Journal of Rural Development, Vol. 39 No. (3) pp. 366-382.
A
Methodology
to Track Economic Mobility of Castes in South Indian
Village,
circa 1866-2001
NIRDPR,
Hyderabad.
Sapana
Ngangbam
and Archana K.366
Roy
366
PUBLIC HEALTHCARE EXPENDITURE
NEEDS IN NORTH-EASTERN STATES
OF INDIA
Sapana Ngangbam* and Archana K. Roy **
ABSTRACT
The present paper assesses the public healthcare expenditure required to provide
sufficient primary healthcare facilities as per the Indian Public Health Status (IPHS) norm
in the rural areas of north-east India. The analysis is based on the data from Rural Health
Statistics (RHS) 2015, National Health Mission framework for implementation and other
macroeconomic sources. The present study has found that healthcare facilities (subcentres, PHCs and CHCs) in the rural areas of north-east India are in a poor condition
which is evidenced by shortages of infrastructure, lack of sufficient manpower, drugs
and medicines, equipment and other necessary provisions. It is imperative that the
north-eastern States should increase their spending on rural public health to provide
universal primary healthcare facilities as per the IPHS in the rural areas. An estimated
additional amount of about Rs. 68 lakh thousand (equivalent to more than 7 per cent of
total public health expenditure or 0.23 per cent of the North-East region’s gross domestic
product) at current prices will be required to be spent across the north-eastern States.
Keywords: Universal Primary Healthcare Facilities, Public Healthcare Expenditure
Needs, Rural Areas, North-Eastern States.
* Assistant Professor, Department of Economics, Lilong Haoreibi College, Lilong, Manipur.
Email: ngangbamsapana@gmail.com
** Professor, Department of Migration & Urban Studies, International Institute for Population Sciences, Deonar, Mumbai –
400088. India. Email: royarchana@yahoo.com
Journal of Rural Development, Vol. 39, No. 3, July - September: 2020
Public Healthcare Expenditure Needs in North-Eastern States of India
Introduction
Public health is concerned with disease
prevention and control at the population
level through organised efforts, and enabling
individuals, communities and organisations
to make informed choices. Access to public
healthcare services is critical in providing
and regulating health services, particularly
in developing countries which has a large
concentration of poor people (Rao &
Choudhury, 2012). Inadequate financial
resources for the public health sector result
in inequalities in health services. The role
of government is crucial to address these
challenges and achieving equity in healthcare
(Lakshminarayanan, 2011). In India, the
government share of the total healthcare
has been falling over the years. Increasingly,
people have to spend more from their own
pockets (Chakrabarti and Shanker, 2015). High
Out of Pocket Expenditure (OOP) healthcare
expenditures exacerbate poverty, with
about 39 million additional people falling
into poverty every year as a result of such
expenditures (Balarajan et al, 2011). According
to the National Health Accounts (2013-14),
government health expenditure accounts for
2.58 per cent of GDP and 64.21 per cent of total
health expenditure in India. This indicates the
inadequacy of public health expenditure to
keep pace with the healthcare needs of India’s
growing population. The relationship between
per capita GDP and the share of GDP spent on
healthcare may be influenced by institutional,
cultural, and economic factors like provider
367
payment methods, degree of universality of
coverage, role of the private sector and relative
prices (Hopkins, 2010).
Thus, the burden of diseases in India in terms
of healthcare expenditure is still high due to
large-scale poverty, developmental disparities
between States, gender discrimination,
increasing number of aged persons in the
population, and failure of government
plans and policies (Gupte, Ramachandran, &
Mutatkar, 2001). Universal coverage should
be the ultimate goal to protect all households
against catastrophic health expenditures.
However, there is no universal pathway to
universal coverage that is appropriate for all
countries. Certain public health programmes
must remain the sole responsibility of the
government regardless of the choice of health
financing options (WHO, 2004). Despite
considerable development in the health
sector of India, there are problems and issues
related to accessibility, efficiency, and quality
of healthcare delivery.
Heavy out-of-pocket healthcare expenditure
due to low and dwindling budgetary
allocations on healthcare at State level pushes
many households below poverty line (Arora &
Gumber, 2008). Poor and uneven distribution
characterises poor public spending on
healthcare in India. Rao and Choudhury (2012)
emphasised reforms in India’s health sector
by increasing public spending on healthcare
in general, and preventative care in particular
with greater accessibility to healthcare for
Journal of Rural Development, Vol. 39, No. 3, July - September: 2020
368
the poor and significant improvement in
the productivity of public spending and its
distribution.
