Thursday, December 25, 2014

Financing Social Sectors

On 2nd December this year over 15000 people from over 150 movements and organizations from across the country descended on Jantar Mantar near the Parliament in Delhi under the banner of Abki Baar Hamara Adhikar (ABHA). They were all demanding the protection of their various constitutional and legal rights, many of which are being threatened by Modi sarkar’s new policies and amendments to existing entitlements and provisions – land and forests, health and education, water and food security, NREGA and worker rights, social security and welfare. ABHA discussed each of these rights in a People’s Assembly over 2 days prior to the rally with experts/activists working on these issues and grassroots activists from each of these movements. At one level the discussions revolved around strategies of how to protect what exists but also on how we can strengthen each of these entitlements. Invariably one of the issues which emerges in such discussions is where will the money come from given that India has one of the lowest Tax:GDP ratios of only 17% amongst group of countries at the same level of development.
Social sector investments like health, education, food security and old age and disability pensions create basic equity amongst citizens and help reduce misery and poverty. With adequate public investments in these sectors and universal access to services and benefits therein the poverty line would be history.  At the minimum for such social security for health we need 3% of GDP, for education 6% of GDP, for Food and Nutrition security 2% of GDP and for pensions 2% of GDP. Thus at today’s prices we need close to Rs. 15 lakh crores for these social sectors. We already spend about Rs. 7 lakh crores by National and subnational governments and the deficit is about Rs. 8 lakh crores. Where will this money come from?
Raising resources or budgets for social sectors and social security is not as difficult a task as it may appear to be given the low level of allocation and spending. What is needed is a small doze of political commitment and will to increase the tax:GDP ratio from the present 17% to atleast 25% so that adequate budgets can be allocated for social sectors. The Modi government seems to be compressing public spending as we see that compared to 2013-14 budget estimates which was 15.7% of GDP, the first budget of Modi sarkar for 2014-15 saw public spending by the national government drop down to a low of 13.9% of GDP. The first casualty of this is the social sector expenditures like health, education and food security where we have already seen some compression in spending.  Jaitley in his first budget speech implied that a lot was being invested in social sectors and these investments were populist and wasteful, harking back to what Modi’s reference to MGNREGA in his election campaign as a dole and a humiliating experience for such beneficiaries. Jaitley pointed out that social sector spending needs to be made more efficient and further increases should happen via the PPP route. The problem in the social sectors is not so much about efficiency as it is about deficiency. It is in fact a shame that in India public resources committed to healthcare amount to only 1.2 per cent of GDP, for education 3.5 per cent of GDP. Social security of the unorganised sector that constitutes over 90 per cent of the workforce accounts for a mere 0.15 per cent of GDP, and the share of the Union government in that being between one-fourth and one-fifth. The global benchmarks are three to five times higher. No wonder India, the third largest economy in the world (in purchasing power parity GDP terms) has a low HDI rank of 136. But this can be changed mostly by mining resources from within the existing kitty, though ultimately new resources will also have to be generated. So here’s where the money can come from:
·         The national government gives  subsidies to the corporate sector of over Rs. 6 lakh crores and atleast  Rs. 4 lakh crores is contestable for any social benefits being accrued.
·         Uncollected taxes because of disputes is Rs. 4 lakh crores and there is no reason why this cannot be first collected and disputes settled later.
·         The daily turnover in speculative markets (shares, commodities, currencies, securities etc) is Rs 5 to 6 lakh crores . This is pure circulation of money and does not create new wealth or value addition and what is worse it is not taxed in any significant way. Even imposing a 0.5% turnover or transaction tax on this would mean Rs. 3000 crores daily as revenues or Rs. 9 lakh crores annually, the precise deficit that exists for social sector budgets
·         Apart from the above there are many other possibilities of raising resources. For instance a small amount like Rs.5 each month as social security cess on mobile connections can raise about Rs. 5000 crores annually; a 2% health  cess on sales turnover of tobacco and alcohol, and personal vehicles can raise Rs. 10000 to 15000 crores; a tax similar to profession tax  from all those working or doing business and not covered by any social security like ESIS or CGHS etc.  could generate substantial contributions etc…
