Published in Livemint | On January 25, 2018
Bengaluru: The growing reports of child deaths from different parts of the country since last summer’s Gorakhpur tragedy have finally put the spotlight on India’s growing healthcare crisis. Poor funding is one big reason behind the crisis but poor management of health funds is equally to blame, a Mint analysis shows.
Notwithstanding a significant rise in allocation to the health sector in the 2017-18 budget over the previous year, the Union government’s spending on health and family welfare amounted to merely 0.3% of GDP (gross domestic product), budget data shows. Even after including states, the overall government expenditure on health remains extraordinarily low. As the chart shows, India’s disease burden is higher than most peers while its spending to combat such diseases is lower than most peers.
The poor provision of healthcare and low insurance cover leads to very high out-of-pocket expenditure on health, impoverishing a large number of households. Health shocks add at least seven percentage points to India’s poverty figures.
The growing recognition of India’s healthcare crisis has led to growing calls for increased public funding of healthcare. But Budget 2018 may not see much of an increase, according to a Reuters report.
One reason why the finance ministry may not have been impressed with the health ministry’s demands for more funds is because a good chunk of health funds remain unutilized.
As with everything else, there is wide variation in utilization rates across the country. Among states, some with the poorest health outcomes, such as Bihar and Uttar Pradesh, were among those with the highest share of unspent funds allocated under the National Health Mission (NHM) in 2016-17.
One reason for unutilized funds could be delays. In Bihar and Maharashtra, funds under National Health Mission were delayed by two to three months in 2015-16 and 2016-17. In 2016-17, nearly 40% of total expenditure under National Health Mission took place in the January-March quarter. The utilization of funds in the health sector is also hampered by a lack of adequate staff who can plan their use, according to Avani Kapur, director at Accountability Initiative.
Even where funds are channelled, quality of care remains poor. As a previous Plainfacts column pointed out, 47% of the people who visit a public hospital do so because they have no choice. And while private clinics are more popular, doctors in such clinics are often inadequately qualified.
Yet, public sector doctors are often unavailable or offer poor quality care, data from the latest round of the National Family Health Survey (NFHS) conducted in 2015-16 shows. Fifty-five percent of households reported not using government health facilities when sick, and 48.1% of such households cited poor quality of care as one reason for avoiding public health facilities. There seems to be a broad correlation between quality of care and usage, the data shows.
A key reason for the poor quality of public healthcare services in India is the lack of adequate data and monitoring. The NFHS report itself comes after a gap of a decade. And the health ministry’s real-time health management information system (HMIS) suffers from poor quality and data gaps. A 2017 Comptroller and Auditor General (CAG) report showed that 18% of health facilities did not even report basic infrastructure data in the HMIS portal in 2015-16. The CAG also found wide-ranging discrepancies between what the HMIS system reported and the physical records. For instance, the number of infant deaths recorded by the HMIS in Jharkhand was substantially lower than the number in the physical records.
The lack of adequate monitoring also threatens India’s disease surveillance system. The integrated disease surveillance programme (IDSP) initiated by the health ministry in 2004 with funding from the World Bank is in poor shape. According to a 2015 World Health Organization (WHO) field study, only 41% of 70 district hospitals visited had a district surveillance committee in place. And of the 117 district laboratories under IDSP, many fail to conduct recommended tests.
Little wonder then that India remains highly vulnerable to infectious diseases even as it under-reports several major infectious diseases. The World Malaria Report 2017 shows India has among the weakest malaria surveillance system with only 8% cases detected, lower than countries such as Zimbabwe, Nigeria, Pakistan, Indonesia, etc. India’s reporting of tuberculosis cases is no better.
Clearly, more funds for the health sector need to be complemented with institutional reforms to ensure greater transparency and accountability. It is likely that more accurate and timely data on diseases and health services will spur governments at all levels to take healthcare more seriously than they do today.