Studies have found that the continued
failure of the government to implement health
policies, inability to provide quality healthcare,
and growing privatisation of health services
has forced the poor into an unrelenting
poverty trap (Roy & Hill, 2007; Wagstaff & van
Doorslaer, 2001). As a consequence, private
healthcare providers have taken over most
of the healthcare system. Greed among
medical practitioners does not even spare the
poorest of the patients. Medical expenses are
now considered one of the major triggers of
impoverishment in the country (Mazumdar,
2015). The study of NSSO data (2004-2010)
on morbidity and health expenditure showed
that the cost per illness episode has increased
in the last decade. This was largely because
of increased morbidities, and the cost of
treatment largely met by borrowing money
(Jayakrishnan, Jeeja, & Paramasivam, 2015).
Only 12 per cent of the urban and 13 per cent
of the rural population received protection
coverage through any of the Publicly Funded
Health Insurance (PFHI) schemes like Rashtriya
Swasthya Bima Yojana (RSBY). These facts
underscore India’s inability to use the funds
on health (which is already low) efficiently
and worse, withdrawal of public expenditure
from the health sector. Also, successive
governments have failed to realise that only a
healthy State could accelerate the process of
economic growth.
Sapana Ngangbam and Archana K. Roy
Need for the Study
India is a vast country and its constituent
States are at different levels of development.
The adequacy of healthcare facilities in
the States also vary significantly, and interregional inequalities in the health sector
exist. The EAG and north-eastern (NE) States
are regions which are in need of expansion
of healthcare services. They require support
and resources — monetary as well as physical.
The Government of India, through NHM, has
recognised north-eastern States among the 18
special focus States, which have weak public
health indicators and weak infrastructure,
to provide effective healthcare to the rural
population. It will not be possible to provide
the desired services until the infrastructure is
sufficiently upgraded.
The north-eastern States account for only
3.8 per cent of India’s total population but
due to inadequate infrastructure, the region
remains backward and has not benefitted from
the country’s development and progress. The
north-east region comprises eight States and
altogether, the prevalence of communicable
(TB, Malaria, HIV, etc.) and non-communicable
diseases (asthma, goitre, thyroid disorders,
anaemia, etc.) here is higher than the national
average. Despite having better infrastructure
than many States, the quality of care and
manpower remains a cause for concern as it is
affecting the overall health-seeking behaviour
of the people. For the resource-starved northeastern States, public funding from the Centre
Journal of Rural Development, Vol. 39, No. 3, July - September: 2020
Public Healthcare Expenditure Needs in North-Eastern States of India
is the only means to save the poor people
of north-east India from ill-health. Though
developmental thrust for healthcare services
and medical education has been taken up,
considerable time is required to ensure
quality healthcare to all the people of northeastern States. As the fund received from
the Government of India and the States’ own
fund are not sufficient to provide sufficient
healthcare facilities, the north-eastern States
may accordingly send proposals for funding
to NEC through designing suitable schemes
and send those to the North Eastern Council
(NEC) for funding (Draft North Eastern
Council Regional Plan, 2019). Moreover, all the
north-eastern States have targeted to reach
millennium development goals (MDG) and
sustainable development goals (SDG) through
proper implementation of the National Health
Mission (NHM) (MoHFW, 2011).
However, because of the rural-urban
differentials in the level of development
like higher levels of marginalisation and
deprivation, the rural areas have limited access
to healthcare resources (Sparks & Sparks,
2012). The policies implemented so far are
heavily skewed to facilitate economic growth,
overlooking the need to ensure equity and
equality. The result is that the gaps between
urban and rural, and the haves and havenots have widened. Nearly 70 per cent of all
deaths (including 92 per cent of deaths from
communicable diseases) occurred among the
poorest 20 per cent of India’s population (Patil,
369
Somasundaram, & Goyal, 2002). It may be
noted that 68.8 per cent of India’s population
lives in rural areas (RGI, 2011). According to the
findings of Chillimuntha, Thakor, & Mulpuri,
(2013), less than 10 per cent of the total health
budget is allocated to the rural sector, 75 per
cent of qualified doctors practice in urban
areas and 23 per cent in semi-urban (towns)
places. Only two per cent of doctors practise
in rural areas.
Studies on the north-eastern States
have highlighted shortage of healthcare
infrastructure in terms of physical facilities,
medical equipment and manpower. To raise
the standard of living of the populace, there
is an urgent need to make quality healthcare
accessible to one and all (North Eastern
Council, 2012). Lyngdoh (2015) also has
highlighted an urgent need to address the
shortcomings faced by the public healthcare
system in the north-eastern States. The state of
rural healthcare infrastructure in these States is
found to be far from satisfactory. Another study
by Saikia (2015) also highlighted the healthcare
sector’s constraints of inadequate physical
infrastructure as well as essential facilities and
trained manpower. The presence of private
sector in remote rural areas is negligible and
hence, to ensure that there is universal access
to healthcare services, the public sector has to
play a leading role.
