The National Health Accounts data for 2013-14 present fresh evidence that India continues to have a non-serious approach to the provision of universal health coverage to all its citizens.
India’s health system is one of the most privatised in the world, poorly regulated and accessible only to those with income levels well above the average.
All these attributes are, once again, strongly borne out by the NHA data, which lay bare the extremely low government spending on health which, at 1.15 per cent of GDP, compares poorly with even Sub-Saharan Africa.
The share of State governments, which are largely responsible for provision of health care, in government health expenditure is estimated at 0.75 per cent of GDP.
Evidently, a health policy that fails to pool the financial risk of illness at the population level results in impoverishing payments made out of personal funds — and the NHA figures confirm that despite rising government revenues, the bulk of Indian health spending, a staggering 64.2 per cent of health expenditure, is met by households out-of-pocket.
That such OOP expenses declined by five percentage points over a decade is encouraging, but this is insignificant in comparison with the achievement in, say, Thailand, where 75 per cent of the population was brought under UHC in just one year.
Details :-
n 2013-14, the Total Healthcare Expenditure (THE) of India was Rs. 4.5 lakh crores, which amounts to 4 per cent of the Gross Domestic Product (GDP).
The Draft National Health Policy 2015 recognises this to be a problem. It says: “Global evidence on health spending shows that unless a country spends at least 5-6 per cent of its GDP on health and the major part of it is from government expenditure, basic health care needs are seldom met.”
Of the total amount of Rs. 4.5 lakh crores, Current Health Expenditure (CHE) constituted Rs. 4.2 lakh crores (93 per cent). Rs. 31.9 thousand crore (7 per cent) went to Capital Expenditure.
Key Findings:-
- Households continue to be the dominant contributors (73 per cent of CHE) to health finance in India. The bulk of the total money circulating in Indian healthcare – around 69 per cent – comes from Out Of Pocket (OOP) payment by households. OOP is the money which individuals pay out of their own.
- High OOP spending is a result of abysmally low government spending on health, constituting just 1.15 per cent of GDP and 30 per cent of CHE – the lowest among the BRICS nations.
- It has long been argued that government spending on health should increase to 2.5 per cent of GDP, a figure also envisaged by the Draft National Health Policy 2015.
- Around 45 per cent is spent on outpatient care (including both general and special treatment) as compared to 35 per cent in inpatient care.
- Overall, the current expenditure on curative care is estimated at Rs 3.4 lakh crores (80.4 per cent) whereas. In contrast, a meagre 9.6 per cent – is spent on preventive care.
- All the government-funded national health programmes such as the National Disease Control Programmes are covered under this category. However, it does not include spending on sanitation or providing access to clean drinking water.
Raising government expenditure on health, in conjunction with the States, should form the basis of policy change; the road map for this was proposed by the Planning Commission’s High Level Expert Group in 2011.
Remedial policies in two key areas can quickly scale up to reduce the OOP burden on households.
- One is to put in place a centralised system for procurement of essential drugs, relying mainly on quality generics and distributing them through the State government system.
- The other is to arrive at the cost of all medical procedures for different classes of hospitals, laying down standards and forming regulatory authorities at the State and district levels under law to enforce the rules.
It was estimated by the Planning Commission group, for instance, that spending 0.5 per cent of GDP (compared to 0.1 per cent spent by the public health system) could ensure the availability of essential medicines free of cost to all Indians.
Regulatory controls would automatically lead to a reduction in costs, and curbing of unethical and corrupt practices by hospitals and diagnostics centres.
It should then be easier to quickly extend free health insurance to more classes of people, such as senior citizens, children and the disabled, and achieve universal coverage early.
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- In the Large States category (overall), Chhattisgarh ranks 1st, followed by Odisha and Telangana, whereas, towards the bottom are Maharashtra at 16th, Assam at 17th and Gujarat at 18th. Gujarat is one State that has seen startling performance ranking 5th in the PAI 2021 Index outperforming traditionally good performing States like Andhra Pradesh and Karnataka, but ranks last in terms of Delta
- In the Small States category (overall), Nagaland tops, followed by Mizoram and Tripura. Towards the tail end of the overall Delta ranking is Uttarakhand (9th), Arunachal Pradesh (10th) and Meghalaya (11th). Nagaland despite being a poor performer in the PAI 2021 Index has come out to be the top performer in Delta, similarly, Mizoram’s performance in Delta is also reflected in it’s ranking in the PAI 2021 Index
- In terms of Equity, in the Large States category, Chhattisgarh has the best Delta rate on Equity indicators, this is also reflected in the performance of Chhattisgarh in the Equity Pillar where it ranks 4th. Following Chhattisgarh is Odisha ranking 2nd in Delta-Equity ranking, but ranks 17th in the Equity Pillar of PAI 2021. Telangana ranks 3rd in Delta-Equity ranking even though it is not a top performer in this Pillar in the overall PAI 2021 Index. Jharkhand (16th), Uttar Pradesh (17th) and Assam (18th) rank at the bottom with Uttar Pradesh’s performance in line with the PAI 2021 Index
- Odisha and Nagaland have shown the best year-on-year improvement under 12 Key Development indicators.
- In the 60:40 division States, the top three performers are Kerala, Goa and Tamil Nadu and, the bottom three performers are Uttar Pradesh, Jharkhand and Bihar.
