Lack of medical/para-medical personnel, chronic failure by states to spend funds make public health diseased.
At a time when the Union government is gearing up to roll out its ambitious National Health Protection Mission, Ayushman Bharat, that includes health insurance cover for 10 crore households in the country and health and wellness centres, an IndiaSpend analysis of data from a 2017 CAG report foregrounds some sobering realities of public health in India. The performance audit of the Reproductive and Child Health component of the National Rural Health Mission (NRHM) that surveyed 1,443 health sub-centres (SCs), 514 primary health centres (PHCs), 300 community health centres (CHCs) and 134 district hospitals found that over three-quarters to nearly 90% of of the surveyed CHCs in 27 states didn’t have specialist doctors such as general surgeons, paediatricians and gynaecologists. In 236 CHCs across 24 states/UTs, only 1,303 nurses were posted against a requirement of 2,360. In 13 states, including Madhya Pradesh, Rajasthan and Uttar Pradesh, 67 PHCs of 305 surveyed were without a doctor.
In terms of public health infrastructure in rural areas, the CAG report highlights a worrisome deficiency—there was a 24% shortfall from the required number for SCs, 28% for PHCs and 38% for CHCs in the 28 states/UTs. This shortfall was more than 50% in five states, including Bihar, Jharkhand and Bengal. In 17 states, medical equipment—from incinerators to cardiac monitors—was lying unused because of lack of trained manpower and, tellingly, of space to set these up. In 24 states, there were instances of non-availability of essential medicines, and in 14, there were cases of medicines being handed out without ensuring basic quality control such as checking for expiry. Nearly a third of the surveyed PHCs in 22 states didn’t have the basic delivery kit, while 63% of the CHCs in 26 states and a quarter of the district hospitals in 12 states were without ECG facilities. Eighty-three percent of Accredited Social Health Associates (ASHAs)—the foot soldiers of the government’s efforts to curb maternal and neonatal mortality—didn’t have a disposable delivery kit, while 22% didn’t have iron supplements.
The commentary on the state of India’s public health focuses—and rightly so—on the public spending on this being barely 1% of its GDP, compared to, say, a Singapore that spends 2.2%, the lowest among countries that have universal health coverage. The CAG report draws attention to chronic underspending of the central funds earmarked for the NRHM by states, which exacerbates the poor allocation. The CAG found that the amount lying unspent with the 27 states increased from Rs 7,375 crore to `9,509 crore between FY12 and FY16. Eight states had spent less than 60% of the funds they had received in FY16, with Uttar Pradesh having spent just 48% and Meghalaya, just 24%. A host of factors contributed to this situation. To start with, state treasuries delayed transfers to health societies; transfers that should have taken 15 days took anywhere between 50 to 271 days. Beyond the uncertainty over the timing of receipt of funds and the actual quantum, a chronic lack of human resources in the administrative network, complicated compliance requirements for spending on activities like construction, etc, have led to such an abysmal performance. The Centre, for its part, has failed to discipline states that delayed the devolution of funds—state governments that fail to pass on the funds are supposed to pay interest at the bank deposit rate. The Centre, and more importantly, the states, must recognise that the priority is working on a cure for the ailing National Health Mission. How, indeed, will health coverage take off if public health itself is on shaky grounds?