The insufficiency of quality healthcare
services (both public and private healthcare
Journal of Rural Development, Vol. 39, No. 3, July - September: 2020
370
facilities) in the rural areas of the north-east
region suggest the need for a systematic
analysis to understand the burden of providing
healthcare services in rural areas in the region,
as the existing studies have some limitations to
present a vivid picture. Further, there is hardly
any evidence of any study which assesses the
burden of healthcare expenditure at the State
level in the north-east region. Moreover, the
Government of India is functioning at the
hierarchical order of Central, State and local
level. A State-level study is important for
gaining the necessary insights that will help to
strengthen the healthcare sector in the northeast region.
To this end, the present study aims to analyse
the health status of the people of north-east
India; to assess the shortfalls — healthcare
infrastructure, facilities or manpower in rural
areas and to estimate the additional public
healthcare expenditure required to provide
essential primary healthcare services (subcentres, PHCs and CHCs) as specified in the
Indian Public Health Standard (IPHS) guidelines
in rural areas of the north-eastern States of
India.
Data and Variables
Data Source: The data sources of the present
paper have been the Census of India, 2011,
Compendium of SRS (1971-2013), Health
Sector Financing by Centre and States/UTs in
India, compiled by National Health Accounts
Cell (Ministry of Health and Family welfare),
Rural Health Statistics (RHS) 2015, and the
Sapana Ngangbam and Archana K. Roy
National Health
implementation.
Mission
framework
for
Methods
The present study has used bivariate, scatter
plots and simple linear regression analysis. The
study also has estimated additional public
resource requirements for primary healthcare
facilities. State-wise shortfalls in the health
sector in 2015 were calculated using data from
Rural Health Statistics (RHS, 2015). It provides
data regarding infrastructural information and
building positions of sub-centres, PHCs and
CHCs. It also has State/UT-wise information
of specialist doctors, health workers, auxiliary
nurse midwife (ANM), nursing staffs, health
assistants, radiographers and pharmacists.
It includes information of staff in position,
requirement of staff and shortfall for existing
public healthcare facilities in rural areas.
District-wise availability of health centres has
also been furnished in the data. To determine
the health gap, i.e. shortage of primary
healthcare facilities as per IPHS guidelines1
for the year 2015, the following norms were
followed:
State-wise shortfalls of sub-centres, PHCs
and CHCs in rural areas of north-eastern States
for the year 2015 were calculated in the present
paper. The process followed is explained as:
•
Journal of Rural Development, Vol. 39, No. 3, July - September: 2020
First, the population of north-eastern
States in 2015 was estimated using
exponential growth rate approach from
2001 to 2011 using figures from Census
2001 and 2011.
Public Healthcare Expenditure Needs in North-Eastern States of India
•
Next, State-wise shortfalls of subcentres, PHCs and CHCs were calculated
following the norm of one sub-centre (SC)
for every 5,000 population, one Primary
Health centre (PHC) for every 30,000
population, and one community health
centre (CHC) for every 120,000 population
in the plains. For tribal and hilly areas, the
corresponding threshold population is
3,000, 20,000 and 80,000, respectively, as
per IPHS guidelines.
•
Shortfalls of health manpower, drugs,
tools, facilities, etc., which are essential
for the functioning of a healthcare facility
were calculated. For this, the available
facilities in the existing sub-centres,
PHCs and CHCs were listed out from RHS,
2015 data and shortfalls were estimated,
according to IPHS guidelines.
•
Next, the cost for providing existing
shortages (manpower, drugs, tools,
utensils, etc.) to sub-centres, PHCs and
CHCs was calculated.
•
Next, the cost for providing shortfalls of
manpower, drugs, tools, utensils, etc., in
the already existing sub-centres, PHCs and
CHCs was calculated separately.
•
Finally, both the above costs in steps 4
and 5 were added together to arrive at total
resources or public expenditure required
to provide universal primary healthcare
facilities in the rural areas of north-eastern
States as per the IPHS guidelines.
371
For the cost analysis of the paper, the
cost structure for healthcare services given
in the Report of National Commission on
Macroeconomic and Health was followed,
as the same cost structure is adopted in the
framework for implementation of NRHM,
(2012-2017).
