The drafting of the National Health Policy (NHP) 2015 is an extremely welcome development. The government’s decision to announce Health as a Right is a huge advance. Public health spending as a share of GDP barely rose from 0.9 to 1.1% under the previous government. Governments in rich countries have been spending 5% of GDP on health for decades.
Why should we welcome the NHP 2015? Countries with lower per capita gross national income than India — like Vietnam and Bangladesh — had a higher life expectancy at birth, according to 2012 data. Total health expenditure as a share of GDP is lower in Sri Lanka than in India, but the former’s life expectancy is much greater. This is because its government spends more, while in India private spending is 70% of total health spending.
People prefer private providers in India since public services do not exist in the vicinity, and when they do exist they are not available 24x7. Despite the National Rural Health Mission (NRHM), the shortfall in public health infrastructure at the end of the 11th Plan (2012) was: 20% for sub-centres, 24% for primary health centres and 37% for community health centres.
The number of 24x7 facilities increased five-fold between 2007 and 2012 but India is still 48% short of the target. In northern and eastern states the shortfall is much higher at 65%. Despite improvements, the gap between staff in-position and staff required in 2012 was 62% for mid-wives and nurses, 67% for doctors, 88% for specialists and 58% for pharmacists.
This situation persists as India’s health budget is 1.1% of GDP. Of the total public spending, the Centre spends about 36% and 64% comes from the states. Under the 12th Five-Year Plan, the health outlay was `2,68,000 crore. In the first three years of the plan, the ministry of health should have received `1,59,000 crore. But the ministry planned only `87,000 crore in expenditure for three years and what they received was around `70,000 crore.
The real problem is that the government has barely maintained health spending’s share in GPD terms, and did not give more priority within total expenditure. Health’s share in total spending has remained the same around 4.6%. We have to wait to see if the total government spending will increase with the launch of NHP 2015.
Another problem, which the NHP 2015 admits, is that all the disease conditions for which national programmes provide universal coverage account for less than 10% of all mortalities and only for about 15% of morbidities.
Over 75% of communicable diseases are not part of existing national programmes. Overall, communicable diseases contribute to 24.4% of the entire disease burden while maternal and neonatal ailments contribute to 13.8%. Non-communicable diseases (39.1%) and injuries (11.8%) constitute the bulk of the country’s disease burden. National Health Programmes for non-communicable diseases are very limited in coverage and scope.
A final problem: While the Centre continues to spend a higher level in states with relatively poor health indicators and levels of spending, a study found that the average increase in the Centre’s health expenditure in the poor-performing states has been lower relative to other major (non-high focus) states.
Between 2006-07 and 2009-10, the Centre’s expenditure in low-performing states increased by about 15% in comparison to 23%in better performing states. In Bihar and UP, central spending increases have been lower than some of the relatively high income states like Punjab, Haryana and Karnataka. Strengthening health systems requires higher levels of investment and human resources. Out-of-pocket spending on drugs constitute 60% of total spending. Hence, procuring and supplying essential generic drugs through government hospitals free of charge will be central to the success of NHP 2015.
(Santosh Mehrotra is a professor of economics at Jawaharlal Nehru University)
(The views expressed by the author are personal)