In the last five years, the government’s health budget has risen significantly fromRs10,040 crore in 2005-06 to Rs24,494 crore in 2010-11. The National Rural Health Mission (NRHM), an umbrella for health programmes, is the largest scheme, with a budget of Rs16,219 crore in 2010-11. Significant as this rise is, overall health expenditure remains woefully inadequate. Public health expenditure accounts for 1.45% of India’s gross domestic product. This is substantially lower than many developing countries: Cuba spends 5.5% and Namibia 4.7%. How have these limited resources been spent?
Let’s look at trends first. Statewide expenditure estimates show that NRHM funds are being spent, particularly among poorer states with a high disease incidence. In 2008-09 (the last year for which complete data is available), Madhya Pradesh reported spending 93% of funds, Uttar Pradesh spent 91% and Jharkhand 89%. Bihar was the lowest among these states at 66%. But the effects of these expenditures seem to be limited.
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According to norms in rural India, there ought to be one primary health centre (PHC) for every 30,000 people. This goes down to 20,000 for tribal and hilly areas. When benchmarked against the norms, Madhya Pradesh has a shortfall of 31% PHCs and, more worryingly, even 53% of existing PHCs do not have the required number of doctors. Uttar Pradesh has a shortfall of 16% PHCs, and 46% of existing PHCs do not have requisite doctors. Jharkhand is an interesting case—it has a shortfall of 60% PHCs, but all the existing PHCs are supposedly staffed with doctors!
Specialists are even harder to find. Countrywide, a mere 31% of required specialists are in position in India, and the state variation is alarming. Madhya Pradesh has a specialist shortage of 82%, and Uttar Pradesh 70%. Shortages apart, one of the biggest problems in the health sector is doctor absenteeism. The last national study placed doctor absenteeism at 40%. While updated numbers are awaited, anecdotal evidence suggests that, with the exception of Bihar, the overall situation is more or less stagnant.
A part of the reason for this limited impact is that governance reforms introduced by NRHM have failed to take root. NRHM was launched after a slew of studies pointed to the severe governance crisis facing the health sector. To address this, the scheme aimed to engineer an “architectural correction” by introducing a range of governance innovations. One key innovation was to decentralize health planning and management to district- and block-level health societies, or Rogi Kalyan Samitis (RKSes). Overall, the performance of these societies has been poor.
There are many reasons for the poor performance. For one, very little effort has been made to train, inform and build capacities of RKS members. Last year, we conducted a study in Bihar and found that the design of the RKSes makes meaningful participation almost impossible. For one, administrative officials—medical officers and civil surgeons—retain all financial control as they have the signatory authority to sanction funds for specific projects and can override all decisions. This is compounded by the fact that RKS functioning is not a priority—members get no training and thus have little understanding of their roles and responsibilities. In Bihar, the RKS members interviewed had little understanding of objectives, functions and fund utilization four years into their tenure. The result: despite decentralization of hospital management to local communities, decision-making and expenditure remain an official privilege. And so, rather than spending discretionary funds on improving health delivery, the money inevitably goes to the tried and tested route of whitewashing and installing ceiling fans.
Poor performance of the RKS is a lost opportunity. Real reform in the health sector requires a radical overhaul of the governance of its human resources. At present, health workers have few incentives to provide quality care and accountability to patients. While NRHM’s architectural correction fails to directly address this problem, a well-functioning RKS could be the starting point for change. For instance, RKS members could use funds to contract in doctors and specialists where availability and absenteeism is a problem. Crucially, the RKSes could be the start of an experiment to involve village councils in delivering health to ensure accountability. What the health sector needs is innovation and the RKS could be a vehicle.
To end on a positive note: The Janani Suraksha Yojana, NRHM’s flagship innovation that provides a cash transfer directly to pregnant women to incentivize institutional delivery, has seen some success. The beneficiaries have risen from 739,000 in 2005-06 to 10.078 million in 2009-10, and 70% are from the poorer states with low health indicators. So there is room for optimism. Innovations can work, we just need to learn from the good stories and for this we need more data and assessments.
(Data collected and analysed by Avani Kapur and Anirvan Chowdhury.)
Yamini Aiyar is a senior research fellow, and director of the Accountability Initiative, at the Centre for Policy Research.
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