Results
The results of the analysis are presented
in three sections. First of all, the health status
of the people of the north-east has been
examined with respect to the relationship with
income and availability of health manpower
and infrastructure at sub-centres, primary
health centres (PHCs) and community health
centres (CHCs) in the rural areas. In the
second section, status of availability of health
manpower and infrastructure at sub-centres
(PHCs) and community health centres (CHCs)
in the rural areas according to IPHS norm has
been analysed. The next section provides the
investments needed to meet the shortfall of
sub-centres, primary health centres (PHCs) and
community health centres (CHCs) as per India
public health standard (IPHS).
Health Status of the People of the NorthEast (at Population Level)
Table 1 shows the health status and human
development indicators: infant mortality rate
(IMR), life expectancy at birth (e00), real per
capita net State domestic product (NSDP), per
Journal of Rural Development, Vol. 39, No. 3, July - September: 2020
372
Sapana Ngangbam and Archana K. Roy
capita health expenditure (PCHE) and per cent
share of GSDP on health expenditure (HE) in
the north-eastern States of India. According
to UNDP (2016), out of 188 countries, India
ranked 131st with a Human Development
Index (HDI) value of 0.624 in 2015, 132nd in life
expectancy at birth (68.3 years), and 140th in
ranked 60 to 100 as per the UNDP (2016)
report. The life expectancy at birth (e00) during
2011-13 was higher than the national average
(68 years) in all the States except Assam (64
years) and Meghalaya (62 years). It ranged
from 69 years in Arunachal Pradesh to 84 years
in Nagaland.
IMR (37.9 infant deaths per 1000 live births)
in 2015. It was ranked 172nd in terms of health
expenditure (1.4 per cent) as a percentage
share of Gross State Domestic Product (GSDP)
in 2014.
Four
north-eastern
States,
namely
Arunachal Pradesh, Assam, Manipur and
Meghalaya have lower real per capita net State
domestic product (PCNSDP) than the all-India
average (₹39,904). It varied from ₹23,392 in
Assam to ₹37,154 in Meghalaya. While the
other four States (Mizoram, Nagaland, Sikkim
and Tripura) had PCNSDP that was higher than
the national average, Sikkim had the highest
PCNSDP (₹83,527) among all the north-eastern
States. However, in spending on healthcare as
percentage of GSDP in 2013-14, all the northeastern States except Assam are spending a
higher share as compared to India average.
North-eastern States present quite a
heterogeneous situation in these indicators
across the States. The inter-State variations in
IMR , which is a measure of health status, range
from 9 in Manipur to 47 in Assam. Only Assam
and Meghalaya had higher IMR than the allIndia average (37). Other States like Manipur,
Nagaland, Sikkim and Tripura have much lower
IMRs, which are comparable to the countries
Table 1: Health and Economic Indicators in North-Eastern States of India
e0 in 2011-13
0
IMR 2013-15
Real PC NSDP
at 2004-05
price, 2013-14
in ₹
PCHE,
2013-14
HE as a per
cent of GSDP,
2013-14
NE States
T
R
U
T
R
U
T
T
T
Arunachal Pradesh
30
32
19
69
67
75
36019
3002
2.83 per cent
Assam
47
50
25
64
59
72
23392
855
1.69 per cent
Manipur
9
10
8
79
79
80
24042
1658
2.92 per cent
Meghalaya
42
44
34
62
61
70
37154
1639
2.02 per cent
Mizoram
32
39
22
81
74
93
41094
2700
2.71 per cent
Nagaland
12
11
15
84
84
91
49963
1707
2.23 per cent
Sikkim
18
20
14
73
72
82
83527
4145
2.11 per cent
Journal of Rural Development, Vol. 39, No. 3, July - September: 2020
373
Public Healthcare Expenditure Needs in North-Eastern States of India
Tripura
20
19
25
78
79
78
47261
1821
2.53 per cent
India
37
41
25
68
66
71
39904
913
1.00 per cent
Note: T=Total, R=Rural, U=Urban, IMR=Infant Mortality Rate, e_0^0= Life expectancy at birth, PCNSDP=Per capita net
State domestic product, PCHE=Per capita health expenditure, HE=Health expenditure, GSDP= Gross State Domestic
Product; Sources of data: IMR has been taken from Compendium of SRS, 1991-2013; e00 for north-eastern states has been
calculated by using abridge life table taking ASMR from SRS; Real per capita NSDP is taken from planning commission
data, and per capita public health expenditure and per cent of health expenditure to GSDP have been taken from National
Health Profile, 2016.
