PUBLIC HEALTH EXPENDITURE IN INDIA
ABSTRACT
Acountry'seconomicprogressandhealthstatusareinfluencedbyitshealthexpenditure.India'spublicspendingisverylowanddiffersfromstatetostate.Inthisview, weassesspublichealthspendinginvariousIndianstatesinrelationtotheirGrossStateDomesticProduct(GSDP)andpercapitaincome.Thedatawastakenfromthe National HealthAccounts (NHA).After the implementation of NRHM, the majority of states decreased their share of health. The highest decline is observed in economicallyadvancedstateslikeMaharashtra,Haryana,Gujarat,Punjab,TamilNadu,andKarnataka.HimachalPradeshistheonlystatethatcontributedmorethan halfofitspublichealthspendingtostatehealthspending.PercapitahealthspendingisveryhighinKerala.Knowledgeoffactorsassociatedwithhealthexpenditure andwell-designedpublicpolicywouldhelptobetterplanforthefuture.
KEYWORDS:Healthexpenditure,GrossDomesticProduct,PercapitaIncome.
1.INTRODUCTION:
Acountry'seconomicprogressandhealthstatusaresignificantlyinfluencedby itshealthexpenditure.IndiahasalowshareofhealthspendinginboththeGross DomesticProduct(GDP)andpublichealthspendingwhencomparedtodevelopedcountriesdespitethefactthatithashigherhealthexpenditureasapercentof GDPthan mostAsian economies. (GOI, 2009).To combat this, the Union government has been implemented in the health sector through the National Rural Health Mission (NRHM) and other smaller programmes. Since its launched in 2005,theNRHMhasexpandedrapidlyandhasbecomeasignificantcomponent ofhealthspendinginIndianStates.AccordingtoNationalHealthAccountsfor theyear2016-17,totalhealthexpenditureinthecountrywasestimatedat3.8percentofGDPandRs.4381percapita,whichisextremelylow Inthisview,
2.OBJECTIVE:
ToevaluatethepublichealthspendingindifferentstatesofIndiaintermsofits GrossStateDomesticProduct(GSDP)andPercapitaIncome.
3.DATAANDMETHODOLOGY:
Health Expenditure and health system financing information were taken from theNationalHealthAccounts(NHA)databaseoftheWorldHealthOrganization. It is an accepted methodology to calculate the actual health expenditure in the health sector from all sources (government, private and external donors). Besidesthis,thedifferentbudgetestimateswereusedforthestudy Health
Figure1showsthesourcesofhealthspendinginIndiaduringthe2016-17years. Itobservedthathouseholdsaccount68percentofhealthspending.Publichealth spendingasapercentageoftotalhealthexpenditureislow Thecentralshare,the stateshare,andthelocalbody’ssharealtogetherconstituteonly26percent.That showsthatmorethanthreebyfourthhouseholdsspendhealthexpenditureoutof theirownpockets.
4.2PublicExpenditureonHealthinIndia: After 2005, with the implementation of the National Rural Health Mission (NRHM)inIndia,thelevelofpublicexpenditureonhealthhasgoneupmarginally,butitstillfallsfarshortof3percentofGDP
4.RESULTS:
4.1. SourcesofhealthspendinginIndia: The first systematic analysis of the distribution of health spending in India by source of funds was published in the National Health Accounts of India. The resultsareshowninfigure1.
Source: Union Budget Documents,RBI State Finances, various years and National Health Accounts of India. Figure2:PercentageofPublichealthexpenditureonGDP
ThetrendsinpublicexpenditureonhealthaspercentofGDPareshowninFigure 2.AtthattimeoftheintroductionofNRHM,India’spublicexpenditureasapercentofGDPwas0.86. Afterthat,publichealthexpenditurerosegraduallyand reached 1.03 percent of GDP during the period 2009-10. The GDP steadily declinedduringtheyears2010-11and2011-12.Atthattime,theexpenditureon WaterSupplyandSanitationwasexcluded.RealisingthelowlevelofGDPintroduced on Universal Health Coverage (UHC) in 2012. It was recommended to increasepublichealthcarefinancingto2.5percentofGDPby2017and3per centofGDPby2022.Afterthatpublicexpenditureincreasedslowlyandwasstagnantat1.01percentofGDPin2012-13and2013-14.Inordertoprovideforuniversalizationofhealthcarewithahealthinallapproach,theNationalHealthPolicywasintroducedin2017.Thispolicyproposesatime-boundincreaseinpublic spending to 2.5 percent of GDPby 2025. TheAyushman Bharat Mission was launchedin2018assuggestedbythenationalhealthpolicyof2017toachieve universalhealthcoverage(UHC)andalsoincreasetheGDP
4.3InterStateAnalysisofPublicHealthExpenditure:
HealthisStatesubjectandstatepolicieshaveasignificantimpactonthepublic healthexpendituresinIndia.Thecentralgovernment’srolehasbeentofundcentrallysponsoredschemes,todeveloppoliciesandguidelinesandtoprovidestatutorygrantsorgeneraltransferstothestates.
