With the state’s public health spend declining from one per cent of GSDP in 1985-86 to just 0.49 per cent in 2017-18, will Arogya Maharashtra become a reality?
Despite Maharashtra being one of the affluent states in the country with the highest Gross State Domestic Product (GSDP), contributing 14.42 per cent of India’s GDP and ranking highest in industrialisation, year-over-year the state’s expenditure on public health has dipped as a proportion of the GSDP, declining from one per cent in 1985-86 to a dismal 0.49 per cent for 2017-18. The low levels of public health spending reflect the shortfalls in the public health system, be it health facilities, shortages of specialists and deteriorating health infrastructure.
The state’s annual budget allocated for 2017-18 was Rs 8,195 crore in public health sector, which was 5.4 per cent less than what was spent by the state last fiscal year, raising eyebrows over the state government’s commitment towards Arogya Maharashtra.
Crippling health budget a pitfall?
Stepping up investment in public healthcare is pivotal for sustainable economic growth. Though Maharashtra health indicators are better than the national average, they are certainly not equivalent to its economic development, according to experts. A study by New Delhi-based International Institute of Health Management Research (IIHMR) stated that the state needs to increase its health spending to over Rs 7,400 crore by 2018.
“Maharashtra health budget needs to be a little more ambitious to overcome the lack of public health and medical facilities and fill in skill gaps of huge vacancies in rural hospitals, primary health centres (PHCs) and other centres as well. The annual budget allocated for the health sector has to be increased to address the rising cost of medical care, especially in view of the growing rate of urbanisation,” the study stated.
According to World Health Organisation (WHO), every state government should spend five per cent of the GSDP on healthcare.
Giving insights into why Maharashtra should improve its health budget, Dr DK Mangal, Dean Research, Indian Institute of Health Management Research (IIHMR) University, Jaipur, said, “With rising healthcare inflation, year-on-year the health budget should increase rather than decrease. Maharashtra’s health indicators may be better than the national average but they are certainly not commensurate to its economic development. If the state has to maintain its achievements in infant mortality rate (IMR), maternal mortality rate (MMR) and further reduce them and move towards the sustainable development goals (SDG), it needs to allocate more budget towards health in next five to ten years. I cannot find any justification for the reduction of the health budget. On the account of efficiency, leveraging other funds could be some justification, but I don’t think that will explain this reduction. The only justification by the state government could be that they would have some competitive priorities on which they wanted to allocate, and may be they would enhance the budget in subsequent years. Moreover, in view of the new National Health Policy where it has been mentioned that the states have to increase allocation for the spending of health sector from the current level of 5.6 per cent to eight per cent, the state’s budget should have been enhanced, not reduced.”
Explaining the state government stand point on the health budget provisions, Dr Vijay Satbir Singh, Additional Chief Secretary, Health, Government of Maharashtra, informed that the budget depends upon the total revenue and money available with the state government and at times there is a shortfall in the resources. That becomes the main reason for the state government not being able to provide sufficient funds.
“Whenever we find that a particular sector needs more money, we ask for supplementary budget. In public health department, Rs 126 crore is allotted for cancer hospital in Aurangabad and Rs 1,549 crore for rural health services. Apart from these schemes, Maharashtra has two exclusive health schemes like emergency healthcare service, under which ambulance is operated 24X7. We have allotted Rs 240 crore for a year. Another ambitious scheme is Mahatma Phule Jan Aarogya Yojna, cashless treatment for the poor, for which the budget allocated is Rs 1,000 crore. These two schemes take away about Rs 1300 crore of the total money available. Due to this, the other health schemes face fund crunch. These are the few teething problems, but we are making efforts to make sure that money is made available for every important health scheme,” Singh said.
Singh also said that unlike other states, in Maharashtra you can find that health sector has several resources to fund its schemes. “Urban areas like Mumbai have Brihanmumbai Municipal Corporation (BMC). They provide funds for their jurisdiction. As far as the Mumbai city is concerned, most of the health schemes are looked after by BMC. Apart from it, we have King Edward Memorial (KEM) Hospital, LTMG Sion, BYL Nair and Cooper Hospital, which are entirely funded by BMC. So you should not look at the amount of money spent only by public health department. You should also take into consideration the money spent by BMC and other corporations in their jurisdiction in urban areas. We have medical college department, which is spending money for hospitals, and looks after majorly tertiary healthcare. Food and Drugs Administration (FDA) is taking care of controlling the licensing of drugs, storage and manufacture with its own budget. Health budget cannot be measured only by what the state government allots to public health department.”
Highlighting that states have the opportunity to prioritise health, Rajya Sabha Standing Committee in a report stated, “In order to improve the overall healthcare of the county, the most effective solution remains greater expenditure by states through their own budgetary provisions. As per the 14th Finance Commission devolution, states have the opportunity to prioritise health and implement programmes that are customised to their state-specific needs and thereby improve health outcomes.