Interlinking IMR, Life Expectancy and PC
Real NSDP (at 2004-05 price)
The relationship between the two health
indicators IMR and e00 with income was found
to be strong as the latter is the improvement
of former (O’Hare, Makuta, Chiwaula, & BarZeev, 2013). Scatter plot 1a and 1b show the
real per capita NSDP with IMR and e00 from
1991 to 2012. The connection between health
and income suggests that in north-east India
too, per capita income and health status
are strongly associated. There is a positive
association between real per capita income and
life expectancy at birth, an inverse relationship
between real per capita income and infant
mortality rate. The influence of real per capita
net State domestic product on infant mortality
rate is higher than life expectancy at birth.
Figure 1: Scattergraphs showing the relationship between a. infant mortality rate (IMR)
and b. life expectancy at birth with Real PC net State domestic product at factor cost at
2004-05 price in north-east India, (1991-2012)
Journal of Rural Development, Vol. 39, No. 3, July - September: 2020
374
Sapana Ngangbam and Archana K. Roy
Relationship of Health Status with Income,
Health Manpower and Infrastructure
0.0007 years significantly at 10 per cent level
of significance. Population pressure per nurse
has no significant effect on IMR and e00. One
Health status is an indicator of development,
which can be improved with an increase
in income and health infrastructure and
manpower development. Linear regression
unit increase in population pressure per subcentre increases IMR by 0.004 points at 10 per
cent level of significance and reduces e00 by
0.004 years at 5 per cent level of significance.
One unit increase in population pressure one
PHC increases IMR by 0.002 points and reduces
e00 by 0.001 years both at 1 per cent level of
result for infant mortality rate and life
expectancy by per capita health expenditure,
per capita GSDP and health infrastructures in
north-east India during 2009-2015 is shown
in Table 2. The regression results indicate
that one unit increase in per capita real net
State domestic product at 2004-05 price
(PCNSDP) reduces IMR by 0.0004 points and
increases life expectancy at birth by 0.0003
years both at 5 per cent level of significance.
One unit increase in population pressure on
doctor increases IMR by 0.002 points at 1 per
cent level of significance and reduces e00 y
significance. One unit increase in population
pressure per CHC increases IMR by 0.0001
points at 10 per cent level of significance and
reduces e00 by 0.0001 years at 5 per cent level
of significance. Thus, health status represented
by IMR and e00 decreases by an increase in
population, however, it can be improved by
increasing State income, availability doctors
and improving health infrastructures.
Table 2: Linear Regression Result for Infant Mortality Rate and Life Expectancy by Per
Capita Health Expenditure, Per Capita GSDP and Health Infrastructures in North-East
India, 2009-2015
Independent variables
IMR
LE at birth
Coef.
Std. Err.
Coef.
Std. Err.
Per capita NSDP
-0.0004**
0.0001
0.0003**
0.0001
Population serve per doctor
0.002***
0.001
-0.0007*
0.0002
Population serve per nurse
0.004
0.003
-0.002
0.0011
Population serve per sub centre
0.004*
0.002
-0.004**
0.0007
Population serve PHC
0.002***
0.0005
Population serve CHC
0.0001*
0.000
-0.0001**
-0.001***
0.00001
Constant
32.2 **
8.01
70.4***
3.57
*:10 per cent level of significance, **:5 per cent level of significance; ***:1 per cent level of significance
Journal of Rural Development, Vol. 39, No. 3, July - September: 2020
375
Public Healthcare Expenditure Needs in North-Eastern States of India
Status of Healthcare Infrastructure and
Manpower Availability
Health infrastructure and manpower play
a key role in improving the health status of
the people in general. This section covers the
status of healthcare infrastructure in rural areas
of north-eastern States of India.
The north-east region has a peculiar feature
- except Assam all States are tribal dominant.
Table 3 shows the total rural population,
proportion of tribal and non-tribal in the
population in rural areas, number of districts,
and average rural population served by each
sub-centre, PHC and CHC in the north-eastern
States of India in 2015. Going by the norms
laid down by IPHS, on average, one subcentre serves 5000 people in north-eastern
States, though the distribution is not uniform
across the States. Population pressure per
sub-centre was found highest in Assam (more
than 6000), which is predominantly a nontribal State. The share of tribal population in
Arunachal Pradesh, Nagaland and Manipur
is 75.8 per cent, 81.1 per cent and 49.5 per
cent, respectively. In these States, each subcentre serves 4112, 3832 and 5155 people,
respectively, which is relatively higher than the
norms of 3000 for tribal areas. In the remaining
States of Meghalaya, Mizoram, Sikkim and
Tripura the status is better.
Regarding population pressure on PHCs,
in all the north-eastern States except Tripura,
the average population served by each PHC is
less than the IPHS norms. However, in respect
of CHCs, Assam, Manipur, Sikkim and Tripura
serve a larger population than the IPHS norms
(1,20,000 people in plain area and 80,000
people in hilly/tribal area).