Source: National Health Accounts Estimates for India
Figure3:PublichealthexpenditureasapercentofGSDP
Figure3revealsthatthepublicexpenditureincreasedinthestatesaftertheintroductionofNRHMexceptforHimachalPradesh,Jammu&Kashmir,Karnataka andUttarakhand. ThestatesofJammu&KashmirandHimachalPradeshspent morethan2percentofGSDPbeforetheintroductionofNRHMandafterthese state's GSDP was reduced. During the 2016-17 period, the economically advancedstatessuchasMaharashtra,Haryana,Gujarat,Punjab,TamilNaduand KarnatakawerespendinglessthanonepercentoftheirGSDPonhealth.Shortagesinthesestate'scontributionsareduetotheirlowprioritisationofhealthover otherdevelopmentneeds.
4.4
StateShareofPublicExpenditureonHealth(PHE):
In 2005, India embarked on a concerted effort to increase government health spendingfromlessthan1percentofGDPto2-3percentofGDPin7years.
TableNo.1:StateShareofPublicHealthExpenditure(PHE)
States StateShareof PHE2004-05 StateShareof PHE2016-17 Percentagechange overtheperiod
Assam 20.89 38.97 +18.08
AndraPradesh 17.99 24.46 +6.47 Bihar 18.15 21.35 +3.20
Chattisgarh 18.94 33.90 +14.97 Gujarat 20.81 38.59 +17.77 Haryana 18.83 29.59 +10.76
HimachalPradesh 41.70 51.18 +9.49
Jammu&Kashmir 51.17 38.83 -12.34 Jharkhand 31.02 31.02 +0.0 Karnataka 28.06 26.80 -1.28 Kerala 9.73 26.59 +16.86
MadhyaPradesh 18.36 28.75 +10.39 Maharashtra 16.81 23.33 +6.51 Odisha 20.28 27.31 +7.02 Punjab 18.18 19.79 +1.61 Rajasthan 24.45 33.01 +8.56 TamilNadu 17.72 27.32 +9.60
UttaarPradesh 13.12 22.25 +9.13 Uttarkhand 34.18 36.08 +1.89 WestBengal 13.72 21.18 +7.46
Source:NationalHealthAccountsEstimatesofIndia
It is clear that after NRHM, the share of public health expenditure increased throughoutthestatesexceptforJammuKashmirandKarnataka.Intheperiodof 2004-05,thepublichealthexpenditurewaslowestinthestateofKerala(9.73percent). Afterthatpublichealthexpenditureincreasedbymorethanone-fourthof thestate'stotalhealthexpenditureinKerala. BesidesfromKerala,statessuchas Assam,Chattisgarh,Gujarat,HaryanaandMadhyaPradeshincreasedtheirpublichealthspendingbymorethan10percent.HimachalPradeshwastheonlystate that utilized more than 50 percent of its public health expenditure to the state healthexpenditure.
4.5StateShareofHealthinGovernmentExpenditure(GE): Thestate'sownpriorityforthehealthsectorisestimatedfromthestatebudget.
Table2:StateShareofHealthinGovernmentexpenditure
States ShareofGE 2004-05 ShareofGE 2016-17 %Changeover theperiod
Assam 3.1 3.3 +0.2
AndraPradesh 3.2 4.2 +1.0 Bihar 4.1 6.4 +1.3
Chattisgarh 3.4 4.0 +0.6 Gujarat 3.1 2.1 -1.0 Haryana 3.2 2.2 -1.0
HimachalPradesh 5.0 3.1 -1.9
Jammu&Kashmir 4.9 4.1 -0.8 Jharkhand 3.8 3.5 -0.3 Karnataka 3.8 2.8 -1.0 Kerala 4.7 4.5 -0.2
MadhyaPradesh 3.2 3.4 +0.2 Maharashtra 2.9 2.9 +0.0 Odisha 4.4 4.6 +0.2 Punjab 3.0 4.0 +1.0 Rajasthan 3.9 3.4 -0.5 TamilNadu 3.4 2.8 -0.6
UttaarPradesh 3.9 6.1 +2.3 Uttarakhand 1.1 2.3 +1.2 WestBengal 4.3 4.7 +0.4
Source:NationalHealthAccountsEstimatesofIndia
From the table, it is observed that the majority of states reduced the share of healthaftertheintroductionofNRHM.Thehighestdeclineisobservedineconomically advanced states like Himachal Pradesh, Haryana, Gujarat and Karnataka.Besidesthesestates,Kerala,TamilNaduandRajasthanshownegative growth. The wealthier states should contribute more to health, which will reduceoutofpocketexpenditurewhileachievingthetargetsof2.5–3percentof GDP ThehighestincreaseintheshareofhealthinGovernmentExpenditureis 2.3percentexhibitedinthepoorerstateUttarPradesh.Governmentsatthestate level are run by different political parties and competition among them should improvetheperformancesofindividualstates.Thisissueisofhighpoliticaland electoralinterestandshortfallsinthesestate'scontributionsaretheresultoflow prioritizationofhealthanddivertingthefundsawayfromotherdevelopment.
