist doctors in position although the posts are sanctioned. Similarly, PHCs and HSCs in these areas also do not have enough human and infrastructural resources to cater to poor population effectively. These interiors are also the areas where senior officials do not venture regularly to monitor the functioning of the health centres. This could also be the reason why health centres are in bad shape both in terms of human resources and physical infrastructure. Although local media regularly reports the events of unavailability/absenteeism of health workers, equipment and other related news from different blocks of the district, you cannot trace the will to change the situation in the statements made by the medical officers and other responsible people. When asked, the officials at every level have set answers for every question.

These beds are being used by resident doctors.

It was 11:00 AM and PHC was still closed.

These shocking stories indicate the kind of improvement primary health centres in the state of Uttar Pradesh have made during first phase of NRHM i.e. during 2005-2012. The state has miserably failed to improve its health centres both in terms of infrastructure and human resources. Forget about the Bureau of Indian Standards (BIS) guidelines about staffing of the health facilities, the state has not been able to fulfil even the ‘essential’ criteria of IPHS which are less resource intensive than BIS. Shortages and inequalities in the distribution of human resources, poor infrastructure (lack of essential amenities, availability, use and misuse of drugs and equipment) and multilayer corruption, the health system in the district has become completely dysfunctional and almost useless for the poor whom they boast to cater to. In the light of the recent NRHM corruption scandal, it can be said that only the infusion of cash alone will not deliver results in Uttar Pradesh. The state needs to revamp monitoring at all levels. The new lease of life given to NRHM till 2017 could be a golden opportunity for Uttar Pradesh to improve the state of health infrastructure and human resources. However, to turn this opportunity into a reality, the state government and the bureaucracy in the state need to be serious and determined.
Aditya Singh
 Original article can be accessed from Governance now website

Making maternity safer and affordable: Some issues and challenges in Uttar Pradesh

In a recent interview published in e-Gov magazine on Tuesday, October 01, 2013, the Mission Director, National Rural Health Mission (NRHM) said:
“Janani Suraksha Yojana (JSY) has seen a phenomenal increase from 7 lakh beneficiaries in 2005 to more than 1 crore a year 2010 onwards… Building on JSY,another major initiative ‘Janani Shishu Suraksha Karyakram’ was launched in June, 2011 to eliminate out of pocket expenditure for pregnant women and sick neonates. The initiative entitles every woman delivering in a public health institution to free drugs, diagnostics, diet besides to and fro transport. Free entitlements have now been expanded to cover antenatal and postnatal complications and sick infants up to one year of age.”
Indeed, while the past few years have seen widespread attempts to revamp the state of health provisioning, on-the-ground evaluation of health care system reveals a huge gap between intention and implementation.
In Sitapur, one of the backward districts in Uttar Pradesh, Kaushlya Devi (name changed), delivers a baby in a 24X7 Primary Health Centre (PHC) located on a brand-new four-lane National Highway-24,which connects Lucknow to Delhi. As per the JSY scheme, not only all the pregnancy-related costs are to be borne by the Government, Kaushlya is also entitled to free transport and food. However, after her delivery in the night, a nurse (Auxiliary Nurse and Midwife) comes and asks for money in exchange for her services. Kaushlya was asked to pay Rs. 320.
Hamari ‘baksheesh’, the nurse demanded. Kaushlya told the nurse about her poor financial condition and expressed her inability to pay the baksheesh. Kaushlya was, in turn, told by the PHC staff that she will not discharged from the hospital until she pays the baksheeh. Kaushlya had no cash money to give, neither at the hospital nor home. But left with no option, she had to mortgage her gold nosepin at the local goldsmith in exchange for some cash to pay to be discharged and be able to go home.
While Kaushlya’s case highlights the problems in the operation of much praised JSY, a conditional cash transfer program which promotes institutional delivery by the means of cash incentives with the overall objective of reducing maternal and child mortality; it is emblematic of the dismal state of health care provisioning in the north Indian state of Uttar Pradesh. Indeed, following the implementation of JSY the percentage of institutional delivery has increased quite remarkably, drawing praise at national and international forums for making safe delivery a reality for the poorest of poor mothers in India. Drawing from the 6-month-long (March-September 2013) field research in the district of Sitapur, Uttar Pradesh, it seems, however that the success of JSY is limited largely to the increasing proportion of institutional deliveries and programme aims of quality of care, reducing out-of-pocket health expenditure on maternity care remain unfulfilled.
Overburdened health system
The current number of health facilities in the district is nowhere near the norms set by the Indian Public Health Standards (IPHS). A district teeming with 4.3 million rural people would need another 17 CHCs, 82 PHCs and almost 400 SCs to cover its total population (IPHS recommends a SC per 5000, a PHC per 30000 and a CHC per 120000 people). Apart from shortage of health facilities, the quality of existing infrastructure is poor with no basic amenities like electricity or water supply. Only 19 CHCs, 2 PHCs and one SC provide delivery care facilities in the district of 4.5 million people. The number of nursing staff in the CHCs is 33 nurses as against IPHS norm of 190 nurses (IPHS recommends 10 nurses per CHC). If current population is taken into consideration, the total number of required nurse goes up to 360 which is 10 times the current number of nurses in the district. Moreover, there are many CHCs running without a nurse. ANMs in such cases have to assume nurse’s responsibility.