·         Universalizing the ESIS to all employees by removing the salary upper ceiling of Rs. 15000 so that all employees earning higher incomes will also contribute compulsorily and this will raise ESIS revenues manifold. For instance a person like Mukesh Ambani who gets a total remuneration of Rs. 36 crores per year would contribute against his such income Rs.2.34 crores (@6.5% wages)  to the ESIS fund. Today ESIS has reserves of Rs.30000 crores and it is using workers money to start 18 medical colleges, 9 dental colleges and 12 PG medical institutes.  ESIS’s mandate is social security and not medical education. The latter would further destroy the already ailing ESIS health system. ESIS should be merged with general public health services and workers benefits from the scheme should be protected and further strengthened. Also the effort should be to extend the ESIS to as many uncovered or unorganised sector workers who can be federated into occupational groups like beedi workers, miners , plantation workers, headload workers etc. so that there is only a single scheme for social security. It would be very easy to cover even NREGA workers under ESIS where all jobcard holders should automatically be registered with ESIS and the NREGA program should contribute say 1% of the wages as social security on behalf of workers.
·         States could raise the VAT by 2.5% and earmark this for social sectors. Ghana for example does this to raise resources for its National Health Fund. There are many other possibilities provided there is a political commitment to seriously support increased budgets for social sectors.
For social sector services human resource availability for frontline service delivery is a huge problem, especially for health and education. The government invests heavily in professional and higher education, nearly Rs. 2 lakh crore each year, but outturns coming into the public system is very small. Compulsory public service for 3 to 5 years by all professionals like those graduating from medical and nursing schools, management and technology schools (IIMs, IITs, IIIT etc..), agriculture,  education, humanities, sciences and social sciences etc. is the only solution.  All those graduating must serve public systems for 3 to 5 years and only if they do so they would be allowed to do PG (say after 2 years of public service) and get their degree after 3 to 5 years. The rationale is that huge public resources are invested in higher education, which is almost free for the recipients and the people of the country have a right to a social return from such investments.  For instance, to train one MBBS doctor the government spends more than Rs. 20 lakhs. Such compulsory service will solve the problem of availability of doctors and nurses in health institutions, of teachers in schools and colleges, of engineers in infrastructure projects, of managers for public programs etc..
Those working in government get huge pensions and family pensions linked to inflation index which secures their old age for a comfortable living. All those crossing age 60 (55 for women) and not receiving any other pension should be entitled for a social pension which should be atleast equal to the minimum wage – why I am saying minimum wage and not 50% is because the minimum wage definition in India is a survival wage.
Often in public services like health and education or in delivery of welfare benefits the issue of efficiency and absorptive capacity is raised.  This is not correct. The issue is not of efficiency but one of gross deficiencies. Investments in public services are very inadequate (health 1.2% of GDP, education about 3.5% of GDP). As a consequence the approach to these services use targeting and/or  para professionals like para teachers or non-allopathic doctors and this distorts the access to these services. Because of inadequate budgetary allocations there are huge vacancies in frontline positions where services are delivered, shortages in critical supplies and consumables and poor maintenance of infrastructure. This impacts the quality of the service and discredits it in the eyes of the user creating a scenario for users to migrate to private provision. The other issue that is raised by the top bureaucracy is lack of absorptive capacity when they are confronted to raise budgetary allocations.
Absorptive capacity is a myth. The problem is of underfunded budgets, that lead to loss of credibility, poor quality, frustration, sanctioned posts not filled up leading to underspending. This underfunding and underspending viciousness is the root cause of poor service delivery and this can certainly not be termed as lack of absorptive capacity at the service delivery level. The problem therefore is not the absorption capacity but the bureaucracy itself which does not have the capacity to plan and budget in a way that service delivery is appropriately structured and financed so it can meet the demands of the people.


