Health for 200 million
The challenge of access in Uttar Pradesh
By Ajoy Bose
Six years ago Uttar Pradesh (UP), India’s most populous state, was rocked by a massive scam in rural healthcare involving senior ministers and bureaucrats siphoning off as much as 100 billion rupees from central government funds destined for the National Rural Health Mission (NHRM) in the state. Despite successfully emerging from the scandal the state government still faces the mammoth task of delivering better access to healthcare for over 200 million people in India’s most populous state.
To improve public healthcare infrastructure and management, the Uttar Pradesh government has also been open to partnerships with international institutions like the World Bank and private foundations like the Gates Foundation. An example is the World Bank assisted, Uttar Pradesh Health System Strengthening Project (UPHSSP). This aims to enhance medical health care facilities in the state with a grant of 170 million US Dollars. There are also several ongoing public health projects and programs supported by the Gates Foundation under its 2012 agreement with the state government to improve health, agriculture and financial services to the poor. Other initiatives to improve access to medicine by the government include collaborations with organizations like World Health Partners, to create public service health delivery networks including telemedicine centres, across selected villages in the state. However, the reach of these centres across such a large and populous state as Uttar Pradesh remains limited.
Delivering at scale
While there are signs that Uttar Pradesh is emerging out of the shadow of the NHRM scandal by establishing a separate system like DPICS, the tasks ahead for improved access to medicine in the state remain mammoth. Consider the following revealing statistics:
- According to the National Sample Survey in 2010, almost six percent of people in UP fell into poverty because of out-of-pocket expenditure on drugs. This is double the national level of three percent. In population terms this means almost 12 million people in UP became poor due to expenditure of medicines in 2010. The survey also found that of all people falling into poverty the greatest proportion by far, 78 percent, were in poverty because of out-of-pocket expenditure on healthcare.
- The government has been making efforts to increase access to drugs in the state of UP. The State Drug Budget in UP increased substantially from Rs.71 crores in 2001-02 to Rs. 315 crores in 2010-11. This resulted in an increase from Rs.4 per capita in 2001-02 to Rs. 16 per capita in 2010-11.
- Despite the significant increase in budget, the budget remains inadequate. Share of total state health expenditure (treasury, not counting NRHM) spent on drugs is hovering around five percent (actually showing marginal fall from 5.22 percent in 2008-09 to 4.65 percent in 2013-14).
- There is systemic efficiency issues in absorbing the funds made available for drug procurement. The audit by Comptroller and Auditor General (CAG) in 2010-11 in UP found that of the Rs. 372. 6 million allocated for procurement of drugs and equipment under NRHM, as much as Rs.264 million were left unspent and only Rs. 108.6 million were transferred to the districts.
Dependence on private sector
With the public healthcare system in Uttar Pradesh still woefully inadequate in providing access to medicine, the majority of people are forced to depend on private healthcare providers. These range from high end hospitals and clinics in cities which charge exorbitant rates, to the unregulated village quacks. Personal health insurance coverage, particularly in rural areas, is dismal and coverage is estimated to be less than one percent. So far the state government’s attempts to implement the central government scheme, Rashtriya Swasthya Bima Yojana (RSBY) to provide health insurance coverage to below poverty line (BPL) families has not worked well. With the scheme hampered by irregularities, faulty smart cards and refusal by many hospitals to provide medicine and treatment to beneficiaries because of low package rates, many of those most in need in UP remain without access to healthcare.
Judging from the poor implementation of insurance schemes in the past, health experts are not optimistic about the prospect of new proposed universal healthcare schemes like Modicare. They feel that any insurance led program to improve access to medicine will not succeed in a state where a third of its 200 million people are still living below the poverty line.