Type: DOMR

Out-of-pocket expenditure (OOPE) as a share of total health expenditure and foreign aid for health has both come down as per the findings of the National Health Accounts (NHA) estimates for India for 2017-18.

What is National Health Accounts (NHA)?

• The NHA estimates are prepared by using an accounting framework based on internationally accepted System of Health Accounts 2011, provided by the World Health Organization (WHO).
• It is released by Ministry of Health & Family Welfare.
• It describes health expenditures and flow of funds in the country’s health system over a financial year of India.
• It answers important policy questions such as what are the sources of healthcare expenditures, who manages these, who provides health care services, and which services are utilized.
• It is a practice to describe the health expenditure estimates according to a global standard framework, System of Health Accounts 2011 (SHA 2011), to facilitate comparison of estimates across countries.

Objective of the NHA

• To describe the Current Health Expenditures (CHE).

The details of CHE are presented according to

• Revenues of healthcare financing schemes: – entities that provide resources to spend for health goods and services in the health system;
• Healthcare financing schemes: entities receiving and managing funds from financing sources to pay for or to purchase health goods and services;
• Healthcare providers: entities receiving finances to produce/ provide health goods and services;
• Healthcare functions: It describes the use of funds across various health care services.

About NHA (2017-2018)

• The 2017-18 NHA estimates shows government expenditure on health exhibiting an increasing trend and growing trust in public health care system.
• With the present estimate of NHA 2017-18, India has a continuous Time Series on NHA estimates for both government and private sources for five years since 2013-14.
• These estimates are not only comparable internationally, but also enable the policy makers to monitor progress towards universal health coverage as envisaged in the National Health Policy, 2017.

Key Highlights

Increase in GDP share: The NHA estimates for 2017-18 clearly show that there has been an increase in the share of government health expenditure in the total GDP from 1.15% in 2013-14 to 1.35% in 2017-18.

Increase in govt share in expenditures: In 2017-18, the share of government expenditure was 40.8%, which is much higher than 28.6% in 2013-14.

Per-Capita increase in expenditure: In per capita terms, the government health expenditure has increased from Rs 1042 to Rs.1753 between 2013-14 to 2017-18.

Focus on total healthcare: The primary and secondary care accounts for more than 80% of the current Government health expenditure.

Social security expenditure: The share of social security expenditure on health, which includes the social health insurance program, Government financed health insurance schemes, and medical reimbursements made to Government employees, has increased.

Decline in foreign aid: The findings also depict that the foreign aid for health has come down to 0.5%, showcasing India’s economic self-reliance.

Decline in OOPE: The government’s efforts to improve public health care are evident with out-of-pocket expenditure (OOPE) as a share of total health expenditure coming down to 48.8% in 2017-18 from 64.2% in 2013-14.

Way forward

• After 18 months of Covid-19, financial year 2017-18 appears to be from another era.
• However, learnings from that year’s NHA help us to plan for health system strengthening in the post-Covid years.
• The special financing packages for Covid emergency response, announced by the central government in 2020 and 2021, represent an extraordinary situation.
• The resolve to increase public financing for health must remain strong even after Covid.

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The Union health ministry released the summary findings of the fifth round of the National Family and Health Survey (NFHS-5), conducted in two phases between 2019 and 2021.

About NFHS

• The NFHS is a large-scale, multi-round survey conducted in a representative sample of households throughout India.
• The previous four rounds of the NFHS were conducted in 1992-93, 1998-99, 2005-06 and 2015-16.
• The survey provides state and national information for India on:

Fertility, infant and child mortality, the practice of family planning, maternal and child health, reproductive health, nutrition, anaemia, utilization and quality of health and family planning services etc.

Objectives of the survey

Each successive round of the NFHS has had two specific goals:

• To provide essential data on health and family welfare needed by the Ministry of Health and Family Welfare and other agencies for policy and programme purposes
• To provide information on important emerging health and family welfare issues.

Key highlights of the NFHS-5

[1] Women outnumbering men

• NFHS-5 data shows that there were 1,020 women for 1000 men in the country in 2019-2021.
• This is the highest sex ratio for any NFHS survey as well as since the first modern synchronous census conducted in 1881.
• To be sure, in the 2005-06 NFHS, the sex ratio was 1,000 or women and men were equal in number.

