HEALTHCARE IN INDIA

Healthcare in India: Nine poorest states' budgets lie unspent, 581 million
affected by inadequate infrastructure

By Ojaswi Rao
Nine of Indias poorest states home to 581 million or 48 percent of Indias population
account for 70 percent of the countrys infant deaths, 75 percent of under-five deaths
and 62 percent of maternal deaths, but do not spend even the money they have set aside
for healthcare, according to an IndiaSpend analysis of 2017 Reserve Bank of
India data on state budgets.

Representational image. Reuters

The data also reveal:

a. The maternal mortality ratio deaths of mothers per 100,000 births in these
states is 32 percent higher (244) than the national average (167).
b. 38 percent and 40 percent children in these states are underweight (low weight-for-
age) and stunted (low height-for-age), respectively, higher than the national average of
36 percent and 38 percent, respectively, according to 2015-16 national health data, the
latest available.
c. Uttar Pradesh, Bihar, Madhya Pradesh and Rajasthan with 372 million people,
more than the combined populations of US, Australia, Sweden and Greece together
contribute to about 58 percent of all child deaths in India.
The nine poorest large states in official jargon called high-focus, a term that implies
they need special attention spent an average of 4.7 percent of their social-sector
expenditure on public healthcare and family welfare annually, marginally less than the
national average of 4.8 percent. Social-sector expenditure includes water supply and
sanitation, housing and urban development.

NOTE: * Actual Figures; ** Maternal mortality ratio in these states (Andhra

Pradesh, Himachal Pradesh, Jammu and Kashmir, Manipur, Meghalaya, Mizoram,
Nagaland, Sikkim, Telangana and Tripura) is 126 deaths per 100,000 births as per the
Sample Registration System (SRS) Report published in 2011-13
Indias average spending on health, as a proportion of gross domestic product, is already
the lowest among BRICS nations, as IndiaSpend reported on 8 May, 2017.
The high-focus states are Bihar, Chhattisgarh, Jharkhand, Madhya Pradesh, Odisha,
Rajasthan, Uttarakhand, Uttar Pradesh and Assam.

In 2005, it was observed by (the) government of India that some states were
performing poorly in various indicators, Avani Kapur, senior researcher, Accountability
Initiative, an advocacy, told IndiaSpend. So, these states were clubbed together as
high-focus states and additional resources were given to improve those indicators.
Poorest states spent less money than their budgets allowed
Of the nine poorest states, Rajasthan spent the highest (5.6 percent) and Bihar the
lowest (3.8 percent) proportion of aggregate expenditure on public healthcare and
family welfare, according to the RBI data on 2014-15 actual spending, lower than the
budgeted 4.1 percent for Bihar and 6.6 percent for Rajasthan.
Seven of the nine high-focus states report such underspending.

High focus states allocate large amounts to social sector to improve their indicators but
in reality they spend only a small amount, compared to what is allotted, Kapur said.
Hence, it is necessary to consider actual accounts in order to know the proper
outcomes.

So, while some high-focus states spent less money than set aside by their budgets,
other states outspent by proportion as ratio to aggregate expenditure other larger
states on healthcare and family welfare, but that had no relation to their healthcare
indicators.

For instance, Rajasthan (68.6 million people) reported an MMR of 244 deaths per
100,000 births in 2011-13, the second lowest in India and worse off than Bangladesh
and Nepal, both poorer countries, by per capita income. In contrast, Andhra Pradesh
(84.6 million people), another big state, spent 4.1 percent of total expenditure on public
healthcare and family welfare but reported an MMR of 92, according to
government data.
Since 2008, Rajasthan increased its spending by 0.8 percent and its MMR decreased 23
percent while Andhra Pradeshs spending increased by 0.5 percent and MMR decreased
31 percent.

Assam, which spends 4.2 percent of its total expenditure on health and has 31.2 million
people, has an MMR of 300 deaths per 100,000 births comparable to Zambia and
Thailand while Kerala, which spends 5.3 percent on 33.4 million, reported an MMR of
61, comparable to Sri Lanka and Poland.

Madhya Pradesh, which reported an infant mortality rate (IMR) deaths per 1,000 live
births of 51 in 2015-16, spends 4.3 percent of total expenditure on healthcare
against 5 percent that was budgeted and, as IndiaSpend reported on January 21,
2016, is worse off than some of the worlds poorest countries, such as the Gambia and
Ethiopia.
Spending more on healthcare did not improve institutional births
In the nine high-focus states we studied, 72.6 percent of all births were in healthcare
institutions, a steady improvement but below the national average of 78.9 percent,
according to the 2015-16 National Family Health Survey (NFHS-4) data, the latest
available.

Tamil Nadu with 72.1 million people spends 4.7 percent of its total budgeted
expenditure on public healthcare and family welfare and reports 99 percent institutional
births, while Jharkhand, with 33 million, spends 4 percent and reports 61.9 percent
institutional births.

Uttar Pradesh (78), Madhya Pradesh (65), Chhattisgarh (64), Bihar (58) and Assam (56)
report Indias highest under-five mortality ratesdeaths per 1,000 live births
IndiaSpend reported on 20 March, 2017.
Odisha reported an 118 percent increase in institutional births over 10 years, but the
IMR declined by no more than 63 percent over this period.

The poor health indicators can be attributed to the lack of healthcare infrastructure and
human resources in these states.

Not enough doctors and healthcare institutions

Bihar is 81 percent short of community health centres (CHCs), which provide secondary
healthcare in the form of referrals and specialists to rural areas, and Jharkhand is 66
percent short of primary healthcare centres (PHCs), the first point of access to a
qualified public-sector doctor in rural areas, according to the RBI report.
There is a 13 percent shortfall of CHCs in the high-focus states, according to
Indias Health Management Information System.
Bihar was 93 percent short of specialists in CHCs, while the comparable figures were 90
percent, 84 percent and 84 percent in Chhattisgarh, Uttar Pradesh and Jharkhand,
respectively, in March 2016, according to Accountability Initiative budget brief on
National Health Mission.

The infrastructure shortage is made worse by the fact that in all the nine states,
healthcare programmes are accessed by richer households while many poor households
are excluded due to high direct and indirect costs, according to this 2012 study in PLOS-
ONE, an online open-access scientific journal.
Such infrastructure shortages exacerbate inadequate spending and deliver low heath
achievements. Increased primary healthcare spending reduces child and infant
mortality rates, according to this 1999 research paper by the International Monetary
Fund.
Promoting community-based education on improved maternal and newborn care, and
home-based treatment for newborn infections could enhance child survival in the high-
focus states significantly, said the 2012 PLOS-ONE study.
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