Chhattisgarh’s budget for the financial year 2018-19 was presented by the Chief Minister, who is also the Finance Minister, on 10th February 2018. This budget is the last one by this government before the upcoming state elections.
Chhattisgarh has allocated 5.5% of its total expenditure on public health and family. This proportion is higher than many other states, however, analysis of Chhattisgarh’s health budget allocations in the previous years reveal that there is a declining trend in budget allocation. In 2016-17 there was a 19% increase in the health budget compared to the previous year, but in 2017-18 there was only a 12 % increase in allocation. In 2018-19, there has only been a 7 % increase in the allocation to the Public Health and Family Welfare Department from the previous year’s budget. If we compare with last year’s revised estimates, then the increase comes to a mere 4%. This measly increase is inadequate and does not account even for inflation.
It is clear from the health budget that rather than focusing on strengthening the government health services, the government is promoting initiatives, like Rashtriya Swasthya Bima Yojana (RSBY) and Mukhyamantri Swasthya Bima Yojana (MSBY) and outsourcing of government facilities and services, that will instead damage the public health system.
The government is planning to hand over health facilities to the private sector. The government has planned to outsource Supela (Durg district) and Mana (Raipur district) civil hospitals, for which an initial budget of two crore has been kept. These two civil hospitals are located in the two biggest cities of Chhattisgarh, and therefore there is no reason that the government cannot get adequate human and other resource to run these hospitals themselves. The government is planning this Public Private Partnership (PPP) despite the fact that all over the country, PPPs for providing healthcare have failed. In Chhattisgarh too all previous efforts, like the Escorts Hospital, Vedanta Cancer Hospital, and Rural Mobile Medical Units have failed and caused loss to public exchequer.
Another threat for outsourcing is the newly announced free diagnostics scheme whereby pathology and radiology tests would be available free of cost at all district hospitals and community health centres (CHCs). A provision of Rs. 30 crore has been made for it in the budget. If the government outsources the government laboratories to private agencies, it will irreparably damage the existing government laboratories. Experiences from other states like Bihar show that outsourcing has resulted in poor quality services, people are forced to pay extra charges, and they do not get the required tests. It has been found that while on one hand public funds are pumped into the private labs through outsourcing, on the other hand the government labs, technicians and radiographers become redundant and non-functional.
Chhattisgarh government itself had attempted to outsource diagnostic services in government facilities in 2013 which was hugely opposed by people of the state. In answer to the advertisement, private agencies refused to go to Sarguja and Bastar divisions and wanted to stay only in Bilaspur and Raipur. The government had to finally cancel the outsourcing plan. Currently there are enough trained lab technicians and other health workers in Chhattisgarh to be posted at all PHCs, CHCs and district hospitals to run labs effectively.
It is shameful that the government is continuing to prioritise RSBY/MSBY despite the fact that the insurance schemes are damaging the government health system, while benefiting the private hospitals. Private hospitals get more than 83% of the insurance claims money. There is enough evidence to show that these schemes are not reaching the poor, tribal and most vulnerable populations. Patients are forced to pay money to the hospital even after they have used the insurance smart card. Private hospitals are engaging in irrational care, unnecessary procedures and choosing to do only those procedures that are profitable. Majority of the state’s population that live in rural areas and in the tribal districts are not getting any benefit from the insurance scheme.
The share of RSBY/MSBY in the health budget has doubled in the last three years, from 6.6% of the total health budget in 2015-16 to 13% in the current budget. An amount of Rs. 447 crore has been budgeted for these two schemes. The state had already increased the annual entitlement under RSBY/MSBY to Rs. 50,000. Senior citizens and journalists would get an additional Rs. 30,000, taking it to Rs. 80,000.
