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8.2 PUBLIC HEALTH EXPENDITURE IN ASSAM: 1990-91 TO 2011-12
As already mentioned in chapter 1 of the thesis, public provisioning is very important in case of health sector as it is a merit good. Therefore the second chapter (chapter 2) examines the pattern of public health expenditure in the state of Assam. The performance of public health system mainly depends on public health expenditure of the state. Increasing the public health expenditure has been one of the focus areas of the most of the health programmes and policies during the recent decades. Public health expenditure of the state
comprises of expenditure on medical and public health and family welfare. The analysis based on secondary level data shows that the average expenditure on health is 1 percent of Gross State Domestic Product (GSDP) of the state for the period 1990-91 to 2011-12. A look at the share of public health expenditure as a proportion of total government expenditure also implies a more or less constant pattern of expenditure over the years65. The study also estimated the per capita health expenditure of the state at 2004-05 prices as base66. Per capita overall health expenditure in Assam rose from Rs. 149 in 1990-91 to Rs.
347.28 in 2011-12. It was lowest during 2002-03 (Rs. 128) while it is highest during 2000-01 (Rs. 153). An increasing trend however in total per capita expenditure has been noticed since the implementation of National Health Mission in 2005. It increased from Rs. 132 in 2005-06 to Rs. 347 in 2011-12.
8.2.1 Expenditure on medical and public health and family welfare
Public expenditure in the state constitute of expenditure on medical and public health and family welfare. However, the bulk of expenditure comprises of expenditure on medical and public health. During 2010-11 expenditure on medical and public health constituted of 89 percent of the total health expenditure of the state. On the other hand expenditure on family welfare comprises of 11 percent of total health expenditure of the state during the same period. It has been noticed that the expenditure on medical health has been increasing since 2006-07 continuously which is basically the period of implementation of the NHM. In contrary the share of expenditure on family welfare as a proportion of total health expenditure of the state has been declining. Although the expenditure on family welfare seems to be declining in the budgetary expenditure, expenditure on this head is incurred under the National Health Mission (under NHM flexipool) which comes under central share of NHM. Thus NHM has been acting as an autonomous financing agency for the state and is contributing in increasing public health expenditure.
8.2.2 Expenditure on rural and urban healthcare services
Under medical and public health expenditure two important components are rural health services and urban health services (already explained in detail in section 2.3 in chapter 2).
65The finance account data shows that public expenditure on health is 14 percent during 2011-12 while the expenditure on education is 58 percent of the total social service expenditure during the same period. Thus the priority on health sector by the government in the state seems to be low.
66It has been already mentioned in chapter 2 that the expenditure data has been deflated using the NSDP deflator (base 2004-05) for the state of Assam.
The analysis on rural and urban healthcare services shows that while the share of rural population is high in Assam, the per capita expenditure on RHS is very low compared to that made on UHS. For instance, the per capita expenditure on rural health services is Rs.
168 in 2011-12 while the per capita health expenditure on urban health services is Rs 348 during the same period. However, the level of per capita expenditure on urban health services is much higher compared to the rural, a consistently declining pattern emerges for the entire period under consideration but the share of per capita expenditure on RHS is increasing over the period. A reversal in the trend has been noticed only after 2006-07 which was probably because of the funds coming from National Health Mission.
8.2.3 Expenditure on public health and medical education research and training
Another important component under medical and public health expenditure is expenditure on public health. The pattern of expenditure on public health shows a declining trend since the period from 2002-03. A rise in the expenditure on public health has been noticed only after 2009-10. This indicates that expenditure on public health has been very low in terms of budgetary provision of the government. The main reason behind the low public health expenditure under public health can be attributed to the low levels of expenditure on prevention and disease control programmes which is one of the major components of expenditure under public health. The share of expenditure on public health declined from 15 percent in 2002-03 to 6 percent in 2009-10. Although there has been a decline in the expenditure on prevention and control of diseases through budgetary heads during the recent years, expenditure through non-budgetary head has increased through National Heath Mission. The mission is spending on prevention and control of diseases under the head National Disease Control Programme (NDCPs).
Expenditure on medical education and research and training are another important area of investment in the state. Share of expenditure on medical education research and training shows that the share of expenditure on this component has been very low during the period of 1990-91 to 2000-01. However, the share stated to increase slowly since 2001-02. Highest increase in the expenditure has been observed for the period 2005-06 to 2009-10. It increased from 29 percent in 2005-06 to 39 percent in 2009-10. However, a slight decline has been observed during 2009-10 to 2011-12.
8.2.4 Revenue and capital expenditure and expenditure on rural and urban health services
The total health expenditure of the state constitutes of revenue expenditure and capital expenditure (discussed section 2.2 of chapter 2). The pattern of revenue and capital expenditure shows that revenue expenditure has always been higher than the capital expenditure of the state. The capital expenditure of the state has been more or less stagnant over the years as a proportion total health expenditure of the state. The pattern thus reveals that there was no systematic allocation of expenditure on strengthening of basic infrastructural facilities in the state.
8.2.5 Health expenditure and National Health Mission (NHM)
Under the purview of overall health expenditure of the state the contribution of NHM cannot be ignored. Therefore an attempt has been made to examine the pattern of expenditure under National Health Mission of the state (explained in section 2.4 of chapter 2). National Health Mission has been working as an autonomous implementing agency in the state. A study on per capita expenditure on NHM at 2004-05 prices shows that the per capita expenditure on NHM was Rs. 39 during 2006-07 which increased to Rs. 174 in 2011- 12.
Before the introduction of the NHM, health expenditure by the centre at the state level was mainly through state treasuries. The flow of expenditure through treasury routes is mainly through grants in aids to the state government and Union Territories 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 routes67 while the flow of expenditure through treasury routes has been declining over the years. The mission has also been giving special focus on improving reproductive and child healthcare services.
The allocation on RCH was highest for the year 2011-12 (44 percent). In terms of centre-
67A 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 position in terms of expenditure incurred on flexible pools (Choudhury et al., 2011)..
state transfer of funds, we found that fund flow through treasury route has been declining over the years.
Thus the discussion in the above section 8.2 fulfils the first objective of the thesis i.e. to study the level, extent and pattern of government expenditure on public healthcare services in rural Assam after Indian economic reforms in the social sector.