Universal Access to Healthcare – How to Drive the 12th Plan

Universal access to healthcare implies that everyone gets equitable access to healthcare and there is no discrimination whatsoever, especially discrimination based on the capacity to pay. Worldwide countries which have established universal or near universal access have clearly demonstrated that public financing of healthcare is critical to realize this. However delivery of health services need not be only in public domain.

For instance Canada, which has the best and most equitable healthcare system in the world assures full access to everyone without the need to make any payment at the point of care. Health Canada, a public Corporation pools all resources and is a single payer for all healthcare services. While most hospitals are run by governments in Canada, private hospitals are also given access to these resources when citizens access them. And for out-patient care most providers in Canada are private providers who are contracted in by Health Canada on pre-agreed fee for services. The NHS in UK is very similar and Brazil, Venezuela, Mexico close to emulating these models. On the other hand there are examples like Sweden, Sri Lanka, Cuba which are completely state run systems which provide universal access to healthcare. Thailand is the most recent entrant into this club and I think we have a lot to learn from the Thai experience because the structure of the healthcare system in India and Thailand historically has been very similar.

In India the NRHM affords us a great opportunity to change the way the healthcare system works in India. NRHM talks about architectural corrections, public-private partnerships and the UPA backs this with a political commitment of providing upto 3% of GDP to realize universal access to healthcare. But so far the UPA and NRHM have failed because the required political backing to make radical changes and shake up the healthcare system has not been forthcoming. So what needs to be done to realize universal access to healthcare? To begin with:

• equating directive principles with fundamental rights through a constitutional amendment

• incorporating a National Health Act (similar to Canada Health Act) which will organize the present healthcare system under a common umbrella organization as a public-private mix governed by an autonomous national health authority which will also be responsible for bringing together all resources under a single-payer mechanism

• generating a political commitment through consensus building on right to healthcare in civil society

• development of a strategy for pooling all financial resources deployed in the health sector

• redistribution of existing health resources, public and private, on the basis of standard norms (these would have to be specified) to assure physical (location) equity

As an immediate step, within its own domain, the State should undertake to accomplish the following:

• Allocation of health budgets as block funding, that is on a per capita basis for each population unit of entitlement as per existing norms. This will create redistribution of current expenditures and reduce substantially inequities based on residence. Local governments should be given the autonomy to use these resources as per local needs but within a broadly defined policy framework of public health goals

• Strictly implementing the policy of compulsory public service by medical graduates from public medical schools, as also make public service of a limited duration mandatory before seeking admission for post-graduate education. This will increase human resources with the public health system substantially and will have a dramatic impact on the improvement of the credibility of public health services

• Essential drugs as per the WHO list should be brought back under price control (90% of them are off-patent) and/or volumes needed for domestic consumption must be compulsorily produced so that availability of such drugs is assured at affordable prices and within the public health system

• Local governments must adopt location policies for setting up of hospitals and clinics as per standard acceptable ratios, for instance one hospital bed per 500 population and one general practitioner per 1000 persons. To restrict unnecessary concentration of such resources in areas fiscal measures to discourage such concentration should be instituted.

• The medical councils must be made accountable to assure that only licensed doctors are practicing what they are trained for. Such monitoring is the core responsibility of the council by law which they are not fulfilling, and as a consequence failing to protect the patients who seek care from unqualified and untrained doctors. Further continuing medical education must be implemented strictly by the various medical councils and licenses should not be renewed (as per existing law) if the required hours and certification is not accomplished

• Integrate ESIS, CGHS and other such employee based health schemes with the general public health system so that discrimination based on employment status is removed and such integration will help more efficient use of resources. For instance, ESIS is a cash rich organization sitting on funds collected from employees (which are parked in debentures and shares of companies!), and their hospitals and dispensaries are grossly under-utilised. The latter could be made open to the general public

• Strictly regulate the private health sector as per existing laws, but also an effort to make changes in these laws to make them more effective. This will contribute towards improvement of quality of care in the private sector as well as create some accountability

• Strengthen the health information system and database to facilitate better planning as well as audit and accountability.