Overburdened ASHAs
During my field research, I interacted with a number of officials at the various layers of health system, from ASHAs to district level officials. ASHAs are local women trained to act as health educators and promoters in their communities.They are considered to be the mainstay of JSY as they are responsible for motivating women to give birth in hospitals.
As of 2013, there are 3008 ASHAs in the district. However, looking at the population norm, the district needs another 1300 ASHAs. Currently, on an average, one ASHA takes care of about 1500 people. It must be noted here that a considerable number of AHSAs actually do not work.
There are a number of reasons behind such retraction. Contractual nature of the job, no guarantee of fixed income and undue delays in paying ASHAs their due, are some of the reasons why they leave the system. It is also important to note that while there is an increase in the demand for health care services, since 2008 there have been no new recruitments of ASHAs. This has resulted into higher work pressure on existing staff, which is reflected in the poor health service delivery. The shortage of staff notwithstanding, ASHAs have been successful in bringing pregnant mothers, especially the poorest of poor, under the radar of public health system.
Lack of basic amenities
Once you reach the CHC, the tall claims about the health system reforms made by many international and national organisations and the governments both at the Centre and the State, fall flat. Let us take a look at how the lack of basic amenities and infrastructure makes a delivery at CHCs a horrible experience not only for pregnant mothers but also for her family and relatives.

Out of nineteen, only five CHCs in the district, have 24 hours electricity. It must be noted here that two of them are designated as First Referral Unit (24X7 CHC with facilities for obstetric surgery, blood transfusion, anaesthesia, specialist paediatric care, operation theatre and required equipment) and remaining three are located on four-lane National Highway-24 connecting the district headquarters to Lucknow. Some of them do have old electricity generators running on diesel but they are rarely used for lighting purposes.

The main purpose of having a generator is to maintain the cold-chain (the place where vaccines are kept).Non-existent seating arrangement in most of the CHCs forces people to retire and sleep on unhygienic floors. Lack of electricity, fans, heaters, chairs, water coolers etc. makes visiting CHCs a horrible experience. Some CHCs become inaccessible during monsoons because they are located off the main road and not connected by a metaled road.
Poor quality of care
ASHAs reveal the real story of quality of care poor rural women receive when they deliver in so-called rural hospitals i.e. CHCs. Since, most of the CHCs have only one or two labour tables, sometimes mothers have to deliver on unsantized floors. Given the fact that electricity is supplied only for 6 hours a day, deliveries during night time are often conducted using light from torch, mobile handset, wax-candles and local kerosene lamps.ASHA is supposed to manage kerosene oil, lamps, candles and even matchboxes before leaving for CHC.

Running water inside labour rooms is a rare luxury in CHCs. There are washbasins stuck in the wall though. Water is generally carried from a hand pump by the family members or relatives of the patient in a bucket. The horror of delivering a baby in a CHC does not end here. Toilets in most of the CHCs are without any running water. One has to carry water of his/her own, from the only hand pump in the campus. It should come as no surprise if they remain untidy all the time.