Table 3: Population, Share of Tribals and Non-tribals, Number of Districts and Population
Served per Health Facility, 2015
Independent
variables
Rural population#
Rural population served per
N
Non-tribal
( per cent)
Tribal ( per
cent)
Arunachal Pradesh
1176078
24.2
75.8
Assam
28478914
86.2
Manipur
2170363
45.5
Meghalaya
524192
Mizoram
563725
Nagaland
Sikkim
Districts
SC
PHC
CHC
16
4112
10052
22617
13.8
27
6163
28086
188602
54.5
9
5155
25534
127668
50.5
49.5
7
1225
4765
19415
3.4
96.6
8
1524
9890
62636
1517443
18.9
81.1
11
3832
11855
72259
464316
56.1
43.9
4
3159
19347
232158
Tripura
2748389
56.9
43.1
4
2702
30202
137419
North-east
37643419
74.9
25.1
86
4898
23151
125898
Note: # rural population for 2015 was calculated using exponential growth rate from 2001 to 2011 census population.
Journal of Rural Development, Vol. 39, No. 3, July - September: 2020
376
Table 4 shows the status of availability of
existing Sub-centres, PHCs and CHCs for 2015
and their requirement as compared to the
Indian Public Health Standard (IPHS) norms,
shortage/surplus and functioning of the units.
Taking the north-eastern region as a whole,
the analysis found that there was a shortage
of sub-centres (24 per cent), PHCs (13 per cent)
and CHCs (18 per cent) in 2015.
While some States showed a surplus of these
facilities, others faced a shortage. Mizoram and
Sikkim had a surplus of sub-centres, whereas
Manipur had an acute shortage of 45 per cent.
In Assam, there was a 26 per cent shortage of
sub-centres and for Nagaland, it was 24 per
cent.
In Arunachal Pradesh, none of the 16
districts experienced shortage of CHCs. In
Assam, 25 districts experienced shortage
of sub-centres than the required number.
Thirteen districts lacked the requisite number
of PHCs whereas 24 faced shortage of CHCs.
In contrast, Meghalaya, Mizoram and Sikkim
showed better health infrastructure as few
districts were having such shortages.
As shown in Table 3, it was seen that, with the
exception of Tripura, the population served per
PHC in all the north-eastern States was far less
than the norms. However, if the surpluses are
ignored and shortages are estimated for each
district, it is seen that the shortage of PHCs is
most severe in Manipur (32 per cent) followed
Sapana Ngangbam and Archana K. Roy
by Tripura (18 per cent), Meghalaya (14 per
cent), while Arunachal Pradesh, Nagaland and
Sikkim had a surplus.
Regarding CHCs, Sikkim and Manipur had
a shortage of more than 50 per cent, while it
was 42 per cent in Assam. Shortage of CHCs
was 11 per cent in Nagaland and 32 per cent
in Tripura which were lower than the northeast average (38 per cent). On the other hand,
Arunachal Pradesh, Meghalaya and Mizoram
had a surplus of CHCs.
Functioning of Health Facilities
The last three columns present the
functioning of the sub-centres, PHCs and
CHCs at the State level in north-east India as
per the IPHS norms. An analysis of the status
of existing health facilities (sub-centres, PHCs
and CHCs) in north-east India shows that
except for a few sub-centres, PHCs and CHCs,
most of the health centres in north-east India
are defunct. In Sikkim, 75 out of 147 subcentres and 23 out of 24 PHCs, in Tripura only
208 out of 1017 sub-centres, 51 out of 91 PHCs
and 14 out of 20 CHCs, were functioning as per
the IPHS norms. In other north-eastern States,
none of the centres were functioning as per
the norms. This indicates a chronic dysfunction
of the existing health facilities in the rural areas
of north-east India, whether in infrastructure,
human resources or supply of drugs.
Journal of Rural Development, Vol. 39, No. 3, July - September: 2020
377
Public Healthcare Expenditure Needs in North-Eastern States of India
Table 4: Estimated Requirement of Healthcare Infrastructure in Rural North-Eastern States
of India in 2015
States
Number of
districts having
shortages of
Estimated
requirement of
Available in the
States
Shortages/surplus from district
information
Functioning as
per IPHS
SC
PHC
CHC
SC
PHC
CHC
SC
PHC
CHC
SC
PHC
CHC
SC
PHC
CHC
Arunachal
Pradesh
NA
NA
0
354
54
14
286
117
52
68
*
*
0
0
0
Assam
25
13
24
6221
1015
254
4621
1014
151
1616
129
107
NA
NA
NA
Manipur
7
3
5
592
101
23
421
85
17
266
29
13
0
0
0
Meghalaya
1
1
0
139
22
5
428
110
27
18
3
*
0
0
0
Mizoram
0
1
0
185
28
7
370
57
9
*
1
*
0
0
0
Nagaland
7
NA
3
468
71
18
396
128
21
110
*
2
0
0
0
Sikkim
0
0
1
120
19
5
147
24
2
*
*
3
75
23
0
Tripura
1
4
3
708
111
28
1017
91
20
55
20
9
208
51
14
North-east
41
22
36
8787
1412
353
7686
1626
299
2133
183
133
283
74
14
Note: *=surplus; shortages were calculated ignoring surpluses in some of the districts and availability is total available
centres in the State, so requirement, availability and shortfall figures may not match; NA=Not Available.
