Serious violations in working conditions under the National Family Health Survey (NFHS) 4 in India
On 12th May 2015, four persons died and two others sustained grievous injury as a result of a head-on collision between a lorry and a Tata Sumo on the NH-13 near Amlapur village in Kudligi taluk in Bellari in the early hours of the day. The deceased have been identified as Rupadevi (30), Basamma (34), Rupa (28) and Manjunath (26), who was driving. Malappa and Chidanand, who were severely injured, have been admitted to the Government Hospital at Kudligi. 1
While this ‘news’ may seem like one of the many road accidents that has come to typify modernising India, it hides a much more sinister story of a series of violations and grievous negligence under the 4th round of the National Family Welfare Survey undertaken by the Ministry of Health and Family Welfare, India. Selection of agency for NFHS4 The NFHS 4, similar to all three prior surveys – NFHS 1, 2 and 3 are conducted under the stewardship of the Ministry of Health and Family Welfare, Government of India, with the International Institute for Population Sciences (IIPS), Mumbai, serving as the nodal agency. IIPS has further sub-contracted to other field agencies.
The contract for NFHS4 has been given to Vimarsh Development Solutions Pvt. Limited for the states of Gujarat, Dadra & Nagar Haveli (DNH), Daman & Diu (DD), Tamil Nadu & Puducherry. A sister concern EHI International (formerly known as EPOS Health Management) has been given the contract for West Bengal, Andaman and Nicobar Island, Punjab & Chandigarh. Of the 23 Population Research Centre (PRC) in the country, not one had been selected by IIPS for the NFHS 4th round, inspite of them being eligible in several ways. The PRCs have infrastructure, boarding and lodging facilities, transport facilities, experience staff and faculty, and extensive experience of implementing these large scale studies.
The PRC in Dharwad, Karnataka, established in 1961 is fully funded by the Ministry of Health and Family Welfare, Government of India for its research activities and has a staff of 23 members, including a Director, Deputy Director, two Research Officers, four Research Investigators, four Field Interviewers, three computers, a tabulator, an assistant librarian, an office superintendent, a stenographer and drivers. The PRC in Bangalore, affiliated to Institute for Social and Economic Change (ISEC) has already had experience of conducting NFHS3. Several of the trainees had previously worked on NFHS 3 with the Population Research Centres and vouch for the care that has been taken of the researchers by this agency. It is ironic that the training at Dharwad in Karnataka for NFHS4 was held in a disreputable lodge by Vimarsh, just one km away from the sprawling PRC campus which had ample space and resources to do the study. The PRC had apparently not been able to compete with Vimarsh as the rates quoted by Vimarsh were ‘very low’. When Vimarsh does not even have an office or an organisational base in the state and is working out of a Gurgaon based office, can low budget quotes be the only factor to select an agency to conduct a large scale survey as the NFHS claims to be? While on the one hand, IIPS claims to have a “ stringent process of selecting agencies with sound financial track record, work experience and expertise in large scale data collection help IIPS to get good quality reliable data” 2 they also repeatedly warned Vimarsh during the training of trainers at Orissa in August 2014 that Vimarsh had a poor financial record and had already been issued a warning by IIPS that they had received complaints about Vimarsh not paying salaries on time.
Onus of equipment for the survey on the researchers
Every equipment and material for the survey such as the Stadiometer, infantometer, BP monitor, Hemocue machine, salt test kits including the gloves and Band Aid have been procured from American companies in the guise of maintaining standardisation and quality. The procurement of this equipment has cost Rs. 220,000,000. Is there a dearth of Indian companies to supply this equipment? The researchers have been repeatedly warned that the weighing machine costs Rs. 45,000 each and the glucometer costs 550 dollars. The equipment is bulky and heavy and often carried by the CAB researcher who would herself weigh no more than 45 kg. The researchers are expected to assemble and disassemble this bulky equipment at each house they visit while ensuring that there is no damage or wear and tear. The researchers are expected to return the equipment undamaged at the end of the survey failing which their salaries would be withheld. Although IIPS claims that the field agency will be held responsible for any damage resulting due to the careless handling of the equipments, the onus has been directly transferred by the agency to individual researchers. The 28 day training contract issued by the agency states that “investigators would be solely responsible for any damage or loss of equipment and that recoveries would be made from them.” In keeping with this threat, apart from irregularly paying salaries, the agency has also withheld Rs. 3000/- every month from each researcher to guarantee payments for future wear and tear of equipment. Are the stalwarts who designed this survey unaware of the extreme harsh conditions that the survey is being done? Is it fair to expect field based researchers to carry such heavy equipment to the field and then bear the onus of wear and tear? Is this the learning we have acquired from years of conducting large scale surveys? Or are we really leaving the powerless researchers to the mercy of the market agents while IIPS feigns innocence that this is ‘between the agent and the researcher”!
