A/HRC/14/20/Add.2 Because of space constraints, it is only possible to consider briefly a handful of the relevant concerns. Particular attention is given to a few issues arising from (a) the health workforce and (b) monitoring, accountability and redress. Among the important issues that are omitted are sexual and reproductive health education, family planning and referral systems. Although the Special Rapporteur visited both Rajasthan and Maharashtra, the discussion does not always set out the data and information for both states. In short, the discussion is selective and illustrative. Occasional references are also made to some other Indian states. A. Health workforce 20. A health workforce is one of the essential building-blocks of a health system and the right to health. The four cornerstone interventions to reduce maternal mortality mentioned above depend upon a well-performing health workforce with a wide range of competencies. Because of space constraints, it is not possible to consider all the human resource implications of these cornerstone interventions. Instead, after some general remarks, the main focus is on skilled birth attendants, technical senior managers, providers of EmOC and providers of anaesthesia. 1. Health workforce in crisis 21. There is overwhelming evidence that India faces a massive, crippling crisis in its health workforce. In many districts, lifesaving care is unavailable to women giving birth. Rural and disadvantaged areas are those most likely to be without a provider in public facilities. This compels many women either to go without any care at all, or to go to the private sector for life-saving services that should be publicly available for free. Recourse to the private sector impoverishes many women and their families. 22. In 2008, the Government of India organized a review of the National Rural Health Mission in Rajasthan. According to the report: “As everywhere else in India, the state of Rajasthan is also facing acute shortage of skilled health human resources to provide quality health care to the rural people in the state. The shortage of staff exists across all levels, including doctors.”8 The report continues: “the state is facing huge problems to obtain adequate manpower to meet the IPHS [Indian Public Health Standard] norms.”9 The report provides some specifics, for example, that there is an acute deficiency of specialists at the first referral unit/community health centre level and that 75 per cent of posts are vacant in Dungarpur.10 Across Rajasthan, at the same level, only 81 of 381 posts for anaesthetists were filled, a shortfall of 79 per cent. Another recent study on Rajasthan found that about 67 per cent — and in tribal areas 83 per cent — of such units and centres did not have obstetricians.11 23. The health workforce crisis extends to Maharashtra. In 2008, the Government of India organized a review of the National Rural Health Mission in that state. According to the report, due to the non-availability of general practitioners (Bachelor of Medicine and Bachelor of Surgery (MBBS) doctors or medical officers), AYUSH doctors (doctors of traditional medicines) “are manning the Primary Health Centres”. The report adds that “the state has been facing the problem for a long time and in fact is interested in seeking 8 9 10 11 GE.10-12866 India, “2nd Common Review Mission: Rajasthan under National Rural Health Mission (NRHM)” (Ministry of Health and Family Welfare, 2008), p. 6. Ibid., p. 7. Ibid., p. 15. S. Iyengar, K. Iyengar and V. Gupta, “Maternal health: a case study of Rajasthan”, Journal of Health, Population and Nutrition, vol. 27, No. 2 (April 2009), p. 279. 7