Source: Rural Health Statistics, 2015
Assessment of Public Healthcare
Expenditure Needs
Table 5 shows the pattern of public health
expenditure and the requirements in the
North-eastern States of India in 2015. Eightyone per cent of the region’s population was
living in rural areas in 2015. At the State level,
the proportion of people living in rural areas
ranges from 47 per cent in Mizoram to 85
per cent in Assam. However, the share of
total health expenditure in rural areas is very
disproportionate in all the States. In Assam,
where the rural population is 85 per cent, the
share of total health expenditure on rural areas
was 62 per cent. Manipur has 81 per cent rural
population and the expenditure was 55 per
cent. The other States were spending a meagre
share in their rural areas (below 20 per cent). It
is evident that most of the healthcare facilities
are concentrated in urban centres of Northeastern States where only one-fifth of the
population resides.
In terms of share of Gross State Domestic
Product (GSDP) on public health infrastructure,
Mizoram was spending maximum (6.4 per
cent) of GSDP on public health, while spending
Journal of Rural Development, Vol. 39, No. 3, July - September: 2020
378
Sapana Ngangbam and Archana K. Roy
was lowest in Assam (2.8 per cent of GSDP). On
average, north-east region was spending 3.1
per cent of GSDP on public health in 2015.
thousand to meet the minimum requirement
as per the standard prescribed by IPHS.
Then a calculation was done to estimate
the expenses required to provide necessary
numbers of functional sub-centres, PHCs and
State-wise, Manipur, Assam, Tripura,
Arunachal Pradesh and Nagaland require 0.41
per cent, 0.26 per cent, 0.25 per cent, 0.22
per cent and 0.17 per cent of their respective
CHCs as per the IPHS norms in rural areas of
north-east region. It was found that north-east
India must increase its spending to 0.23 per
cent of north-east Region’s Gross Domestic
Product, which comes around Rs. 68 lakh
GSDPs. Meghalaya, Mizoram and Sikkim
require 0.05 per cent each of their respective
GSDPs to provide sufficient primary health
facilities (sub-centres, PHCs and CHCs) as per
IPHS norms.
Table 5: Health Expenditure Pattern and Requirements in North-East India, 2015
(‘000 Rupees)
Total
public
health
expen
diture
Total rural
public
health
expen
diture
per
cent
Rural
popul
ation
per cent
Rural public
health
expenditure
to total
public
health
expen
diture
6729606
2474859
76.2
Assam
49919734
30693048
Manipur
5359074
Meghalaya
6225022
Mizoram
Nagaland
NE States
Arunachal
Pradesh
GSDP at
current
price (201415)
per cent
public
health
expen
diture to
GSDP
Expenditure
required to
provide SC,
PHC and
CHC as per
IPHS in rural
areas
per cent of
GSDP to be
increased
for rural
areas
36.8
150336000
4.5
336438
0.22
85.4
61.5
1784791000
2.8
4613665
0.26
2966045
80.8
55.3
161191120
3.3
653739
0.41
1129767
79.7
18.1
214796302
2.9
117950
0.05
6448283
1415421
46.9
22.0
101360686
6.4
48420
0.05
5880643
1349105
67.0
22.9
161371010
3.6
268189
0.17
Sikkim
3075445
579524
69.9
18.8
133179444
2.3
66383
0.05
Tripura
8294012
1213425
70.5
14.6
274840548
3.0
686732
0.25
North-East
91931819
41821194
81.4
45.5
2981866110
3.1
6791517
0.23
Journal of Rural Development, Vol. 39, No. 3, July - September: 2020
Public Healthcare Expenditure Needs in North-Eastern States of India
Conclusion
In the context of the Alma Ata Declaration
(1978), health equity is viewed as equal
health, equal access to healthcare, equal
utilisation of healthcare, and equal health
status (Acharya et al., 2011). However, rural
and urban areas differ widely in opportunities
and infrastructures, be it in education, health
or other indicators of development. In India,
healthcare facilities are concentrated in urban
areas and north-east India is not an exception
to this. North-eastern States of India have poor
healthcare infrastructure. There is a shortage
of trained manpower which, combined with
difficult hilly terrain and remote tribal areas,
lack of private investment and low per capita
income (except Sikkim), is a major healthcare
challenge. Healthcare facilities in this region
are lagging far behind the rest of India (Tada,
2016). Therefore, the major findings of this
paper are to find out the evidence that can
be taken as the base for advocacy to increase
both State and Central budgetary allocations
to reduce the burden of healthcare on the
people of the north-east. State governments
are responsible for providing preventive and
curative healthcare services to the people.
