Mumbai: Over the last two years, states and union territories have utilised no more than 7% of the funds released to them for the National Programme for the Healthcare of the Elderly (NPHCE), the government told parliament in this December 29, 2017, response to a question.

On average, only 5% of the Rs 1,414 crore released for NPHCE under the non-communicable diseases (NCD) flexible pool during 2015-16 and 2017-18 has been utilised. The NCD flexible pool is one of the six major financing components of the National Health Mission (NHM), the country’s largest public health programme. The flexible pool provides freedom to state governments to use funds for varying purposes and not restrict them to specific uses.

India’s elderly population increased by 26.8 million in the decade ending 2011, as IndiaSpend reported on October 7, 2017. At present, one in 10 Indians is aged above 60 years, but by 2050 a fifth (19%, nearly one in five) of all Indians will be aged 60 years or more.

“Health is a State subject and it is the basic responsibility of the State Government to ensure optimal utilization of funds, while implementing the scheme in the districts. It is also submitted that NPHCE is now a part of National Health Mission under its NCD Flexible Pool. NPHCE is also being monitored by the National Health Mission Division of the Ministry,” the government stated, citing this 2015 action-taken report of the department-related parliamentary standing committee of the Rajya Sabha (upper house of Parliament) on health and family welfare. “The Committee finds that the Department has been too slow in ensuring optimum utilization of funds which would adversely affect the actual implementation of the activities not to mention the cost overruns,” the report said.

In the following year, the committee made a similar observation on underutilisation of funds and urged the department to act. “The Committee feels that factual statements should be borne by results in form of healthy utilisation of funds allocated and recommends that the operational flexibility does not mean abnegation of responsibility. The Committee, therefore, exhorts the Department to ensure strict monitoring for optimum utilisation of allocated funds,” the 2016 report stated. It recommended that “'strict instructions' instead of just 'reminders' should be issued to States to ensure proper utilization of funds.”

In a similar report presented in the Rajya Sabha on December 18, 2013, the committee had noted a lack of planning and improperly defined targets.

“Most state governments, overwhelmed with existing health care [responsibilities], do not have the appetite for a new programme,” Dr A.B. Dey, professor and head of geriatric medicine at the All India Institute of Medical Sciences (AIIMS) in New Delhi, told IndiaSpend. “Apathy of state governments, bureaucratic attitude of ministry officials, poor selection of implementing centres, unwillingness to accept technical advice from experts are some of the reasons for the failure of the programme.”

A national programme

The NPHCE was launched in 2010-11 to provide separate, specialized and comprehensive healthcare to senior citizens (aged 60 years and above) at various levels of the state healthcare system.

The programme aims to set up geriatric departments in identified regional geriatric centres (RGCs), 10-bedded geriatric units at district hospitals, rehabilitation units at all community health centres, and weekly geriatric clinics by trained medical officers at primary health centres.

In 2015-16, NPHCE was moved under the NCD flexible pool.

During the 12th Five Year Plan (2012-17), Rs 1,710.13 crore was approved for NPHCE. Two-thirds (67%) of this, Rs 1,147.56 crore, was earmarked for activities up to district level and Rs 562.57 crore for tertiary-level activities such as advanced consultative care and diagnosis.

States fail to spend funds

Uttar Pradesh has the largest population of the elderly (15 million) in India. But from 2015-16 to 2017-18, the most the state government spent was 13% of the released amount, in the year 2016-17. Since 2015, it has spent Rs 18 crore (8%) out of the Rs 220 crore released.

The state spent the amount allocated only once between 2012-13 and 2014-15--Rs 1.8 crore in 2013-14--according to this December 4, 2015, government response in the Lok Sabha (lower house of parliament).

Similarly, Tamil Nadu has only once recorded any expenditure since 2012-13--it spent Rs 1.26 crore from a release of Rs 21.45 crore in 2016-17.

The project director of the Tamil Nadu Health Systems Project had requested the state government to authorise the project’s non-communicable disease cell to implement the geriatric healthcare programme and waited until 2013 for approval. Such approval was unnecessary, according to a report by the government’s auditor, the Comptroller and Auditor General, Scroll.in reported on September 5, 2017.

