Chapter 8: Summary and Conclusions
2.4 NATIONAL HEALTH MISSION IN ASSAM
The National Rural Health Mission is an initiative launched by government by India in 2005 to meet the health needs of the rural poor and underprivileged section of the country. The programme initially aimed at meeting the health needs of 18 states with weak health
0.00 10.00 20.00 30.00 40.00 50.00 60.00 70.00 80.00 90.00 100.00
1990-91 1991-92 1992-93 1993-94 1994-95 1995-96 1996-97 1997-98 1998-99 1999-2000 2000-01 2001-02 2002-03 2003-04 2004-05 2005-06 2006-07 2007-08 2008-09 2009-10 2010-11 2011-12
Figure 2.7 Share of public health in total Medical and Public health expenditure (M and PH), Assam, in per cent, 1990-91 to 2011-12
0.00 10.00 20.00 30.00 40.00 50.00 60.00 70.00 80.00 90.00 100.00
1990-91 1991-92 1992-93 1993-94 1994-95 1995-96 1996-97 1997-98 1998-99 1999-2000 2000-01 2001-02 2002-03 2003-04 2004-05 2005-06 2006-07 2007-08 2008-09 2009-10 2010-11 2011-12
Figure 2.8 Share of expenditure on prevention and control of diseases in total Medical and Public Health expenditure, Assam, in per cent, 1990-91-2011-12
outcome indicators11. The main objective of the programme is to reduce infant and maternal mortality rate, to provide universal access to public health services including women’s health, child health, water, sanitation, and hygiene. It also emphasizes on universal access to immunization and nutrition for the general masses. The mission also aimed at prevention and control of communicable and non-communicable diseases, proper access to comprehensive primary health care, to stabilize population and gender and to maintain demographic balance, to revitalize local health tradition and mainstreaming AYUSH and to promote healthy lifestyle among the rural poor. Table 2.4 shows the various components of National Health Mission (previously National Rural Health Mission).
Table 2.4 Components of National Health Mission
Health systems
strengthening
Reproductive, Maternal, Newborn, Child and Adolescent Health (RMNCH+A)
National Disease Control Programmes (NDCPs) 1. Mobile Medical
Units 1. Maternal health
a. Janani Sishu Suraksha Karyakram b. Janani Suraksha Yojana
1. .National Iodine Deficiency Disorder 2. Patient transport
Service 2. Child health and immunization a. Pulse Polio Programme
b. Rashtriya Bal Swasthya Karyakram c. National Deworming Day
2. National Vector Borne Disease Control Programme 3. Infrastructure 3. Adolescent health
a. Adolescent friendly health clinics b. Weekly iron and folic acid supplementation
c. Menstrual hygiene scheme
3. Revised National TB Control
4. Human resources 4. Family planning 5. National Leprosy Eradication Programme
5. Drugs and logistics 6. Integrated Disease
Surveillance Project
6. Telemedicine 7. National Mental
Health Programme 8. National
Communicable Disease Control Programme 9. Programme for
Prevention and Management of Burn Injuries
Source: Government of Assam, National Health Mission, 2008.
11The eighteen states constitute of the Empowered Action Group (EAG) states together with the north- eastern states of the country. The EAG states include, Uttar Pradesh, Uttaranchal, Madhya Pradesh, Chhattisgarh, Bihar, Jharkhand, Orissa, Rajasthan, Himachal Pradesh, and Jammu and Kashmir. On the other hand, the north-eastern states constitute of Assam, Arunachal Pradesh, Manipur, Meghalaya, Nagaland, Mizoram, Sikkim and Tripura.
The discussion on extent and pattern of public health expenditure in the previous section has shown that there has been an increase in the total health spending after 2005 which is mainly because of the implementation of the programme of NHM in the state12. Before the introduction of the NHM, health expenditure by the centre at the state level was mainly through state treasuries. However, after introduction of NHM many donor funded health programmes has come into being which are outside the state treasuries. During the recent time period health expenditure by the centre at the state level is incurred through non- treasury routes. These are in the form of expenditure on institutions located in the states, direct transfer to the implementing agencies under centrally sponsored schemes and expenditure under Central Government Health Schemes (CGHS). The increase in expenditure through these agencies in the state has resulted in an increase in health expenditure through the non-treasury routes13 while the flow of expenditure through treasury routes has been declining over the years. The flow of expenditure through treasury routes is mainly through grants in aids to the state government and Union Territories.
