Encephalitis deaths: Sadly, this has been happening every year either in Bihar or Uttar Pradesh. After expressing shock and sympathy, everything is back in business until the issue stirs up again the next year.
The chilling details of the death of almost 170 children due to Acute Encephalitis Syndrome in Muzaffarpur in Bihar should stir the conscience of every human being. Sadly, this has been happening every year either in Bihar or Uttar Pradesh. After expressing shock and sympathy, everything is back in business until the issue stirs up again the next year. While we keep talking about the demographic dividends, unfortunate children are left to die without care. We come up with slogans and programmes like “Ayushman Bharat”, but for these scores of children, there is no ayush (lifespan). The governments have simply failed these children and, it seems, the governments don’t have any accountability.
The Indian Constitution assigns the responsibility of providing healthcare to the states. The states, even after they receive transfers recommended by the Finance Commission, do not find adequate resources, nor do they care to assign the required priority, to ensure that people have access to basic healthcare. The per capita expenditure on medical and public health, family welfare, and water supply and sanitation incurred by Bihar in 2016-17 was a paltry Rs 671 and in Uttar Pradesh, it was Rs 863. In Haryana, Kerala and Telangana, it was more than three times the amount spent in Bihar. It is also seen that states with higher per capita incomes have significantly higher per capita expenditures (see graphic). This shows that despite the transfers from the central government, low-income states could not, and did not, spare adequate resources to ensure basic health services.
The Indian Public Health Standards, brought out by the Ministry of Health and Family Welfare, specifies that there should be a sub-centre for every 5,000 people (3,000 people in hilly, desert and tribal areas), a Public Health Centre (PHC) for every 20,000 people and a Community Health Centre for a group of 4 PHCs. It also specifies the standards in terms of the number of health workers, equipment and medicines in each category. The sub-centre is the first contact between the public healthcare system and the community, and should be staffed with a female nurse (midwife) and a male multi-purpose worker, besides a male and a female assistant. However, much of what is specified is simply aspirational and does not exist on the ground. In fact, the healthcare systems in the states like Bihar and Uttar Pradesh simply do not have the requisite number of sub-centres and health centres. Nor are they equipped with the required personnel, equipment and medicines. For example, in Muzaffarpur district, which has 1719 villages, there are only 630 health centres! Not one of the 103 PHCs has a NITI Aayog rating higher than zero. Almost 80% of the children do not have access to basic healthcare facilities. Do we care?
Who is responsible for this unfortunate situation? Surely, the state government cannot escape the blame, as it is in its domain. At the same time, given that health is an important “merit good” and primary healthcare has very high degree of externalities, questions on the role of the union government are equally important. Although the unconditional transfers recommended by the Finance Commission go to finance a variety of activities, when there is a specific-purpose grant in the name of the National Health Mission (NHM), the states try to minimise allocation from the general pool to finance other sectors. Besides, many low-income states find the resources inadequate, even after the Finance Commission transfers. Therefore, the role of specific-purpose transfers is critical. The objective of such specific-purpose transfers is to ensure a minimum standard of service across all states and, therefore, the design of the NHM comes under scrutiny.
The NHM document states that the NHM is meant to provide “accessible, affordable, accountable, effective and qualitative” healthcare in all states. The stated objective of the programme is to provide assistance to states to ensure universal access to equitable, affordable and quality healthcare services with certain core values:(i) safeguard the health of the poor, vulnerable and disadvantaged persons; (ii) strengthen public health systems as a basis for universal access and social protection against rising costs; (iii) build an environment of trust between the people and health service providers; (iv) empower communities to become active participants in attaining the highest possible levels of health; and (v) improve efficiency and optimise the use of resources.
Although these objectives are laudable, the design does not ensure funds flow simply to establish facilities as per the specified norms. Instead, the programme has taken multiple functions, such as reproductive and child health, control of communicable and non-communicable diseases, augmenting infrastructure, human resources programme management and patient transport, control of blindness, mental health, tobacco control, healthcare of elderly and infrastructure maintenance. Not surprisingly, there is no clarity on achievable goals and the funds are transferred under 2,000 budget heads. While this has served the bureaucracy well, it has failed to ensure primary healthcare in low-income states.
For allocating funds to individual states, the Union Ministry of Health and Family Welfare works out resource envelops determined on the basis of area and population, weighted by the socio-economic backwardness and health lag in the states. The weight assigned for the large Empowered Action Group states (Madhya Pradesh, Bihar, Rajasthan and Odisha) is 1.3, the states of Jharkhand and Chhattisgarh are given a weight of 1.5; the eight north-eastern states, including Sikkim, are assigned a weight of 3.2; the small Union Territories, excluding Delhi and Puducherry, are assigned a weight of 3; and the remaining states are given the weight of 1. 10% of the funds is given to the state that demonstrates its capacity to efficiently absorb it. The allocation for NUHM is done based on urban population and slum population by giving 50% weightage to each of the two factors.
If ensuring minimum standards of the service was the objective, the transfers should have been targeted to offset the shortfall in infrastructure from the specified standards. Not surprisingly, the design of NHM transfers is not targeted to overcome this deficiency. There is also considerable difference between the original allocation and the final disbursement, and the difference is much higher for low-income states. Low-income states find it difficult to make the required matching contribution, which was increased to 40% from the 25% prior to the reorganisation of Centrally Sponsored Schemes in 2015. This is the time to rationalise the NHM to focus on ensuring basic primary health care facilities, rather than taking up several interventions and spreading resources thinly.
The author is a Counsellor, Takshahila Institution and Chief economic adviser, Brickwork Ratings (Views are personal)