Infact the NRHM clearly articulates the need for architectural correction. Such restructuring will be possible only if:



 The healthcare system, both public and private, is organized under a common umbrella/framework as discussed above

 The financing mechanism of healthcare is pooled and coordinated by a single-payer system

 Access to healthcare is organized under a common system which all persons are able to access without any barriers

 Public finance of healthcare is the predominant source of financing

 The providers of healthcare services have reasonable autonomy in managing the provision of services

 The decision-making and planning of health services is decentralized within a local governance framework

 The healthcare system is subject to continuous public/community monitoring and social audit under a regulated mechanism which leads to accountability across all stakeholders involved



The NRHM Framework one way or another tries to address the above issues but has failed to come up with a strategy which could accomplish such an architectural correction. The framework only facilitates a smoother flow of resources to the lower levels and calls for involvement of local governance structures like panchayat raj institutions in planning and decision making. But the modalities of this interface have not been worked out and hence the local government involvement is only peripheral. The 12th Plan will need to focus on developing such modalities to bring in the structural changes.



In order to accomplish the restructuring that we are talking about the following modalities among others would need to be in place:



 All resources, financial and human, should be transferred to the local authority of the Health District (Block panchayats)

 The health district will work out a detailed plan which is based on local needs and aspirations and is evidence based within the framework already worked out under NRHM with appropriate modifications

 The private health sector of the district will have to be brought on board as they will form an integral part of restructuring of the healthcare system

 An appropriate regulatory and accreditation mechanism which will facilitate the inclusion of the private health sector under the universal access healthcare mechanism will have to be worked out

 Private health services, wherever needed, both ambulatory (FMP) and hospital, will have to be contracted in and appropriate norms and modalities, including payment mechanisms and protocols for practice, will have to be worked out

 Undertaking detailed bottom-up planning and budgeting and allocating resources appropriately to different institutions/providers (current budget levels being inadequate new resources as suggested in the paper will also have to be raised)

 Training of all stakeholders to understand and become part of the restructuring process

 Developing a monitoring and audit mechanism and training key players to do it

The above is not an exhaustive list but certainly critical issues to be addressed under the 12th Plan strategy. Further the most important challenge would be reining in the completely as yet unregulated private health sector. Where the private health sector is concerned it functions completely on supply-induced demand which fuels unnecessary procedures, prescriptions, surgeries, referrals etc.. leading to its characterization as an unethical and mal-practice oriented provisioning of healthcare. This has huge financial implications on households, inflating costs of healthcare, spiraling indebtedness and pauperization and being responsible for the largest OOPs anywhere in the world.



The challenges across the country differ due to different levels of development of the public and private health sectors in the states. For instance a state like Mizoram, a small and hilly state, already has an excellent primary healthcare system functioning with one PHC per 7000 population and one CHC per 50000 population and since it has virtually no private health sector the demand side pressures are huge and hence the public health system delivers. Each PHC has 2 to 3 doctors on campus available round the clock with 15 – 20 beds which are more or less fully occupied and 95% of deliveries happen in public institutions. So Mizoram has indeed realized the Bhore dream. The problem in Mizoram is that there are very few specialists available and hence higher levels of care become problematic – the CHCs are however run by MBBS doctors who have received some additional trainings. Mizoram does not have a medical college but it does have reservations in other state medical colleges. While the state cannot provide tertiary care it has a budget to send people elsewhere to seek such care. And Mizoram does this with 2.7% of its NSDP and has the best health outcomes in India. In some sense Mizoram is like Sri Lanka – a statist model. There are few other states in India which can do a Mizoram because they too do not have a significant private health sector but to do that they have to demonstrate the political will of Mizoram.



Even though extremely successful Mizoram cannot be the national model because the reality across most other states is very different, the reality of an entrenched private health sector which is unethical and unregulated. The private health sector has to be reined in and this can only happen with a strong political will which declares healthcare to be a public good and which takes on the private sector to get organized under public mandate. Under NRHM sporadic efforts towards this end are being undertaken in the name of public-private-partnerships like Chiranjeevi in Gujarat, Yeshasvani in Karnataka, Arogya Rakshak in AP, Rajiv Gandhi Hospital in Raichur (Karnataka Govt and Apollo Hospitals) etc. They may have achieved limited success but then healthcare systems cannot be built by segmenting it into programs and one-off initiatives like PPPs. There have to be serious efforts at building a comprehensive healthcare system and it goes without saying that given India’s political economy of healthcare the private sector will have to be a significant partner in this process. So states have to think beyond the Chiranjeevis and Yeshasvanis and learn from the recent experiences of Thailand, Mexico and Brazil to invest in an organized healthcare system, and with a booming economy resources will not be a constraint.