To conclude the question of absorptive capacity is a convenient tool which the bureaucracy uses to circumvent real issues that are a cause of the underfinancing and underspending of social sector budgets. The lack of bottom up planning and budgeting that is based on expressed needs and demands of the community for which services are being provided, and the lack of decision-making power and autonomy to govern and manage the provider institutions are the main causes for poor service delivery. This needs to be remedied immediately if resources invested in public services have to realize the policy goals.

Friday, July 11, 2014

Budget 2014-2015: New Government but Same Old Budget

High on everyone’s expectation the Modi-Jaitley juggernaut failed not only the aam aadmi but also the markets. What we see in the budget is a strong continuum from where the UPA-2 ship got grounded. The fiscal policy does not change in any significant way, infact there is an amazing continuity. What is different though is that Modi and Jaitley do not have the compulsion of coalition politics stifling the implementation of their policies. Thus the big thing that emerges in the budget is a strong market economy push, including “PPPizing” the public sectors/services to complete the full circle of neo-liberal reforms. A clear push further to the right of centre. To consolidate this in their spirit of “minimum government and maximum governance” they have proposed the setting up of an Expenditure Management Commission “which will look into various aspects of expenditure reforms to be undertaken by the Government” and help “overhaul the subsidy regime, including food and petroleum subsidies, and make it more targeted”.

Thus from the market perspective the increased FDI limits for sectors like Defence and Insurance upto 49 percent equity share has been welcomed, as also the construction sector where FDI norms have been further liberalized. But this was not something that Modi-Jaitley seeded, it has been in the pipeline of the UPA. Manmohan Singh’s government did not have the numbers and support from its coalition partners to push this through and this was labeled by right wing economists as policy paralysis. Further Public Sector Units would be encouraged to seek fresh capital from the markets thus increasing their private stake. No significant changes in tax rates are seen and the tax expenditures (revenue forgone) for the corporate sector also remains intact. This means growth in tax revenue is small so the tax to GDP ratio would continue to stagnate. Most of the increase in revenues comes from non-tax sources, including divestment/disinvestment income. So the markets are generally pleased on this account though they wanted much more.

From the aam aadmi perspective, except for the small hike in the tax exemption limit (which perhaps the UPA budget too would have done if they had presented a regular budget), there is nothing that this budget offers. The social sector’s status quo in terms of the budget allocations is maintained. Infact if we factor in inflation there is a decline in social sector budget commitments. This has largely happened due to expenditure compression. In 2013-14 total expenditure of the Union government was 15. 7 percent of GDP and in the Modi-Jaitley budget it is down to a low of 13.9 percent of the GDP, clearly an effort to rein in the fiscal deficit. This has considerably reduced the fiscal space for raising allocations for key social sector programs and services. Jaitley in his speech implied that a lot was being invested in social sectors and these investments were populist and wasteful, harking back to what Modi in his election campaign had referred to MGNREGA as a dole and a humiliating experience. He emphasized that social sector spending needs to be made more efficient and further increases should happen via the PPP route. Thus for MGNREGA he mentioned that the works have to be directed towards more productive assets and that instead of further investments in MGNREGA resources should be directed towards promoting self-employment initiatives and this would be linked to the multi skill development program called Skill India and to support this a new program called Star Up Village Entrepreneurship program will be launched.

While efficiency may be an issue for social sector programs, as for all other economic and general services programs, the problem is not so much about efficiency as it is about deficiency. It is infact a shame that in India public resources committed to healthcare is only 1.2 percent of GDP, for education 3.5 percent of GDP, social security of unorganized sector workers who constitute over 90 percent of the workforce a mere 0.15 percent of GDP, and the share of the Union government in that being between one-fourth and one-fifth. The global benchmarks are 3 to 5 times higher. No wonder India which is the 3rd largest economy in the World (in PPP GDP terms) has a low HDI rank of 136.