While the RSBY/MSBY budget has seen a steady increase in allocations in the last few years, allocations for the government health system have either decreased or have remained stagnant. This year while RSBY/MSBY saw an increased allocation of 18% from last year, there has been a decrease in allocation to the core institutions providing government health services. Primary Health Centres (PHC) saw 4% decrease and Sub health centres (SHCs) saw 13% decrease in infrastructure and 4 % decrease in basic services budget. Theincrease in allocation for many other critical government healthcare institutions was paltry, like 1% increase in Mukhyamantri Urban Health Programme, 2% increase in Urban Health Centres and 4% increase for Community Health Centres. Only the allocation for District Hospital saw an increase of 31%. In the budget speech the CM mentioned about new facilities to be built and upgraded. This includes construction of buildings for two CHCs, ten PHCs, 25 SHCs and approval for one 100 bed hospital in Sarangarh and one 50 bedded civil hospital in Devbhog. It was also mentioned that 283 PHCs would be upgraded to provide health services 24*7, however, as is evident from above, thebudget provided is not commensurate with this plan. The CM also mentioned about upgrading the District Hospitals of the newly formed districts of Baloda Bazar, Gariaband, Balrampur & Surajpur to IPHS standards by creating 268 new posts, that would most probably be done from the district hospital budget and about additional human resource, provision of modern equipment and building construction in six medical college hospitals.
Critical programmes like the AIDS control programme have seen a drastic 100% decrease with an allocation of only one lakh, which will mainly affect the training and IEC component. This does not bode well for preventive and curative work on HIV-AIDS as the Government of India has also cut funds to the AIDS control programme. The CM also mentioned that the government will start work oncomputerising patient’s health records in government hospitals. The fear is that, as seen in other instances, this usually means that the Aadhaar card would be used to identify patients and their records. Making the Aadhaar mandatory for accessing health services is leading toexclusions and creating more barriers in access. Moreover, such a move would be disastrous for patient’s privacy, as currently there is no robust system for protecting privacy or patient’s choice.
There are nearly 70,000 Mitanins (ASHAs) in Chhattisgarh. Chhattisgarh government pays 50% additional incentive to the Mitanins current above the incentive given by NHM. In this budget the CM announced that this contribution will be increased to 75% of what NHM provides as incentive to Mitanins. As per the current average incentive received by Mitanins, the average increase in incentive will be by a mere Rs. 370 per month. Though the government seems to have increased its budgetary allocation under the Mitanin Kalyan Nidhi (Rs. 101 crore), the budget requirement commensurate with this announcement falls nearly Rs. 46 crore short of what is required to pay for this increase. Moreover, the government has failed to agree to the longstanding demand for a similar state contribution for the Mitanin support structure that consists of the Mitanin Trainers and Block Coordinators.
The government’s announcements on improving nutrition services too does not seem to be backed by adequate budget provision.Though in the budget speech several announcements were made regarding increase in the entitlement per child in the anganwadi and increase in the honorarium of anganwadi workers and helpers, the budget for ICDS remains stagnant with only a 0.6% increase!
Jan Swasthya Abhiyan demands that health sector budget allocation should be increased from the current 1.3% to atleast 3% of state GDP. The Chhattisgarh government should use the health budgets to strengthen the public health system instead of transferring funds to the private health sector through insurance schemes and public private partnerships that are actually damaging the public health system. A strengthened government health system can cater to all the people of the state, especially the poor, tribal and vulnerable populations more effectively. The budgets for the core public health institutions like CHCs, PHC and SHC and for free medicines and other critical programmes have to be increased. The government should to cancel its plans to outsource the two civil hospitals and instead plan for improving their functioning themselves. The free diagnostics scheme should not be implemented through outsourcing and instead the government laboratories should be resourced, upgraded and improved and lab technicians recruited to provide diagnostic services free of cost. Private practice of government doctors has to be regulated in accordance with the Bilaspur High Court’s order of February 2017. The government needs to show higher commitment to people’s health and to its own public health system.
Jan Swasthya Abhiyan Chhattisgarh