[2] Fertility has decreased

• The Total Fertility Rate (TFR) has also come down below the threshold at which the population is expected to replace itself from one generation to next.
• TFR was 2 in 2019-2021, just below the replacement fertility rate of 2.1. To be sure, in rural areas, the TFR is still 2.1.
• In urban areas, TFR had gone below the replacement fertility rate in the 2015-16 NFHS itself.

[3] Population is ageing

• A decline in TFR, which implies that lower number of children are being born, also entails that India’s population would become older.
• Sure enough, the survey shows that the share of under-15 population in the country has therefore further declined from 28.6% in 2015-16 to 26.5% in 2019-21.

[4] Children’s nutrition has improved

• The share of stunted (low height for age), wasted (low weight for height), and underweight (low weight for age) children have all come down since the last NFHS conducted in 2015-16.
• However, the share of severely wasted children has not, nor has the share of overweight (high weight for height) or anaemic children.
• The share of overweight children has increased from 2.1% to 3.4%.

[5] Nutrition problem for adults

• For children and their mothers, there are at least government schemes such as Integrated Child Development Services (ICDS) that seek to address the nutritional needs at the time of childbirth and infancy.
• However, there is a need to address the nutritional needs of adults too.
• The survey has shown that though India might have achieved food security, 60% of Indians cannot afford nutritious diets.
• While the share of women and men with below-normal Body Mass Index (BMI) has decreased, the share of overweight and obese (those with above-normal BMI) and the share of anaemic has increased.

[6] Basic sanitation challenges

• Availability of basic amenities such as improved sanitation facilities clean fuel for cooking, or menstrual hygiene products can improve health outcomes.
• There has been an improvement on indicators for all three since the last NFHS. However, the degree of improvement might be less than claimed by the government.
• For example, only 70% population had access to an improved sanitation facility.
• While not exactly an indicator of open defecation, it means that the remaining 30% of the population has a flush or pour-flush toilet not connected to a sewer, septic tank or pit latrine.

[7] Use of clean fuel

• The share of households that use clean cooking fuel is also just 59%.

[8] Financial inclusion

• The share of women having a bank account that they themselves use has increased from 53% to 79%.
• Households’ coverage by health insurance or financing scheme also has increased 1.4 times to 41%, a clear indication of the impact of the government’s health insurance scheme.

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The report on ‘Health Care Equity in Urban India’ exploring health vulnerabilities and inequalities in cities in India was recently released.

About the report

• The report is released recently by Azim Premji University in collaboration with 17 regional NGOs across India.
• It notes that a third of India’s people now live in urban areas, with this segment seeing rapid growth from about 18% (1960) to 28.53% (2001) to 34% (in 2019).
• The study draws insights from data collected through detailed interactions with civil society organizations in major cities and towns.
• This also included an analysis of the National Family and Health Surveys (NHFS), the Census of India, and inputs from State-level health officials on the provision of health care.
• It also looks at the availability, accessibility, and cost of healthcare facilities, and possibilities in future-proofing services in the next decade.

Key highlights of the report

• Urban poverty on rise: Close to 30% of people living in urban areas are poor.
• Declining life expectancy: Life expectancy among the poorest is lower by 9.1 years and 6.2 years among men and women, respectively, compared to the richest in urban areas.
• Chaotic health governance: The report, besides finding disproportionate disease burden on the poor, also pointed to a chaotic urban health governance.
• Multiplicity and non-coordination: The multiplicity of healthcare providers both within and outside the government without coordination challenges to urban health governance.
• Lack of political attention: Urban healthcare has received relatively less research and policy attention.

Major recommendations

The report calls for:

• Strengthening community participation and governance
• Building a comprehensive and dynamic database on the health and nutrition status, including co-morbidities of the diverse, vulnerable populations
• Strengthening healthcare provisioning through the National Urban Health Mission, especially for primary healthcare services
• Putting in place policy measures to reduce the financial burden of the poor
• A better mechanism for coordinated public healthcare services and better governed private healthcare institutions

Conclusion

• As urbanization is happening rapidly, the number of the urban poor is only expected to increase.
• A well-functioning, better coordinated, and governed health care system is crucial at this point.
• The pandemic has brought to attention the need for a robust and resourced healthcare system.
• Addressing this will benefit the most vulnerable and offer critical services to city dwellers across income groups.

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