Reviewing the budget allocations another big change one notices is the unusually sharp decline in social sector and rural development allocations in the Union budget. For social services it has declined from Rs. 1382.31 billion to a mere Rs.610.78 billion (mostly SSA, NRHM, water and Housing) and for rural development from Rs 426 billion to Rs.29 billion (mostly MGNREGA ). This would shock even the most rabidly right wing economist and politician but when one looks into the detailed budget document the story is not so shocking. Yes these sectors, if corrected for inflation, have seen a decline in resource commitment. What has changed in this budget (and again this actually happened within the UPA’s interim budget of Feb 2014) is that a very large proportion of the social sector and welfare budgets has been moved from the Union governments direct spend and/or allocation to implementing agencies (what were off-budget schemes like SSA, MGNREGA, NRHM etc..) to the state sector plans; and these get reflected in the Union budget under grants to states and union territories. Thus the Grant in Aid allocations in the Union budget have seen a corresponding jump from Rs. 2400 billion to Rs. 3730 billion and this effectively means that the transfers with respect to these schemes will now reflect in the state government budgets. This would certainly cheer the state governments. What kind of flexibility will be available to states in the use of these funds we will have to wait and see?

What the above could also mean is gradually the Union government abdicating its responsibility towards the social sectors and shifting the onus on the states. This has been apparent in Modispeak as well as in Jaitley’s budget speech and in his presentation of the Economic Survey to Parliament. Both Modi and Jaitley are against an entitlement approach and would like to use the decentralization of fiscal resources as a mechanism to kill this and say that they are instead empowering them. But isn’t entitlement a pre-condition for empowerment? That is why MGNREGA and RTI as also Food security now are relatively strong in sharp contrast to NRHM, SCSP, TSP and other social sector programs which do not have the backing of a legal entitlement.

To conclude, key social sector program budgets whether they are legally entitled programs or not continue to be neglected. As can be seen from the Table below not only the allocations remain low both in terms of total government spending as well as in terms of GDP, but also there seems to be a declining trend in budgetary support for these programs. Health, education, social justice and labour welfare seem to be the worst affected in terms of deficiency of resource allocations. Also for many of the announcements in the budget speech one does not see actual allocations in the budget document. For instance for healthcare Jaitley mentioned that free drugs and diagnostics would be made available in public health facilities but we don’t see any allocation for that in the budget. So the road ahead for social sector budget commitments continues to be difficult and there is every indication that it could get worse under the new government.


Table: Social Sector Allocations 2012-2013 t0 2014-2015 in Union Budget (Rs. Crores)
2012-13 A/c
2013-14 BE
2014-15 BE
percent increase 14-15 over 13-14
percent of GDP 14-15
percent of A/C 12-13
percent of budget 13-14
percent of Budget 14-15
Food Security
86220
91035
115657
27.05
1.00
6.11
5.47
6.56
Drinking Water Sanitation
12969
15266
15265
-0.01
0.13
0.92
0.92
0.87
Health and Family Welfare
25133
33278
34382
3.32
0.30
1.78
2.00
1.95
AYUSH
715
1259
1256
-0.24
0.01
0.05
0.08
0.07
Health Research
720
1008
1018
0.99
0.01
0.05
0.06
0.06
AIDS Control
1316
1785
1771
-0.78
0.02
0.09
0.11
0.10
Housing & Urban Poverty
933
1468
5286
260.08
0.05
0.07
0.09
0.30
School Education & Literacy
45631
52701
54205
2.85
0.47
3.24
3.16
3.07
Higher Education
20423
26750
26865
0.43
0.23
1.45
1.61
1.52
Labour and Employment
3646
5081
5055
-0.51
0.04
0.26
0.31
0.29
Minority Affairs
2174
3531
3724
5.47
0.03
0.15
0.21
0.21
Rural Development
50187
74478
78408
5.28
0.68
3.56
4.47
4.45
Social Justice & Empowerment
4940
6752
6204
-8.12
0.05
0.35
0.41
0.35
Disabilty Affairs
633
0.01
0.00
0.00
0.04
Tribal Affairs
1400
1779
4398
147.22
0.04
0.10
0.11
0.25
Urban Development
8467
10364
19143
84.71
0.17
0.60
0.62
1.09
Women and Child Development
17036
20440
20801
1.77
0.18
1.21
1.23
1.18
Total Social Sectors
281910
346975
394071
13.57
3.41
19.99
20.84
22.35
TOTAL Govt Expenditure
1410367
1665297
1763214
5.88
15.27