- In the 90:10 division States, the top three performers were Himachal Pradesh, Sikkim and Mizoram; and, the bottom three performers are Manipur, Assam and Meghalaya.
- Among the 60:40 division States, Orissa, Chhattisgarh and Madhya Pradesh are the top three performers and Tamil Nadu, Telangana and Delhi appear as the bottom three performers.
- Among the 90:10 division States, the top three performers are Manipur, Arunachal Pradesh and Nagaland; and, the bottom three performers are Jammu and Kashmir, Uttarakhand and Himachal Pradesh
- Among the 60:40 division States, Goa, West Bengal and Delhi appear as the top three performers and Andhra Pradesh, Telangana and Bihar appear as the bottom three performers.
- Among the 90:10 division States, Mizoram, Himachal Pradesh and Tripura were the top three performers and Jammu & Kashmir, Nagaland and Arunachal Pradesh were the bottom three performers
- West Bengal, Bihar and Tamil Nadu were the top three States amongst the 60:40 division States; while Haryana, Punjab and Rajasthan appeared as the bottom three performers
- In the case of 90:10 division States, Mizoram, Assam and Tripura were the top three performers and Nagaland, Jammu & Kashmir and Uttarakhand featured as the bottom three
- Among the 60:40 division States, the top three performers are Kerala, Andhra Pradesh and Orissa and the bottom three performers are Madhya Pradesh, Jharkhand and Goa
- In the 90:10 division States, the top three performers are Mizoram, Sikkim and Nagaland and the bottom three performers are Manipur and Assam
In a diverse country like India, where each State is socially, culturally, economically, and politically distinct, measuring Governance becomes increasingly tricky. The Public Affairs Index (PAI 2021) is a scientifically rigorous, data-based framework that measures the quality of governance at the Sub-national level and ranks the States and Union Territories (UTs) of India on a Composite Index (CI).
States are classified into two categories – Large and Small – using population as the criteria.
In PAI 2021, PAC defined three significant pillars that embody Governance – Growth, Equity, and Sustainability. Each of the three Pillars is circumscribed by five governance praxis Themes.
The themes include – Voice and Accountability, Government Effectiveness, Rule of Law, Regulatory Quality and Control of Corruption.
At the bottom of the pyramid, 43 component indicators are mapped to 14 Sustainable Development Goals (SDGs) that are relevant to the States and UTs.
This forms the foundation of the conceptual framework of PAI 2021. The choice of the 43 indicators that go into the calculation of the CI were dictated by the objective of uncovering the complexity and multidimensional character of development governance
The Equity Principle
The Equity Pillar of the PAI 2021 Index analyses the inclusiveness impact at the Sub-national level in the country; inclusiveness in terms of the welfare of a society that depends primarily on establishing that all people feel that they have a say in the governance and are not excluded from the mainstream policy framework.
This requires all individuals and communities, but particularly the most vulnerable, to have an opportunity to improve or maintain their wellbeing. This chapter of PAI 2021 reflects the performance of States and UTs during the pandemic and questions the governance infrastructure in the country, analysing the effectiveness of schemes and the general livelihood of the people in terms of Equity.
Growth and its Discontents
Growth in its multidimensional form encompasses the essence of access to and the availability and optimal utilisation of resources. By resources, PAI 2021 refer to human resources, infrastructure and the budgetary allocations. Capacity building of an economy cannot take place if all the key players of growth do not drive development. The multiplier effects of better health care, improved educational outcomes, increased capital accumulation and lower unemployment levels contribute magnificently in the growth and development of the States.
The Pursuit Of Sustainability
The Sustainability Pillar analyses the access to and usage of resources that has an impact on environment, economy and humankind. The Pillar subsumes two themes and uses seven indicators to measure the effectiveness of government efforts with regards to Sustainability.
The Curious Case Of The Delta
The Delta Analysis presents the results on the State performance on year-on-year improvement. The rankings are measured as the Delta value over the last five to 10 years of data available for 12 Key Development Indicators (KDI). In PAI 2021, 12 indicators across the three Pillars of Equity (five indicators), Growth (five indicators) and Sustainability (two indicators). These KDIs are the outcome indicators crucial to assess Human Development. The Performance in the Delta Analysis is then compared to the Overall PAI 2021 Index.
Key Findings:-
In the Scheme of Things
The Scheme Analysis adds an additional dimension to ranking of the States on their governance. It attempts to complement the Governance Model by trying to understand the developmental activities undertaken by State Governments in the form of schemes. It also tries to understand whether better performance of States in schemes reflect in better governance.
The Centrally Sponsored schemes that were analysed are National Health Mission (NHM), Umbrella Integrated Child Development Services scheme (ICDS), Mahatma Gandh National Rural Employment Guarantee Scheme (MGNREGS), Samagra Shiksha Abhiyan (SmSA) and MidDay Meal Scheme (MDMS).
National Health Mission (NHM)
INTEGRATED CHILD DEVELOPMENT SERVICES (ICDS)
MID- DAY MEAL SCHEME (MDMS)
SAMAGRA SHIKSHA ABHIYAN (SMSA)
MAHATMA GANDHI NATIONAL RURAL EMPLOYMENT GUARANTEE SCHEME (MGNREGS)