Quality of training
The trainees all being from Karnataka are fluent in the local language Kannada. However, the trainings were conducted in English. Trainees had been repeatedly requesting that the questionnaire was technical and they would require the training to be primarily in Kannada. In response to this, the trainers responded that “How come you people don’t know basic English. If you don’t know English, just leave the training.”When the language issue was raised with Vimarsh, the response was ‘Chup chap bait jao. Tumhara kaam sirf sunna. Bath math karna.” Trainees were told not to make any complaints in the presence of IIPS representatives. ” It seems ironic that to suit one trainer who speaks only English, 110 Kannada preferring trainees were expected to be quiet or leave the training!!
Quality of data of NFHS4
This is a survey with a 31 million dollar budget with contributions from the Government of India, USAID, Bill and Melinda Gates Foundation, UNFPA, UNICEF and MacArthur’s Foundation.2 Each of these agencies has staked a claim on some part of the survey to meet their own data requirements. ICF International, a venture capital firm based in Fairfax, USA has been the technical partner but how and why they have become the technical partners is unclear. The Technical Advisory Group (TRG) of NFHS4 has been left completely in the dark about the entire survey. The market survey nature of the NFHS4 is amply demonstrated. One question has a list of brands of mosquito nets such as Dawa Plus, Duranet, Interceptor, Lifenet, Magnet, Netprotect, Olyset, Permanet, Royal Sentry, Yorkool and the researchers are expected to read out each and every one of the product and company names and tick mark if these are being used by the families or not! One question was on “LAM”. Although the expanded form is Lactational Amenorrhea Method, researchers were asked not to expand this question but just ask the question. “Please just ask the question. Dont ask us for any explanation. Dont expand it. Just say LAM’ Fred Arnold, Consultant with Macros (alias ICF International) – technical partner for NFHS 4
40 questions are related to domestic violence including intimate sexual violence. NFHS 4 field researchers have repeatedly asked how it is possible to ask intimate sexual questions in a large scale survey especially when it is next to impossible to ensure privacy. The only answer has been that the questionnaire is finalised and it has been done before. This issue has been raised as a critique of the NFHS third round but no cognisance has been taken to identify problems from the previous round to ensure better quality in this round. 3 The questionnaire for men is 38 pages with 843 questions of which 43 questions with several sub-sections each are dedicated to HIV and STD. There are a total of 4 questions regarding tuberculosis and the entire survey does not contain even one section on disability, possibly because of the lack of investors interested in this domain.
Labour law violations under NFHS4
It has also been seen that several unethical practices including coercing the interviewers to sign a contract that they would attend the 28 day training under this ‘prestigious’ Ministry of Health national survey without being entitled to a stipend and that their original marks cards would be taken away by the private agency till such a time the agency so desired. The researchers were also made to sign that they would pay from their own salaries if there was any wear and tear or damage to the equipment that they would be carrying to the field.
Despite having given representations to the private agency Vimarsh seeking safe and secure arrangements for accommodation, medical insurance during the course of the survey, the salary of Rs. 13,500/month on the 5th of the month and a DA of Rs. 200 per day per investigator as mentioned by the MoHFW tender document and seeking that the onus of the equipment not be placed on the researchers, all original marks cards be returned, signed contracts be issued and a stipend paid for the period of training. Apart from threats of termination by Vimarsh, there has been no response till date from either IIPS or MoHFW. With undue coercion and verbal assurances, the trainees were made to continue the training. The nightmare had begun for the researchers but a combination of economic necessity and faith had put them entirely at the mercy of an unscrupulous agency and an unresponsive Ministry of Health and Family Welfare.
The middle agent International Institute of Population Sciences has been silent in the face of each and every violation inspite of several letters and emails and phone calls made by the researchers to the director of the institution as well as the state representative. Although the training without any form of payment was completed on the 4th of February, researchers were made to wait without a salary for another month and half before the survey was initiated. Till then their original marks cards were in the possession of Vimarsh. After start of the survey However, they have been plagued by non-payment of wages, payment of less than mandated wages and unsafe conditions. On the day of this paper was being written (10th June 2015), the researchers in the field have not been paid salaries for the month of May and have received a combined salary of Rs. 14,000/- for February and March as opposed to the Rs. 19,500 they are supposed to receive per month, including a dearness allowance (DA) of Rs. 200 per day. They have not been paid for the 28 days of training that they had undergone previously. They have not been issued contracts or salary slips.