GDP
9388800
10472800
11550000
10.29




Source: Union Budget Expenditure Statement Vol 1, Budget 2014-15,  Ministry of Finance, Govt of India, New Delhi 10th July2014; GDP data from Economic Survey 2013-14 (2014-15 projection by author)

Sunday, June 22, 2014

The Political Economy of Absorptive Capacity – Case of the Health Sector

written for CBGA's Budget Track - special issue on the 14th Finance Commission
Resource distribution between Centre and States is determined by provisions in the Constitution. The subjects are divided between the Centre and States and post 73rd/74th Amendment also further devolved to districts, municipalities and panchayats. There is a constant tussle between the Centre and States for a fair share of the resources and the mandate to determine this is given to the Finance Commission under Article 280. Each five years the Finance Commission defines the envelope of the share between the Centre and States as well as determines the broad parameters for sectoral allocations which states receive from the Centre’s share (Article 275) through the Planning Commission and/or centrally sponsored schemes. The Centre under Article 282 can also give discretionary grants as per its own prerogative.
On the state’s part they want a larger share in the overall envelope so that they can autonomously design their own policies and programs. At present states feel constrained in terms of resources earmarked as their direct share from the national kitty. They get only about 32 percent directly as their own share and the remaining from the central pool. From the latter the states get about half the share through policies and programs that is determined by the Centre mostly via the Planning Commission.
Politics of Fiscal Federalism
Being a federal country the states are perhaps right in their assertion that the share they get directly as their own resources is quite meagre and inadequate for them to plan boldly, especially for key social sector allocations like health, education, social welfare, rural development etc.., which are all primarily state subjects. In reality the states get only about one-third share of the revenues but share the burden of over two-thirds of the expenditure. This imbalance of spending with limited resource generation sources, since the Centre appropriates the main sources of revenues under its control, reduces state’s capacity to develop on its own free will. Given this asymmetrical fiscal federalism, the politics within the states has been changing over time with regional parties becoming dominant and national parties increasingly becoming dependent on the regional parties in coalition governments. This political scenario is now exerting pressure on liberalizing the fiscal federalism towards a much larger share for states but such a demand for increased regional hegemony is often construed by the Centre as being “anti-national” and weakening the unified integrity of the Indian nation state.
The Centre’s logic is that if states get a larger share directly or they are given more lucrative revenue raising options under their control there would be unhealthy rivalry amongst states leading to unnecessary conflicts which would be a burden for the Centre to manage. Further the huge regional imbalances of resources and capacities across different states, backwardness in development etc. may get exacerbated if the Centre has less control over distribution of resources. Also the states’ fiscal management capacities are questioned given that their ability to manage existing resources is weak and an increased volume of resources may be beyond their “capacity to absorb”.
The Quest for Fiscal Devolution
Politically the trend over the last two decades has been greater decentralization wherein more powers and subject devolution has moved from Centre to States and from States to local governments. Representative governance has been devolved, administrative devolution has happened but there is strong reluctance by the Centre for fiscal devolution. As mentioned earlier politics and administration has regionalized and good governance is not possible without adequate control over fiscal resources. So the new battle-ground in Centre –State relations is going to be greater fiscal devolution and so the task of the 14th and subsequent Finance Commissions is going to be achieving a more acceptable balance in resource distribution both between Centre and States as well as across sectors, especially the share for social sectors like health, education, social security, employment guarantee, food security, social welfare, dalit and adivasi development etc., given that many of these entitlements are being legislated into rights.
During the UPA decade under the flagship programs such entitlements have increased and have raised demand expectations. Resource commitments by the Centre to these flagships have also seen an increase but most of these programs being state subjects one has not seen in most states any substantial increases in state budget commitments. While allocations may have increased gross underspending happens and for this the Centre blames the states for lack of absorptive capacity. Is this allegation by the Centre correct? The story is not as simple as it is made out to be. The political economy of absorptive capacity is quite devious. I will illustrate this through the example of the health sector.
Absorptive Capacity Issue – the case of the Health Sector