Dais conduct deliveries
Lack of nurses and ANMs in the state health system still forces UP to take help from traditional birth attendants. Moreover, nurses and ANMs in UP still consider delivery to be a dirty ‘task to be performed only by ‘dais‘ (local midwife)’. Hence, they rarely involve themselves in labour process. CHCs have to hire private dais (midwives) who conduct deliveries to earn (Rs.50-100 per delivery) their bread. The role of a staff nurse or ANM at CHCis currently restricted only to “‘monitoring’ the process of delivery, intervening only when necessary and administering necessary injections”.
Safe maternity still requires money
ASHAs reveal that after delivery, it is usual to administer some injections like Methergine and provide essential medicines to mother. These medicines are generally not available in the hospital dispensary and need to be bought from private drug stores located just outside CHC. The expenditure on these medicines is actually an out-of-pocket expenditure which Janani Shishu Suraksha Karyakram launched in 2011 aims to eliminate.
Normally, the total expenditure varies between Rs.100 to Rs.200. However, after dark, the drug stores usually take advantage of the fact that there are no other shops around and charge the poor patients more than the maximum retail price.When either the government ambulance is being used for other emergencies or the driver is not available, it is not possible to drop the patient home after delivery. In this situation, patients sometimes have to pay up to Rs.500 to hire a private vehicle such as a taxi or a jeep/van, especially during night time.
Pay ‘mandatory’ bribes and ‘baksheesh’, get JSY money
After delivery, the nurse processes necessary documents and distributes cheques to patients. In some CHCs, especially poorly accessible ones located in Eastern part of the district, it is mandatory to pay Rs.320 after delivery regardless of who you are – a poor peasant or a rich landlord. There is no receipt given for this payment. ASHAs revealed that this money (Rs.320) is distributed among nurse, dai, and sweeper-cum-watchman at the spot. The patient has to pay another Rs.20 to receive her cheque. North India is known for its son preference. Therefore, whenever the baby is a boy, nurses, dais and others in the CHC usually ask for a monetary gift from the family members of the patient. The amount varies from as little as Rs.100 if the patient belongs to a poor family to as high as Rs.2000 plus gifts if the patient belongs to a rich family.
ASHAs do not receive what they are entitled to
ASHAs are supposed to receive an amount of Rs.600 per institutional delivery. However, from this money, they also have to pay Rs.120 to CHC staff in order to get the payment sanctioned and thus, their actual payment is Rs.480 per case. This amount of Rs.120 is distributed among the Superintendent and the accountant/clerk (Rs.100 for the Superintendent+ Rs.20 for accountant). ASHAs receive an honorarium of Rs.150 for each regular immunization (RI) drive and thus, they are paid Rs.3000 every four months for these RIs. However, the money reaches their bank account only when they pay Rs.1500 in advance to the account manager at CHC and too without a receipt. They further revealed that a part of money actually goes to Chief Medical Officer. It is also possible that the chain goes on even further.
Final words
What government has been successful in is that it has been able to provide delivery care in rural hospitals (CHCs). However, low quality of care and financial burden is still a problem. Although the money under JSY attracts women to deliver in a health facility, a lot of JSY money is actually being squandered on bribes to health workers. Apart from that patients have to spend on necessary medicines and injections and sometimes on transport as well. On the other hand, whatever money government pays to ASHAs for their services, one-fifth of that goes to the pockets of accountants/clerks and superintendents. This is a sheer wastage of taxpayer’s money.
The infusion of money into the system will not do any wonders until it is ensured that it reaches the right person at the right time and place. Therefore, the major challenges is to ensure accountability and transparency in the implementation of JSY. Apart from that health system in UP needs a revamp in terms of physical infrastructure and human resource without which we cannot expect any scheme to perform well. NRHM has been extended till 2017 and may prove another opportunity for UP to make much needed “architectural corrections” in its health system. However, any hope for rapid change in the health system of UP would be a fallacy until health as an issue remains at the bottom of the agendas of political parties in the state.

[Original article was published here]

How to create high resolution JPEG or PNG from MS Word Chart

We often come across this problem especially academics. I often have figures to put in my papers. Its easy to prepare figures but saving them into high quality pictures could be a tricky thing to do as most of these word processors do not allow us to covert the figure into a JPEG directly. I have found one way out of this problem.
1. save your one page document, which have the figure you intend to save as a JPEG, into a PDF.
2. Open that PDF in a PDF reader. I do not know whether 'snapshot' facility is available in Adobe Reader. I use an open access (free of cost to all) PDF reader called Foxit reader. I find it far better than Adobe reader.
3. Okay so make your PDF file as big as you want. By doing this, you may see that the font etc. of figure is getting bigger in size without any distortion in quality of the font and the figure. Make it as large as you want your picture to be.
4. Go to snapshot tool, select it, now go to main area of PDF reader, select the figure. As the figure is zoomed a lot, you need to scroll left right up and down the page in order to cover entire figure, while doing this don't let snapshot option go. Once you have selected it, the areas selected by snapshot will become blue.
5. You copy it, paste it in word now as a picture and save it from there on your desktop as picture or go to Home, then to create, and under that heading go to from clip board. It will open a new tab in the same reader showing your figure. You can save this figure as PDF.