New Delhi: India has a “long way to go” to achieve its target of public health spending, its primary health infrastructure is inadequate, and the country faces a dearth of data to track its progress to achieve the Sustainable Development Goals (SDGs) for health by 2030, the Comptroller and Auditor General (CAG) of India, the government’s auditor, has said.

These gaps “represent risks for the achievement of the key objectives of the 2030 Agenda”, the CAG said in a July 8, 2019, report.

While the health ministry proposed to increase India’s public health expenditure to 2.5% of its gross domestic product (GDP) by 2025, “it has remained within a narrow band of 1.02-1.28% of GDP”, the report said.

For this report, the CAG audited the NITI Aayog, the health ministry, the ministry of statistics and programme implementation, and 14 other ministries for preparedness to achieve SDGs. To analyse states’ performance, seven states--Assam, Chhatitsgarh, Haryana, Kerala, Maharashtra, Uttar Pradesh (UP) and West Bengal--were chosen based on their ranking on various health indices for 2015-16.

The NITI Aayog’s three-year action agenda (2017-2020) envisaged a rise in the Centre’s health budget to Rs 1 lakh crore ($14.5 billion) by 2019-20. But, the allocations have fallen short: India allocated Rs 53,294 crore ($7.7 billion) in 2017-18, Rs 56,045 crore ($8.1 billion) in 2018-19 and Rs 65,038 crore ($9.4 billion) in 2019-20, the report noted.

India’s National Health Policy 2017, framed in line with the SDGs, prescribes increasing the health expenditure of states to more than 8% of their annual budgets by the year 2020, but the seven states evaluated spent between 3.29% and 5.32% for the period of 2012-2017, according to the report.

The National Health Mission--which provides for universal access to equitable, affordable and quality health care services--was conceived as the primary tool to reach health targets: maternal mortality ratio (MMR) of less than 70 deaths per 100,000 live births, neonatal mortality rate (NMR) of 12 deaths per 1,000 live births and under-five mortality rate (U5MR) of 25 deaths per 1,000 live births.

In 2017, India’s MMR was 130 deaths per 100,000 live births, according to Census data, while its NMR was 24 deaths per 1,000 live births and U5MR was 39 deaths per 1,000 live births, as IndiaSpend reported on September 20, 2018.

Yet, allocations to the National Health Mission fell short by 13.6% in 2018-19 compared to the budget projections, according to the CAG’s report.

Source: Report of the Parliamentary Standing Committee, cited in the Comptroller & Auditor General’s report

The standing committee of parliament on health, while examining the allocations, had observed that these shortfalls would affect the strengthening of health facilities.

India’s neonatal mortality rate (24 deaths per 1,000 live births) is higher than the global average (18). Sri Lanka (8), Bangladesh (18) and Nepal (21) are better off despite having lower per capita incomes, as IndiaSpend reported on September 20, 2018.

In 2015, India spend 1% of its GDP on public health, second-lowest in the south east Asia region, according to data cited in the National Health Profile 2018. That same year, Maldives spent 9.4%, Sri Lanka 1.6%, Bhutan 2.5% and Thailand 2.9%.

State spending on health yet to increase

To reach the 2025 target of spending 2.5% of GDP on health, the National Health Policy mandated states to increase their health spending on primary care by at least 10% every year. In addition, a 4% health and education cess was also proposed which was not implemented.

The Policy, as we said, also prescribes increasing states’ health spending to more than 8% of their annual budgets by the year 2020. Yet, none of the seven states studied for this report by the CAG spent that amount by 2017.

Further, 29% of NHM funds with states were not spent over five years to 2016, as IndiaSpend reported on August 20, 2018.

Health shortages affect progress

Rural India has a shortfall of between 24% and 38% in the number of sub-centres, primary health centres (PHC) and community health centres in 28 states and union territories, data from the CAG’s 2017 audit report on reproductive and child health under the National Rural Health Mission, which seeks to strengthen the delivery of public health services in rural India, showed.

Each PHC with a load of more than 20 deliveries per month needs at least two medical officers, according to Indian Public Health Standards set in 2006. Chhattisgarh has a total of 341 doctors in PHCs, which makes for 0.43 doctor per PHC, lower than required, according to the data cited in the CAG’s report. There were “considerable” human resource shortages in Chhattisgarh and UP, the report said.

UP is one of the worst-performing states in infant and under-five mortality rankings, as IndiaSpend reported on March 16, 2017. While UP has a 30% shortage of PHCs, West Bengal has a shortage of 69%.

With a rural population of 62 million, West Bengal has one PHC for every 68,000 people--less than half the prescribed number of one PHC per 30,000 people.

Health Resources In Select Indian States, 2016-17
State Primary Health Centres Required Primary Health Centres Functioning Shortfall In Primary Health Centres Doctors in Primary Health Centres Average Doctors Per Primary Health Centre
Assam 1112 1014 98 1048 1.03
Chhattisgarh 870 785 85 341 0.43
Haryana 501 366 135 429 1.17
Kerala 1141 849 292 1169 1.38
Maharashtra 2461 1814 647 2929 1.62
Uttar Pradesh 5183 3621 1562 2209 0.61
West Bengal 3046 914 2132 918 1

Source: Report of CAG (No. 25 of 2017)

The population-doctor ratio in India was 11,082:1 in 2017 in government hospitals, 25 times higher than the World Health Organization recommendation of 25 professionals per 10,000 population, as IndiaSpend reported on January 28, 2019.

Dearth of data

The NITI Aayog, the government’s policy think tank and the body responsible for overseeing implementation of SDGs, and the statistics ministry in consultation with the state governments, were to prepare the National Indicator Framework, the backbone for monitoring of SDGs.

However, data for 137 of 306 national indicators were not available for 13 SDG goals, the CAG’s report said.

The framework includes 50 indicators related to health, but data for 23 of these--such as screening for cervical cancer among women and incidence of viral hepatitis--were not available, according to the report.

At both the Centre and the state levels, there was “evidence of insufficient efforts at putting in place a comprehensive indicator framework, identification of data sources, production of disaggregated data” for Goal 3 (good health and well-being), the report said.

“Better measurement, greater evidence and more informed reporting are expanding voter awareness and deepening policy debates,” as IndiaSpend reported on May 15, 2019. “This makes it imperative for central and state governments to improve the quality of public health data.”

(Ali is a reporter with IndiaSpend.)

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Sana Ali