Ankita Handoo, 8 June 2006
The United Progress Alliance (UPA) government that has completed two years of its term as the ruling party is still falling short of its targets that were set for itself under the Common Minimum Program (CMP).
Since its inception of the UPA government, India has witnessed hectic political activity around the idea of monitoring performance of the UPA government vis-à-vis CMP and accepted norms of good governance.
This willingness of the government to be open for evaluation around tangible benchmarks and commitments made in the CM is noteworthy. Through this opportunity, the media and the civil society have been able to successfully built pressure on the government for providing effective and citizen centric government.
Under the CMP, healthcare system of the country was given prime importance in which the UPA government had pledged to increase public spending on health to at least 2-3 % of the Gross Domestic Product (GDP) over the next five years of its term with a focus on primary health care.
The other commitments made by the UPA government were:
• Introduction of a national scheme for health insurance for poor families.
• Increased family planning programmes to reduce population.
• Stepping up public investment in programmes to control all communicable diseases.
• Provide leadership to the national AIDS control effort.
• Ensure availability of life saving drugs at reasonable prices.
• Nutrition programmes, particularly for the girl child will be expanded on a significant scale.
During the second year review of the CMP, health expert, Dr. Ravi Duggal examined the allocations for health in the budget in the light of the commitments made in the National Common Minimum Programme (NCMP) and the trend in the state governments’ expenditure with a focus on National Rural Health Mission (NHRM).
He pointed out that the public expenditure on health and education, taken together, including government spending, must constitute 9% of the GDP, as per the commitment to the NCMP. However, the present government seems to be a phenomenal distance away from realising this goal. If 3 % of the GDP as public expenditure on health is taken into account, by 2008-09, assuming the current growth rate, the public expenditure on health would be a total of 1, 50,000 crores, which would be nearly five times of what the state and central governments currently spends on health.
At present, the health budget of state and central government combined is less than 1% of the GDP. The central government has shown that its capacity is limited to increasing its contribution by about one-third and the state government only by one-sixth. Such tardy progress in allocation makes the target unrealistic and unachievable.
If the trends in health programmes are observed, one will find that sectors like hospitals and medical education and family planning services are receiving a smaller chunk of the health budget in comparison to sectors like reproductive and child health (RCH), HIV/AIDS and immunisation since these concerns have become important in the International scenario. In order to keep up with international standards, selective areas are getting more attention instead of holistic, comprehensive health programmes which are becoming secondary.
Under the flagship programme of the UPA government, the NRHM proposes the availability and access to quality healthcare by people, especially those residing in the rural areas. This would be achieved through strengthening the three levels of rural healthcare which are:
i. the sub-centre
ii. primary health centre (PHC)
iii. community health centre (CHC)
An accredited social health activist (ASHA) would be appointed at the village level who will be the link worker for the rest of the rural public health.
The problem that comes to the fore with regard to the NRHM is that the budget heads do not address a missing link in rural healthcare- the medical care. In that sense, the integration into comprehensive healthcare that the document talks about does not get reflected in the budget. Moreover, the allocations to rural health would get restricted to the NHRM and other source of funds for rural health may get blocked. This narrowing of health programmes adds to the dismal condition of the health system.
Thus, the key issue in access to healthcare that even the NRHM fails to address is the mechanism for allocating resources. Most often, the allocated budget for the PHC and the CHC is not in sync with the demand and the needs of the areas. Secondly, even the amount allocated is siphoned off before it reaches the beneficiaries reflecting poorly on the transparency and accountability of the system.
The state budget is a critical component in public health financing as it accounts for about four- fifths of the total public health budget. However, during the last decade, there has been a slowing down of investments in the public health in most of the states.
The International funding agencies like the World Bank, USAID, and DFID among others, invariably direct certain reforms which focus only on a small part of the public health system and advocate for commercialisation of healthcare. The reduction in state’s own resources and the injection of external funds have created a scenario wherein the state governments are loosing control over their public health system.
In retrospect, one finds that very little has been done in the area of public health. Less than 1% of the GDP is spent on health by the government. The NRHM is mainly focussing on rural areas creating an urban-rural dichotomy. Selective programmes are getting more attention due to international support while other diseases and health concerns get neglected.
The changes proposed are:
• From selective to comprehensive healthcare programmes
• Appropriate fiscal devolution
• Build multi stake holder partnerships involving government, private sector and the civil society.
• Encourage local participation in programmes
• Restructure the health system for proper allocation of resources
• Muster political will for the upliftment of the masses.
1. Is the trend in health changing? – Dr. Ravi Duggal
2. Wada Na Todo Abhiyan (WNTA) reference material