To begin with I want to give the example of how underfunding destroyed one of the best healthcare systems in India, the health services run by the Municipal Corporation of Greater Mumbai (MCGM). Right through the sixties, seventies and eighties between one-fourth and one-third of the MCGM core budget was committed to public health and healthcare services. Almost everyone in Mumbai, especially for hospital care, utilized these services even though there was overcrowding and waiting in long queues. At the turn of the nineties, under structural adjustment reform policies the MCGM too came under its impact and social sector expenditures were compressed and a declining trend emerged. From 25 percent of its budget for healthcare in 1991 to 15 percent by 1996 and down to an abysmal 9 percent in 2014[1] the public health services of MCGM were starved of resources resulting in crippling them. The first impact was on consumables like medicines and diagnostic inputs for which prescriptions were provided to procure privately, next was maintenance of facilities and equipment which created frustration amongst staff and patients. The consequence was that the middle class patients deserted the system and opted for the emergent health insurance option, often with employer support, for treatment in private hospitals. This was a tremendous loss to the public health system as the voice of the system that kept it on its heels was snuffed out. As though this was not enough the MCGM introduced user fees from 1999 and this was the proverbial last straw that broke the camel’s back. Next a lot of the dedicated health professionals left, new recruitments stopped and the public health system, from a universal access system, became a system for the poor and consequently it became a poor and underfinanced system. This is reflected in declining budget commitments over the last two decades and which is at its lowest today.
Why I have narrated the Mumbai story is because there is an important message in it for the Finance Commission to reflect upon - running any service delivery system requires a reasonable amount of resources which need to be costed properly. The failure to do so in India has wasted huge resources in the social sectors, especially health and education. Health centres and hospitals, schools and colleges are set up without proper determination of unit cost of these services for the population it is supposed to serve. Budget allocations are made in an ad hoc manner and consequently they do not result in effective services and benefits that reach people. For instance according to WHO to run a robust comprehensive primary health care system with adequate support of secondary and tertiary services a country on average would need to invest about 5% of its GDP. In India’s case we are still hovering around 1% of GDP despite the UPA promise of upto 3% GDP commitment before the end of its term. Without such a volume of rationally allocated resources the healthcare system will continue to remain a targeted and selective health system which would prevent any significant progress towards better health outcomes. The Finance Commission needs to consider this very seriously and push for budgetary allocations which have a rational cost basis. The absence of the latter is what brings to the fore the question about absorptive capacity.
To illustrate the problem of absorptive capacity let us look at how resources are allocated.  A Primary Health Centre is set up, staff sanctions are made and most staff recruited, medicines, diagnostics etc. are provided. But if we look at allocations they are not adequate to meet the needs of the PHC which has to cater to 20000 to 30000 population. Studies for instance show that medicine requirement for outpatient care is Rs. 50 to 60 per capita per year whereas the average PHC gets only Rs. 8 to 10 per capita annually for medicines. Naturally this reduces credibility of the PHC and only the very poor come to it. So there is clearly underfunding in the PHC budget. Further because of the poor conditions of the PHCs it is difficult to find doctors and nurses, the key professionals, to work at the PHC. So because sanctioned posts are not filled there is underspending. The story for rural, district and teaching hospitals is the same – underfunded budgets, leading to loss of credibility, poor quality, frustration, sanctioned posts not filled up leading to underspending. This underfunding and underspending viciousness is the root cause of poor service delivery and this can certainly not be termed as lack of absorptive capacity at the service delivery level.
The problem therefore is not the absorption capacity but the bureaucracy itself which does not have the capacity to plan and budget in a way that service delivery is appropriately structured and financed so it can meet the demands of the people. Further, the central and state bureaucracies are unwilling to let loose their control over the healthcare delivery system, despite a lot of talk about decentralization. They may allow decentralized planning through the panchayats and even provide some untied funds for the direct use by the latter, but they will never transfer fiscal, governance and management autonomy and control to units who directly provide services and have to face the direct flak of people day in and day out for inadequate and poor quality services. This is where the problem lies in resource allocation and use. Those who deliver care, who understand and know the situation and hence can plan and budget the resources, have no role in decision making and those who govern from the state and national capitals take all decisions without having a clue to what the ground realities are[2].