So the challenge for the 12th Plan is enormous demanding huge restructuring of the healthcare system in the country through strong regulatory mechanisms both for the public and private sectors, education of professionals in ethics of practice, pushing the politicians for creating a strong political will to make healthcare a public good as well as generate and commit adequate resources to realize universal access. The restructuring of the healthcare system and its financing strategy, given the price advantage of India and economies of scale it offers, will actually reduce nearly by half the healthcare spending in the country and reduce substantially the household burden to access healthcare. Calculations I have done show that for universal access to healthcare across India we need less than 3% of GDP provided we show the political will to shift healthcare from the domain of the market to the category of a public good. This will indeed do a lot of public good!

Ravi Duggal / rduggal57@gmail.com

Revenues Forgone and Social Sector Budgets

In undertaking budget analysis somehow the larger focus has been on looking at expenditures while the revenue side of the budget is often ignored, except perhaps oil and gas or other mineral/natural resource based revenues when the particular economy is driven by such resources. However, often taxes do receive some attention in budget analysis within a macro-economic analysis with a focus most often on reducing or increasing tax rates or the tax base. The composition, character, nature and depth of the revenues have received very scant attention. Thus revenues not collected, revenues forgone, equity impact of revenues, etc. are often overlooked in mainstream budget analysis. It is time to shift gears and give greater weight to the revenue side of the budget because expenditure can only happen when there are adequate revenues.  

Across OECD countries, as well as in a number of emerging economies, where tax:gdp ratios range between 30-50 percent, we see more responsible and accountable governance as well higher expenditures on social and welfare sectors. This is possible because adequate revenues, especially through taxes are raised but also because there is a large tax base, better tax compliance and minimal tax expenditures or forgone revenues. In most developing countries the contrary is true – lower tax:gdp ratios, smaller and skewed tax base, poor tax compliance, large scale evasion, large tax expenditures and incentives – and hence social sector spending is small and inadequate. For instance, in 2005 the average tax revenue to GDP ratio in the developed world was approximately 35%. In the developing countries, it was equal to 15%, and in the poorest of these countries, the group of low income countries, tax revenue was just 12% of GDP. The cocktail of tax avoidance, tax expenditures and tax evasion are widely believed to be important factors limiting revenue mobilization in the developing world. Further in developing countries in addition there is the international dimension of tax evasion via price distortions or transfer pricing, that is  sending of overpriced imports into developing countries and underpriced exports from developing countries. This shifts incomes to the host countries of MNCs and results in revenue losses within the developing countries. And finally there are the tax haven countries and the “Swiss banks” which attract tax evaded incomes and shadow economy incomes from both developing and developed countries and this also leads to revenue losses for the state.

India, despite being a rapidly growing economy has revenue characteristics of developing country economies. The present tax:gdp ratio is a meager 17% and this is certainly not adequate to finance social sector budgets if we accept the ESCR commitments to realize universal access to all social and economic rights like education, health, housing and social security. So why does the Indian government fail to realize adequate tax revenues. There are many reasons but some of the important ones are:

1. Lax tax collection: Adequate efforts are not put in to maximize tax collections. Small businesses, large volumes of unregistered or even illegal economic activities, evade taxes completely. It is estimated that in India the parallel economy is atleast 60% (conservative) to 150% of the legal/registered economy. If revenues were realized from this through efficient tax administration at least 50% more tax revenues would be generated.

2. Corrupt Practices: Revenue officials like income tax officers, excise inspectors, customs collectors often are in league with businesses and individuals to facilitate tax evasion, including transfer pricing and transfers to tax havens ( it is estimated that the equivalent of India’s GDP is parked in “swiss banks” and this is mainly money belonging to the business elite and politicians from India). This results in huge losses to the state exchequer.

3.  Tax Expenditures: Fiscal policies and decision making lead to concessions in taxes for selected individuals and businesses. The latest budget 2010-11 estimates that for the Central government alone these tax expenditures account for 85% of Tax revenues during 2009-10 and the trend is increasing (see Table below) – so a clear potential for doubling tax collections if most of these tax expenditures, especially for businesses are taken away.

4. Subsidies that are not declared as tax expenditures: Organisations registered as Trusts under the Public Trusts Act are exempt from tax payments. A large number of private educational institutions, hospitals, religious institutions etc operate as Trusts and accumulate huge surpluses. Such institutions are supposed to engage in charity and provide social benefits but the reality is that most of them do not and neither do the concerned government agencies monitor their financial transactions. So these are again clear losses of revenues for the state exchequer.