According to experts, the crippling public health budget will have aggressive impact on the quality of the service and access to the service and this gets reflected in the abysmal condition of the public health system with deteriorating infrastructure, shortfall of doctors and nurses. Due to these factors, the state sees a proliferation of the private medical sector.
Shortfall of services
Despite Maharashtra having over 50 medical colleges, there is a huge gap in the doctor-patient ratio in government hospitals. The specialist doctors remain unavailable year after year. Large public hospitals, which deal with scores of patient a day don’t have patient-friendly guidance or grievance redress systems. Overworked doctors and impatient patients lead to tussles and doctors’ strike in the state.
Informing that recruiting doctors on contract and giving incentives for performance are short-term solutions, which have been already tried by the state under National Health Mission (NHM), Mangal said, “The state government should find out a permanent solution and make sure that the minimum number of specialists, doctor’s position defined in Indian Public Health Standard should be filled in. If they have to be filled, the state should provide at least minimum facility in the district, CHC, PHC as many doctors and specialists are reluctant to work because of the conditions in these centres. For all these measures, again the state would have to optimise the health budget.”
Highlighting the option the state government is offering, Satbir Singh states that the state governments are providing an option of tele-medicine and are appointing Bachelor of Ayurveda Medicine and Surgery (BAMS) doctors in rural and tribal areas to fill in the gap.
Mangal chooses to disagree and informs, “Ayurveda doctors could work in PHC or in remote areas where they can undertake the roles which they are trained in, but they cannot replace MBBS doctors or specialists. The doctors via tele-medicine can give only second opinion.”
According to Central Bureau for Health Intelligence (CBHI), Maharashtra has the worst doctor- patient ratio. The state needs 1,440 specialist doctors in rural hospitals across the state, but only 578 are available. The shortfall is a whopping 60 per cent. Out of the 360 rural hospitals in Maharashtra, only 127 meet Indian Public Health Standards.
Throwing light on the implementation of digital technology, Rajeev Ahuja, Development Economist, formerly with Bill & Melinda Gates Foundation and the World Bank, said, “Digital technology is changing the way healthcare services are delivered the world over. It is challenging the older brick-and-mortar model of delivering care. Telemedicine, e-consultation, patient helpline, task shifting to lower cadre of health workers, shifting of care to primary level and so forth are fast becoming standard templates of delivering care. Use of technology has the potential to make healthcare accessible to patients in home setting and at a much lower costs. Any durable strategy to integrate the use of digital technology in delivering healthcare is a welcome move, provided these are properly piloted before scaling. Use of technology has the potential to alleviate constraints of health personnel to some extent but given the huge shortage of such personnel in India it will still mean continued emphasis on increasing their supply at least for next few years.”
Experts also cite conflicts and violence between doctors and patients, which indicates the failure of the overall health system. A substantial increase in health budget will help in providing better infrastructure and technology, which will lead to increase in healthcare staff, which would ensure essential services in public hospitals.
Boosting funds – Road ahead
Maharashtra needs to revive its public health spending by increasing the health budget. As the new National Health Policy clearly states that health is a state subject and its regulation lies with states. The state has to spend significantly more on health, for its healthcare delivery to improve.
According to Jan Swasthya Abhiyan, a global network which brings together grass roots health activists, civil society organisations, Maharashtra was performing well in public health services until the mid-1980s. However, given the subsequent crunch on financial resources, as well as declining political priority and the privatisation of healthcare, there were shortfalls in providing health services at various levels, forming the backdrop to rising public dissatisfaction.
Reiterating that Maharashtra government needs to make the public health system work, for which there is a tremendous scope, Ahuja said,“Since two-thirds of total government health spending comes from the states, state governments spend too little on healthcare. In absolute terms, Maharashtra spends the second highest amount, after Uttar Pradesh. But this doesn’t mean much in per-capita terms as Maharashtra also has second highest population, after Uttar Pradesh. A share of state health spending in state’s aggregate expenditure indicates a sense of prioritisation that any state attaches to healthcare. That is why the new health policy has set an ambitious target of raising this share in each state to eight percent by 2020.”
According to experts, the failing nature of better health outcome can easily be reversed with high level of public funds allocation in this sector. Specifically, Maharashtra, one of the wealthiest and most urbanised state, needs to increase its health spending from its existing level.
“Maharashtra health systems will remain ailing and a large numbers of its citizens, who cannot afford expensive private healthcare, will remain diseased and undernourished. In order to enhance the delivery system highest, political commitment and strong leadership and vision is required. In the end, nevertheless health is a state-subject,” concludes Mangal.