To conclude the question of absorptive capacity is a convenient tool which the bureaucracy uses to circumvent real issues that are a cause of the underfinancing and underspending of social sector budgets. The lack of bottom up planning and budgeting that is based on expressed needs and demands of the community for which services are being provided, and the lack of decision-making power and autonomy to govern and manage the provider institutions are the main causes for poor service delivery. This needs to be remedied immediately if resources invested in public services have to realize the policy goals. The 14th Finance Commission must engage with these concerns and suggest mechanisms which will strengthen local capacities to take charge of fiscal management and determine their own budgetary requirements to fulfil demands of its communities.



[1] Budget documents of various years of the MCGM; also see DNA Mumbai edition 25-09-2013 Minimum Healthcare for Maximum City (pg 4) and Ravi Duggal: An increase in healthcare budget to 1991 levels is urgent need DNA 25-09-2013 (pg 4)
[2] Ravi Duggal: Sinking Flagships and Health Budgets in India, Economic and Political Weekly, Vol XLIV No 33, Aug 15 2009

Mumbai’s Healthcare – Looking Back for its Future

written for Health Action's 25th Anniversary special issue
When Health Action emerged on the scene 25 years ago Mumbai’s public healthcare system was one of the most robust in the country delivering near universal access healthcare not only to Mumbaikars but also to many from across the country and many other neighbouring countries. But post nineties the neoliberal economic reforms had adverse consequences for the public health sector. Since then this primacy of Mumbai’s public healthcare system has unfortunately withered away and today it stands at the cross roads neglected and undernourished.
This situation also generally applies to public healthcare across the country wherein public health commitment in the budgets under the Minimum Needs Program post 6th Five Year Plan which had seen substantial increases and peaked around 1988 to 1.5% of GDP saw a reversal and over the last 25 years have been hovering around 1 percent of GDP despite political commitments during the UPA decade of reaching 3% of GDP. While NRHM may have brought in a bit more resources and some improvements the public healthcare services are nowhere close to in its reach and access of what it was 25 years ago. With huge global changes where an increasing number of countries from amongst developing countries are investing towards establishing universal access to healthcare, there is no reason why India should lag behind. In India we have a strong civil society build up towards demanding universal access to basic healthcare. Jan Swasthya Abhiyaan and its various state level initiatives amongst others have actively been pushing for right to healthcare and now with a new government at the helm it is an opportune moment to push harder for right to healthcare. Even the pages of Health Action over the years have discussed this and advocated for appropriate changes. Here we discuss briefly how the public health services of Mumbai have been decimated over the last two decades.
The present status of public health services in Mumbai, as also countrywide, is both unacceptable and unpardonable. For a city which is India’s financial capital and contributes over one-third of all national taxes, the healthcare deal for the Mumbaikar is unjust. This must change in the coming years. For this to happen the Brihan Mumbai Municipal Corporation (BMC) would have to more than double its health budget. Mumbai may have the wealth that any world class city has (percapita income over Rs. 2 lakhs per year) but its public health doesn’t match up. Filth, malnutrition, communicable diseases, life-style diseases, sanitation, hygiene and environmental health are all close to the bottom of comparable cities globally. Public health facilities are under-financed, lack human resources and are in a state of disrepair.
A peep into history tells us that the situation was not always like this. Infact right upto 1991 public health and healthcare services were quite robust with the BMC spending between 25 to 35 percent of its budget on healthcare (see Table 1). Until then most Mumbaikars, the poor, the middle classes and even the rich (for super specialty care) used the public health system ranging from health posts and dispensaries to maternity homes, hospitals and teaching hospitals.  This was possible because a reasonable proportion of budgetary allocations were made, most staff was in position, medicines and diagnostics were adequately provided for, even though there was overcrowding and wait lists. The tertiary hospitals of the BMC and the state government were leaders in the country and were endowed with the most recent medical technologies and equipment.