Researchers are being made to stay at government hospitals and anganwadis while their accommodation per diems of Rs 100/- day is being withheld by the agency. Researchers who have wanted their marks cards at anytime in between, or have wanted to leave, have been made to pay at Rs. 500 per day for every day from the date of joining the training. Repeated complaints to IIPS have fallen on deaf this – this being an agency that claims that “IIPS has good capacity and track record to ensure that its finances are well managed and grant funds are spent efficiently. The IIPS maintains a set of written financial policies that guide staff on allocating and spending grant funds, based on best-practices. The IIPS Board has a Finance Committee that reviews the budget regularly to ensure that funds are spent according to plan’. 2
As per the IIPS protocol, a fixed minimum salary to the interviewers is Rs. 13,500/- per month (rate approved by the MoHFW for IIPS Field Staff). In addition, a minimum DA of Rs. 200/-per day is to be given to the interviewers/other field staff. Field Agencies should ensure timely payment to field staff as per the contract and a copy of the receipt should be sent to the IIPS in the first week of every month. Any complaint reported by field investigators regarding irregularity/non-compliance of this clause in the payment of salary or DA will be taken seriously by IIPS and MoHFW, as it directly affects the data quality. Further, IIPS reserves the right to check whether the FA follows the above mentioned norms and to cancel the contract of any FA that is not complying with these requirements.” 4
Further, the International Institute for Population Sciences would have to be viewed as the principal employer of these workers who are engaged by the contractor Vimarsh. It would be the responsibility of the IIPS to ensure that the payment of wages are properly made to the interviewes, and that they are provided with safe working conditions.
Provision of essential support for research
As per MoHFW guidelines ‘For effective and efficient implementation of the field operation, every FA must, compulsorily provide one vehicle to each survey team (consisting of 7 members). IIPS reserves the right to stop the fieldwork/cancel the contract any time if any team is not provided with vehicle as per protocol’4. Inspite of this two to three teams were crammed into vehicles and sent to different villages. “Vimarsh had hired white board vehicles for the survey. They used to take any local vehicle that was available. White board vehicles are meant only for family consumption and never for commercial purposes. The drivers were not trained and didn’t have good experience. Then they used to ask two or three teams to go in one vehicle.” says a researcher at the site of the accident which claimed the lives of 3 NFHS4 researchers and one driver leaving the fourth with grievous injuries.
Till date the families of the researchers who died have not received any form of compensation on the pretext that the documents of the vehicle involved in the accident are not available. The deceased researchers in fact did not even have the necessary documents such as the contract from Vimarsh to show that they were in fact employed for NFHS4. The researcher, Mallappa, who is still in hospital on the day of submitting this commentary (9th June 2015) has incurred an expenditure of Rs. 3,00,000 lakhs. He has sustained extensive facial injuries with loss of teeth and is unable to speak. He is only able to communicate through SMS and sign language. Vimarsh representatives visited him on the first day and promised to pay all his bills. Now they are not responding to phone calls by the family. He has not received his pending salary from Vimarsh and neither any reimbursements although the MoHFW guidelines clearly state that “FAs must make provision and pay for group insurance to all the field staffs deployed in NFHS-4”(ref). How will Mallappa, a young active researcher be able to earn an income and support his family if he is unable to speak?
Questions about NFHS4
The death of four persons and injury caused to two workers on 12th May 2015 brings to the forefront the unsafe working conditions under which they continue to work. Contracting out of health services has been the mantra of late, riding on the back of the urgent need to privatise the entire health care system. The reason for this large scale and often surreptitious but mostly blatant and visible process of privatisation has been the opening up of markets to multiple elements that look to make a quick buck from the ill health of populations. Rajan and James have raised serious concerns about the fact that the inflated costs of large scale surveys such as NFHS3 has not led to an increase in quality but providing profit to the consulting organisations. Anecdotal evidence that the profits of the private agency is as much as 50% of the funds that have been invested. 3
While the quality of the survey itself is redoubtable, the violations of the researchers under the contract has been kept under close wraps. Even when these violations are brought to light, there is a serious lack of cognition by any of the agencies that are involved. In this instance, the Ministry of Health and Family Welfare and IIPS are inaccessible and unresponsive and the private agency is allowed to break multiple labour laws with impunity.
There are several questions that public health professionals, academicians and researchers need to ask ourselves and each other. Are we turning a blind eye to the large scale violations that are happening in the country? Do we not have to question the ethics, the principles, the standards and the quality of a survey on the magnitude of the NFHS4? Whose interests are we meeting? Who is responsible for the death of the 3 researchers?
1. Ahiraj, M. Four killed, two injured in accident. The Hindu (2015). at <http://www.thehindu.com/news/national/karnataka/four-killed-two-injured-in-accident/article7197258.ece>
2. Annual Review Summary, National Family Health Survey 4 (NFHS 4) in India. (2014).
3. Rajan, S. I. & James, K. S. Third National Family Health Survey in India: Issues, Problems and Prospects. Econ. Polit. Wkly. November, 33–38 (2007).
4. International Institute for Population Sciences. Request for Proposal (RFP) from Field Agencies to Implement National Family Health Survey (NFHS)-4 Bid Document. (2015).