Health expenditure pattern under NHM
The NHM funds are generally routed through state health societies. Only a part of the funds are routed directly through state treasuries and get reflected in the state budget documents.
Therefore, adding state share of NHM and central share will lead to overestimation of the total health expenditure of the state. The state share of health expenditure has to be deducted before calculating central spending of NHM for the state. NHM has been acting as an independent implementing agency in the state. It is a separate entity and funds are allocated separately for the programme. Only the state share of NHM is reflected in the finance accounts or the detailed demand for grants. The per capita expenditure on NHM has been calculated in Rs. per capita at 2004-05 prices to show the expenditure pattern under NHM. Figure 2.9 indicates the per capita government health expenditure and per capita NHM expenditure in from 2005-06 to 2011-12. To recall, the government/budgetary expenditure here include the expenditure statements available in Finance Accounts documents.
12There has been an increase in the total health spending of almost all the states after implementation of NHM at the central level (Berman and Ahuja, 2008).
13A major component of expenditure through non-treasury routes is through implementing agencies in the form of “Flexible Pool for the state Programme Implementation Plan (PIP)”. Assam, Uttar Pradesh, Maharashtra, Andhra Pradesh and West Bengal are at the top five positions in terms of expenditure incurred on flexible pools (Choudhury et al., 2011).
It can be observed that the per capita budgetary expenditure increased from Rs. 153 in 2005-06 to Rs. 355 in 2010-11. Similarly, the per capita NHM expenditure has also been increasing from Rs. 3 to Rs. 246 in 2011-12. The proportion of increase in NHM expenditure is however higher. There is a slight decline in both per capita budgetary expenditure and per capita NHM expenditure during 2011-12. The per capita budgetary expenditure declined to Rs. 311 during the period of 2011-12 and per capita NHM expenditure declined to Rs. 202 during the same period.
During the recent period the expenditure through independent implementing agencies like NHM has been increasing. The highest share through implementing agencies constitute of expenditure through the NHM flexible pool. The transfer of funds through non-treasury routes especially through the NHM flexible pool is higher for the north-eastern states. Uttar Pradesh, Assam, Maharashtra, Andhra Pradesh and West Bengal are the states receiving highest share of NHM flexible pool. These states account for 47 percent of expenditure incurred through NHM flexible pool. One of the reasons of high expenditure in these states is that they have a higher population share with respect to the other states of the country (Choudhury et al., 2011).
Components of National Health Mission (under National Health Mission)
Expenditure on universal immunization programme (UIP) was highest during the period of 2005-06 (26 percent). In 2006-07, the share of expenditure on reproductive and child health
153 3 201 45 146 197 183 238 364 355 311
180 246
202
0 100 200 300 400 500 600 700 800 900 1000
2005-06 2006-07 2007-08 2008-09 2009-10 2010-11 2011-12 Figure 2.9 Per capita governement health expenditure and per capita NRHM
expenditure in Assam at 2004-05 prices, 2005-06 to 2011-12 (in Rs. per capita)
Per capita budgetary health expenditure Per capita NRHM expenditure
scheme (RCH) (44 percent) is the highest. The share of UIP has been declining since the period of 2007-08 (4 percent). Since 2009-10, the share of UIP is constant at 2 percent till 2011-12. During the recent period a major amount is spent on RCH (44 percent) in 2011- 12. Expenditure on prevention and control of diseases (PCOD) constituted of 37 percent in total NHM expenditure. The percentage share spent on NHM flexipool is 17 percent for 2011-12. The pattern of expenditure by NHM indicates that the main focus of the programme is on preventive care. This has an impact on the rural households because for curative care they have given preference to private health facilities or district or civil hospital. This is mainly because of the fact that the basic health facilities for curative care are not available in the government health facilities. Moreover, the quality of care is low in case of curative care in the nearby public health institutions (Table 2.10).