The prescribed health allocation as recommended by the 15th Finance Commission can fulfill a mandate on primary care
In early November 2021, a potentially game-changing and transformative development took place, almost unnoticed – the release of ₹8,453.92 crore to 19 states as health grants to rural and urban local bodies (ULBs) by the Department of Expenditure. Ministry of Finance. The allocation has been made as part of a health grant of Rs 70,051 crore to be released over five years from FY 2021-22 to FY 2025-26, as recommended by the Fifteenth Finance Commission. The grant has been earmarked to address identified gaps in primary health care infrastructure in rural and urban settings. Of the total ₹13,192 crore to be allocated in FY 2021-22, Rural Local Bodies (RLBs) and ULBs will receive ₹8,273 crore and ₹4,919 crore, respectively.
it’s important
By some comparisons the allocation in FY2021-22 is relatively less. This would be 2.3% of the total health expenditure (both public and private expenditure) of ₹5,66,644 crore in India and 5.7% of the annual government health expenditure (Union and State combined) of approximately ₹2,31,104 crore (both). Figures for 2017-18), the most recent financial year for which data on National Health Accounts are available (https://bit.ly/3I39G77).
This grant is equivalent to 18.5% of the Union Health and Family Welfare Department’s budget allocation for FY 2021-22 and about 55% of the second COVID-19 emergency response package announced in July 2021. Nevertheless, it is arguably the single most important health allocation in this financial year with the potential to have a far greater impact on health services in India in the years to come.
good intentions gone wrong
In 1992, as part of the 73rd and 74th Constitutional Amendments, responsibility for providing primary care and public health services was transferred to local bodies (LBs) in rural (Panchayati Raj Institutions) and urban (Corporations and Councils) areas. It was expected that this would lead to greater focus on allocation of funds for health services in the geographical jurisdiction of local bodies. Also, rural settings continued to receive funding for primary health care facilities under ongoing national programs.
However, the decision proved to be a major setback for urban health services in particular. Government funding for urban primary health services was not routed through the state health department and ULBs (which come under different departments/systems in different states) did not increase the allocation for health uniformly. Reasons include a lack of resources or a lack of clarity on health services-related responsibilities, or completely different spending priorities. Often, it was a diverse combination of these factors. The well thought out legislative move inadvertently undermined health services in urban areas more than in rural areas.
In 2005, the launch of the National Rural Health Mission (NRHM) to strengthen the primary health care system in India partially mitigated the impact of health-spending RLBs. However, urban dwellers were not equally lucky. The National Urban Health Mission (NUHM) can be launched after eight years and with a meager annual financial allocation that can be as low as ₹1,000 crore (or about 3% of the budgetary allocation for NRHM or ₹25 per person per urban dweller) 4,297 per capita (year health expenditure in India).
In 2017-18, 25 years after the constitutional amendments, ULBs and RLBs in India were contributing between 1.3% and 1% of the annual total health expenditure in India. In the urban environment, most local bodies were spending less than 1% to about 3% of their annual budget on health, which is almost always less than what urban local bodies spend on installation and repair of street lights . The result hasn’t been entirely surprising. Both urban and rural India need more health services; However, the challenge in rural areas is poor functioning of available primary health care facilities while in urban areas it is lack of both primary health care infrastructure and services.
some obstacles
Urban India, with only half the rural population, has one-sixth of the primary health centers as compared to rural areas. Contrary to what many may think, urban primary health care services are weak compared to the services available in rural India. Regular outbreaks of dengue and chikungunya and two waves of the novel coronavirus pandemic have resulted in people struggling for COVID-19 counseling and testing services. The low priority given to health and inadequate funding is compounded by a lack of coordination among the multitude of agencies responsible for different types of health services (by areas of their jurisdiction). A few years back, there were some reports of Delhi refusing to allot land for the construction of three municipal corporations. Street Clinics (an initiative of the state health department) and even some under construction clinics were vandalised.
It is against this background that the Fifteenth Finance Commission health grant – the urban portion is about five times the annual budget of NUHM and the rural allocation is one and a half times the total health expenditure by the RLB. In India – there is an unprecedented opportunity to fulfill the mandate provided under two constitutional amendments in 1992. However, for it to work, some coordinated steps are required.
necessary steps
Firstly, to use the grant as an opportunity to sensitize key stakeholders in local bodies, including elected representatives (councillors and representatives of Panchayati Raj Institutions) and administrators, about the role and responsibilities in the delivery of primary care and public health services. needed. Second, the awareness of citizens about the responsibilities of local bodies in health care services should be increased. Such an approach can serve as a powerful tool to enable accountability in the system. Third, civil society organizations need to play a greater role in raising awareness of the role of LBs in health and possibly in developing local dashboards (as a mechanism of accountability) to track progress made in health initiatives. Fourth, the health grants of the Fifteenth Finance Commission should not be considered as a ‘replacement’ for health expenditure by the local bodies, which must be accompanied by regularly increasing their own health expenditure to make a meaningful impact. needed. Fifth, mechanisms should be institutionalized for better coordination between multiple agencies operating in rural and urban areas. Time bound and coordinated action plans with measurable indicators and road maps need to be developed. Sixth, local bodies continue to be ‘health greenfield’ areas. Such young administrators in charge of RLBs and ULBs and motivated councilors and members of Panchayati Raj Institutions need to seize this opportunity to develop innovative health models. Seventh, before the novel coronavirus pandemic began, many state governments and cities had planned to open a variety of community clinics in rural and urban areas. But it got derailed. The money should be used to revive all these proposals.
a much awaited springboard
India’s health system needs more government funding for health. However, when it comes to local bodies, it is health leadership, multiple agencies coordinating with each other, increased citizen engagement in health, the establishment of accountability mechanisms and incremental financial support supplemented by elected representatives guiding the process. There should be a mix of allocations. Under a multidisciplinary group of technical and health experts. The health grants of the Fifteenth Finance Commission have the potential to create a health ecosystem that can serve as the much-awaited springboard for mainstream health in the working of rural and urban local bodies. The Indian health care system cannot and should not afford this opportunity.
Dr. Chandrakant Laharia, a Physician-Epidemiologist, is a Vaccines and Health System Specialist based in New Delhi
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