Table: Revenues Forgone (Tax Expenditures) during 2008-09 and 2009-10 Central Government, India – figures are INR crores (1 crore = 10 million)

Source: Govt. of India Budget 2010-11

To conclude, if the tax administration becomes more efficient, disciplined, and ethical at one level and most of the tax expenditures, especially the non-personal income tax, and other subsidies which do not provide effective social returns are done away with there is clear plausibility that India’s tax:gdp ratios should reach the level of over 35% (without increasing tax rates) and this would provide the “maximum available resources” to meet the ESCR commitments, especially universal school and college education, universal access to healthcare and universal access to housing.

Ravi Duggal

rduggal57@gmail.com

Rising Healthcare Costs – Consequence of Declining Public Health Investments and Expansion of Private Healthcare and Insurance

As a strong advocate of public health systems, especially public financing of health care, recently I found my self in an embarrassing and helpless situation when I was forced to resort to a private health facility for a surgery of my haemorrhoids.  I had a long standing problem and since last year the severity and frequency of bleeding had increased as had my travel for work. So it was clearly time to deal with them radically because in the past two decades I had tried various homoeopathic, ayurvedic, naturopathy etc.. therapies, apart from allopathic interventions, which did not give any substantive relief.

 I consulted a surgeon friend, an erstwhile employee of a public teaching hospital but now working in the private sector after having suffered severe frustrations within the former. He suggested haemorrhoidectomy of the three large haemorrhoids and he was willing to do the surgery at one of the private hospitals (a hospital registered as Trust and Research Centre implying that it was getting tax waivers and rebates) to which he was attached. We agreed to the particular hospital because it had a cashless facility for the health insurance policy that I thought I had the fortune to have over the past two decades through my employment. Well one thought that with the insurance cover all would be well and I would get my surgery and treatment without any direct costs and that finally there was an opportunity to use the benefit of the insurance premiums I was paying for over twenty years. For the current year the premium I had paid was over Rs.16,000 for myself, my wife and daughter. 

 I informed the insurance company and their third party administrator (TPA) about my surgery and they said that I should request the hospital to send an estimate of the cost and they would accordingly sanction the amount. The hospital sent an estimate of a whopping Rs. 100,000 as I had selected an ‘A’ Class room. The TPA responded by sanctioning only Rs.40,000. I discussed this with the hospital and the TPA and then I was told that as per my policy cover and sum assured which was Rs. 250,000 I was entitled to 1% of that as daily room and nursing charges, that is my “class” was restricted to Rs 2500 per day for room and nursing care. (this was the fine print that I had not read in the policy document). So I got my class changed to ‘C’ Class which was a triple sharing room, instead of the single deluxe room of Class ‘A’. What I also learnt was that the other charges for the hospital like OT, surgeons fees, anaesthesia, diagnostics etc.. were charged according to class, so greater the room rent the greater the charges for all other services and facilities.

 On admission day I went to the hospital with the assurance that I was going to get cashless service against the insurance cover I had. The first shock was the hospital demanded a security deposit of Rs. 10,000. Since I was already mentally prepared for surgery I went to the ATM in the hospital and withdrew Rs. 10,000 and deposited it with the hospital and they assured that this would be returned once the insurance company cleared their bill. With this assurance I went through the surgery and had to spend 4 nights at the hospital.

 A day before discharge I got shock number 2 that my bill had exceeded the Rs.40,000 that the insurance company had sanctioned for the surgery and I should pay the difference of Rs. 9000 something. I told them that they had my deposit of Rs. 10,000 already and that on day of discharge with the final bill we will talk to the TPA and settle the amount. On day of discharge I got the final bill of Rs. 59,722 and the hospital demanded Rs. 19,722 as payment for the discharge. I discussed the bill with the billing section as I found it a little excess and they turn around and tell me that from April 1 the charges of their hospital had increased, that is the Rs.2500 for the ‘C’ class room had become Rs. 2800, as also other charges too had increased. I was admitted on 31^st March and I told them that my contract was for that day and that they had not even informed me of the changes in their rates. But they said that their computers were set for the new rates and they could not do anything about it. We had sent the final bill to the TPA by fax and they were to get back in two hours, so with all the pain I waited two hours but the TPA did not send the final sanction. I was in tremendous pain and waiting to get home at the earliest so I decided to pay the Rs 19,722 using my debit card and leave the hospital. When I reached home the hospital calls me and informs me that the TPA had actually reduced the sanction to Rs. 31,000 without assigning any reason and I now owed the hospital another Rs 9000. I could not believe that this was happening to me. The little respect I had for the private sector and insurance just vanished.