Kerala, which is planning to start a budget analysis for the elderly from next year, has only spent 14% of a total released amount of Rs 24.16 crore between 2015 and 2017 (as of December 2017). At 13%, Kerala has the highest proportion of senior citizens among all Indian states, IndiaSpend reported on October 7, 2017.

No clear answers

The resultant facilities are sub-standard or non-existent, Anupama Datta, director of policy research and development at the non-profit HelpAge India, told IndiaSpend. “In rural areas, where most of the elderly population in India reside, there are no facilities,” she said, adding, “The state governments are often not keen on spending on programmes like the NPHCE as they find additional funds needed for qualified staff, training, salary, etc. unavailable. Once they embark on the programme they must source funds to cover the requirements.”

However, NPHCE is now under the flexible pool, and states are still not spending the funds. IndiaSpend reached out to the joint secretary and two directors at the health ministry, and the principal secretary of the health department as well as the director of NHM in Tamil Nadu to understand why funds lie unused. Only one officer at the health ministry agreed to talk, while preferring to remain anonymous; other officials did not respond despite repeated attempts.

Although central funding for salaries and administrative expenses are for a finite period, the centre front-loads these expenses to facilities state governments, Sujaya Krishnan, formerly a joint secretary at the central health ministry, told IndiaSpend. However, states still remain wary, or uninterested, she said.

A health ministry officer, who did not wish to have their identity revealed, said shortage of trained medical staff for geriatric care at the state level, and delays in release of funds from state treasuries to district administrations, lead to underutilisation of funds.

“Despite the flexibility provided at the state level by NHM,” said Sakhtivel Selvaraj, Director Health (Economics and Financing) at Public Health Foundation of India (PHFI), “it is often observed that the lower level of the bureaucracy expect a norm or a guideline to be set for fund utilization. It adds to delays.”

Also, in some years, central and state treasuries direct that expenditure be cut back, especially during periods when they want to trim fiscal deficits, Selvaraj said.

Lack of training

Since the NPHCE is a clinical care programme, training of healthcare professionals is vital. “Only a handful of medical colleges have done anything visible,” Dey of AIIMS said, explaining that the Medical Council of India does not easily allow starting of new postgraduate programmes such as to train doctors in geriatric care. He said only AIIMS started a new MD (Medicinae Doctor) programme in Geriatric Medicine, and one medical college in Chennai had one already.

“The programme has no direction,” Dey said, adding that most healthcare professionals have no training in geriatric care, no specialised training programme has been created, and there is little IEC (information, education and communication) material to create awareness. “The programme needs technical support, and leadership from bureaucrats,” he said.

The government is supporting the development of two specialised national centres for ageing (NCAs) at AIIMS and Madras Medical College, Chennai. NCAs would provide healthcare services, train professionals, and conduct research, all focused on the elderly.

Additionally, there are 18 regional geriatric centres (RGCs) across India. These provide outpatient departments for the elderly and post-graduate courses in geriatrics.

As of December 29, 2017, Rs 40 crore had been utilised from a total release of Rs 175 crore for RGCs and NCAs between 2015-16 and 2017-18--23% of the total amount released.

“Social attitudes toward the elderly need to change to observe better results,” said Datta of HelpAge.

The government should focus on establishing more RGCs and NCAs across the country, particularly in rural and backward regions, recommended the 23rd report of the Committee on Estimates on Medical Education and Health Care in the Country presented in Lok Sabha on December 21, 2017. There should be greater emphasis on geriatric medicine courses at undergraduate and postgraduate levels as well as in paramedical courses, it said.

As per data in the Lok Sabha response, in 2013-14, the states spent Rs 24 crore from a central release of Rs 1 crore, and close to 96% of the funds the year after.

(Paliath is an analyst with IndiaSpend)

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Shreehari Paliath

    Shreehari has reported on public policy around labour and employment, agriculture, water, and elections. He received a special mention at the 2019 Red Ink Awards. He has a post-graduate diploma from the Asian College of Journalism, Chennai, and a master's degree in development from Azim Premji University.