4.6PublicHealthExpenditurepercapita: Therealpercapitahealthexpenditure(2011-12prices)andthestateshareoftotal budgetforhealthareshowninTable3.Kerala,withhigherhumandevelopment indiceshasthehighestpercapitaspendingduring2017-18whereasBiharspends theleast.
Table3:PercapitaHealthSpendinganditsshareinStateExpenditure, 2016-17
State PercapitaHealth Spending Rs. Rank ShareinState expenditure Rank
Assam 2562 19 15.41 15
AndhraPradesh 4600 7 22.06 6 Bihar 2358 18 22.04 7
Chattisgarh 3648 14 17.72 13 Gujarat 3703 13 18.77 10 Haryana 4533 8 16.26 14
HimachalPradesh 5501 3 13.35 18 Karnataka 5183 5 21.37 8
Jammu&Kashmir 3952 12 10.68 19 Kerala 8083 1 27.95 3
MadhyaPradesh 2820 17 14.98 16 Maharashtra 5210 4 26.40 4 Odisha 4059 10 18.14 11 Punjab 5960 2 28.98 1 Rajasthan 3412 16 17.76 12 TamilNadu 4734 6 20.96 9 UttarPradesh 3469 15 24.69 5 Uttarakhand 4019 11 14.63 17 West Bengal 4277 9 28.27 2
Thehealthexpenditureinrealpercapitashowsthereishighinterstatevariation. InthelowincomestateslikeBihar,MadhyaPradeshandRajasthanpeoplespend verylittleonhealth.Inthesestates,thestateshareofhealthisalsolow Theshare ofstateexpenditureonhealthshowsthatPunjab,WestBengalandKeralaspend nearly 28 percent of their state budget. In the high income state Himachal Pradeshthepercapitahealthspendingis5501rupeesbuttheshareofstateexpenditure to health expenditure is only 13.35 percent lowest in the Indian states. Thereisaneedforhigherpublicspendingtoreduceoutofpocketexpenditure.
5.SUGGESTION:
Indian health care policies and programmes have been deeply influenced by internationaldevelopmentsandbodies.Theimplementationhasbeenmanaged by the local bureaucracy and political leadership, which has led to underutilizationandfailures.Traininghasgiventhemanunderstandingoffactorsassociatedwithhealthexpenditurethatwouldhelpthemtobetterplanforthe future.
REFERENCES:
I. Berman Peter, RajeevAhuja 2008 : “Government Health Spending in India”, EconomicandPoliticalWeekly,Vol.43,No.26and27
II. Choudhury Mita, H.K Amar Nath 2012: An Estimate of Public Expenditure on HealthinIndia,NationalInstituteofPublicFinanceandPolicy(NIPFP),NewDelhi, May
III. GlobalReport2019:Thehealthfinancingtransition,Underfasteconomicgrowth, GlobalSpendingonHealth:AWorldinTransition,WorldHealthOrganisation,
IV HealthExpenditureandFinancing2015:NationalHealthStatisticsinIndia,Central Statistical Office, Ministry of Statistics and Progrmme Implimentation, GovernementofIndia,NewDelhi,May,Pageno.158-172
V GovernmentHealthExpenditureinIndia2006:ABenchmarkStudy,Undertakenfor theMacArthurFoundation,India,EconomicResearchFoundation,NewDelhi,
VI. GovernementHealthExpenditureinIndia,2017: NationalHealthAccountsSecretariatNationalHealthSystemsResourceCentre,MinistryofHealthandFamilyWelfare,GovernmentofIndia
VII. Manual on Health Statistics in India, 2015:Central Statistical Office, Ministry of StatsticsandProgrammeImplementation,GovernmentofIndia,May
VIII. National HealthAccounts India, National HealthAccount Cell, Ministry of Health andFamilyWelfare,GovernmentofIndia,Variousyears
IX. ShailenderKumarHooda,2013:ChangingPatternofPublicExpenditureonHealth In India, Issues and Challenges, ISID-PHFI Collaborative Research Programme, WorkingPaperSeries01,March2013.
X. SrinathPavanetal,2018:AQualitativeandQuantitativeAnalysisofPublicHealth ExpenditureinIndia:2005-06to2014-15,WorkingPaper2018-01,July
XI. SudhakaraH,RajendraPrasad,2016:HealthCareExpenditureinIndia-AnAnalysis, www.reasearchgate.net/publication,Volume5,Issue1,December