The present paper studied public healthcare
expenditure needs in rural areas of Northeastern States of India.
The study found that income, primary
health facilities and manpower are important
for improving health status. But facilities
(sub-centres, PHCs and CHCs) in rural areas
379
of the north-east were in a poor condition, as
evidenced by shortages of infrastructure, lack
of sufficient manpower, drugs and medicines,
equipment and other facilities. It is imperative
that the north-eastern States should increase
their spending on rural public health. Studies
on the north-eastern States have highlighted
shortage of healthcare infrastructure in terms
of physical facilities, medical equipment and
manpower. To raise the standard of living of
the populace, there is an urgent need to make
quality healthcare accessible to one and all
(North Eastern Council, 2012). In the present
study also, authors have found that primary
health facilities in the rural areas of northeastern States are in a poor condition with
most States having a shortage of facilities.
Though it may seem that an average PHC is
serving a population that is less than the IPHS,
and some districts have a surplus, in reality, six
States have a shortfall of PHCs. It is also seen
that none of the existing facilities in the NorthEastern States, with a few exceptions in Sikkim
and Tripura, were functioning as per the IPHS
norms.
In order to provide universal primary
healthcare facilities as per the IPHS in rural
areas of north-east India, an estimated
additional amount of about Rs. 68 lakh
thousand (equivalent to more than 7 per cent
of total public health expenditure or 0.23 per
cent of north-east region’s gross domestic
product) at current prices will be required to
be spent across the north-eastern States. Thus,
increase in State income, health infrastructure
Journal of Rural Development, Vol. 39, No. 3, July - September: 2020
380
Sapana Ngangbam and Archana K. Roy
and manpower will have a positive impact on
health, but primary health facilities in rural
areas which play an important role, especially in
north-east India, are in a disgraceful condition.
The State governments need to put urgent
emphasis not only on providing the additional
resources required to provide universal
primary healthcare in both rural and urban
areas but also on ensuring accountability for
quality, equitable and affordable healthcare
delivery in north-east India.
Appendix
Note: As per IPHS, the expenditure
required for health facility is classified into
two categories – revenue expenditure and
non-recurring capital expenditure. Revenue
expenditure of a sub-centre, [which does not
result in the creation of physical or financial
assets, is treated as revenue expenditure)
(recurring per annum)] includes salary on one
male and one female health worker, another
one voluntary worker, drugs, travel allowances
for staff and other expenses. The capital
expenditure leads to the creation of assets
(non-recurring) on building, staff quarter,
equipment and furniture costs. Similarly, a
PHC requires revenue expenditure (recurring
per annum) of one medical officer (MO), one
pharmacist on contract basis, three staff
nurses, one lower divisional clerk (LDC), one
laboratory technician, drugs, travel allowance
for staff, one grade IV staff on contract basis,
telephone bills, emergency transport hiring
charges, other expenses in addition to
capital costs or expenditures (non-recurring)
of building, staff quarter, equipment and
furniture. A CHC requires revenue expenditures
(recurring per annum) for seven medical
specialists or medical officer, 10 staff nurses,
a public health nurse, a computer clerk, a
dresser, a pharmacist, a laboratory technician,
a block extension educator, one radiographer,
five ward boys, two upper divisional clerks
(UDC), an LDC, an epidemiologist, drugs, travel
allowance for staff, others (mali, aya, peon,
etc.), vehicle on contract basis, telephone bill,
mobility support to MOs for holding clinics
in PHCs, other expenses in addition to capital
costs of building, staff quarters, equipment
and furniture.
ENDNOTES
1. IPHS guidelines are a set of uniform standards envisaged to improve the quality of healthcare
delivery in India. The IPHS guidelines act as the main driver for continuous improvement in
quality and serve as the benchmark for assessing the functional status of health facilities.
Journal of Rural Development, Vol. 39, No. 3, July - September: 2020
Public Healthcare Expenditure Needs in North-Eastern States of India
381
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