From 1991 with the new economic policy under structural adjustment reforms the funding for healthcare contracted to an unbelievable level of 15% of that of BMC’s total budget by 1995 and since then has been on a downward slide bottoming at 8.8 percent of the budget in 2012-13. The new economic policies also brought in health insurance and the rising incomes of the middle classes facilitated often by employers buying health insurance cover for organized sector employees leading to their migration to the private health sector. The consequence of this was that the aggressive voice of the middle classes disappeared from the public health system making it a health system for the poor. And anything meant for the poor becomes a poor system as it gets neglected.
Post nineties we saw the public healthcare system in Mumbai deteriorate. The declining commitment of resources (Table 1) was the first blow. This created shortages of supplies like medicines and diagnostic consumables, inadequate maintenance, embargo on new recruitments, and curtailment of new investments for setting up additional public facilities to cater to an increasing population of the city. All this contributed to affecting the credibility of the public health system. In the meanwhile the private health sector began to boom under the liberalized economy, as also corporates entered in a big way setting up hospital and diagnostic chains. At the same time with health insurance being opened up most employers and middle class professionals opted for health insurance and the latter facilitated migration of the middle classes to the private health sector. This was the second blow to the public health system. Before the turn of the new millennium public health services introduced user charges for most services under the World Bank sponsored health sector reforms project and this alienated the poor patients too. This was the third blow. With persistent under-financing leading to deteriorating quality of public health services the staff, especially doctors and nurses, had to face the angst of the patients and this led to widespread frustration within the system. With the private health sector expanding rapidly doctors and nurses from the public system found new opportunities and began to exit from public hospitals and dispensaries. This was the final blow, the proverbial last straw that broke the camel’s back.
So looking forward to the future of public healthcare in Mumbai we actually need to look back into its history and revive the public health system we had and we were proud of. We would have to return to an expenditure level of atleast 25% of the BMC budget and this will help improve the healthcare facilities, bring back the doctors and nurses and also the patients from all classes. The middle classes who have migrated to insurance based financing and the use of the private health sector are not very happy with either. They get a raw deal, are subject to irrational therapies, malpractices and frauds. Healthcare is a public good and we need to re-establish that. For this we have to go back to the time when Health Action started and rebuild the public health system from where we left it 25 years ago. Infact, Health Action is one of the few magazines that has recorded the ups and downs of the public healthcare system, among other health issues, and discussed options of how to change the situation for the better. Mumbai has the resources and can take the lead to show that we can get back on the path towards universal access to a good quality of public healthcare services. The rest of the country will follow. And Health Action will be a witness to the changes we want to see.
Table 1: BMC’s Health Expenditure Trends 1960-61 to 2013-14 Rs. Crores
Year
Health Expenditure
Total BMC Expenditure
Percent Health
1960-61
5.46
15.84
34.45
1970-71
16.85
53,52
31.48
1980-81
50.98
187.29
27.22
1985-86
93.19
360.63
25.84
1990-91
187.63
760.85
24.66
1995-96
294.48
1913.37
15.39
2000-01
467.81
3175.14
14.73
2005-06
660.6
4902.91
13.47
2010-11
1156.77
12666.66
9.13
2011-12
1493.24
15223.52
9.81
2012-13 RE
1826.66
20687.50
8.83
2013.14 BE
2508.62
27578.67
9.10

Expenditures include revenue and capital. Source BMC budget documents various years