 The above cited personal experience is the true reality of private health financing in India. You are not sure what you will be charged, you are overcharged, the insurance cover you may have may actually not cover you fully, the cashless insurance cover is a fraud and to top this all the quality of service, especially nursing care, is grossly poor despite paying a whopping Rs. 60000 for 4 days or a unit cost of Rs. 20,000 per haemorrhoid excised. All this happens because of a complete lack of regulation, standards and norms for treatment and pricing, exploitation by both the hospital and the insurance company (especially the TPA) of the vulnerability of the patient and the absence of an organized healthcare and health financing system.

 The trend in public health financing over the last two decades clearly shows inadequate investments and declining expenditures across states and this has led to the collapse of the public health system in most states, including states like Kerala which were doing very well prior to that (see Table 2). In most states again within the public health system privatization has taken root – you are charged, albeit less than market rates, for almost all services that you seek. You may have a waiver if you are below the poverty line or are SC or ST or a government employee or politician. But even when you pay you may not get satisfactory care. With user fees in public facilities quality has certainly not improved but what has definitely happened is that the access of the poor has got reduced. Further, human resources within the public health system have been out-migrating to the private sector or abroad because of the frustrations they face and the lack of resources for delivering appropriate care. For example the Mumbai Municipal Corporation’s (BMC) hospitals which were regarded as one of the best in the country and attracted patients from all over the country are in bad shape because they have been starved of funds and investments for the last two decades. In the seventies and eighties nearly 30% of the BMC budget went to healthcare but today it is only 13%. The consequence of this under-financing has resulted in a loss of credibility with the middle classes migrating to private care, committed doctors and nurses quitting and moving to the private sector or going abroad, and user fee being levied which reduces the access of the poor to these hospitals. Twenty years back my daughter was born in a public hospital and we got excellent service but today I was unwilling to take that risk. Well if our Prime Ministers, politicians and bureaucrats dont have faith in them and use private providers or hospitals then how can the “aam aadmi” risk using public facilities.

 The consequence of the above is that the out-of-pocket spending for hospital care has also zoomed (see article by this author in Health Action, January 2008). There is some absorption of this through private health insurance for the middle and upper middle classes but the poor regulation keeps the out of pocket burden high. Infact private health insurance in such an unregulated environment may not be such a good deal for the consumer and this realization is dawning on them. For instance, over the last two decades I have paid nearly Rs. 300,000 as mediclaim premiums for my family and made one claim of Rs. 30,000 for my wife afew years ago and the current one that I am trying to negotiate presently. Alternatively if I had invested the premiums into a recurring deposit account, this Rs. 300,000 would have been worth Rs. 12 lakhs – the capital would have been mine and I could access it for any medical needs that I may have had. Infact, governments should rethink the tax rebate given for mediclaim premiums and extend this to bank deposits that may be assigned as medical savings accounts, similar to PPF accounts with periodic withdrawals permitted as and when medical needs arise. Thus having a medical savings account during ones earning years is a far better option than buying mediclaim kind of insurance cover (Singapore has demonstrated this very well and have rejected insurance as an option). And one could top this for the high risk medical problems with life insurance risk cover through critical care policies, wherein again most of the capital remains with the insured and does not accrue to the insurance company.

 So given the above scenario with public health financing and systems collapsing and private insurance not being a viable option we have no alternative but to be left to the mercy of the market and the private health sector and this can only mean rising healthcare costs on individual households which during catastrophic illnesses would invariably lead in most cases to pauperization, as evidenced by NSSO data that over half the population seeking healthcare takes loans or sells assets to access hospital care.

 As a country the health sector in India presently grosses 6% of GDP or Rs. 3500 billion and of this only Rs. 600 billion or 17% is financed by ministries of health. Upto another 5% comes from social insurance and local government funds. This means that 78% or Rs. 2730 billion is privately financed and of this a whopping 98% is out-of-pocket. Given the wide scale poverty and malnutrition in the country this is indeed the most regressive way for financing healthcare and makes cost of healthcare to individuals unaffordable.

 Of the total government spending about one-fourth comes from the Central budget and three-fourths from the state’s own resources. The Central government’s budget pays for the national disease control programs, family planning, maternal and child care (RCH, immunization etc..) through the NRHM and apart from this some central government hospitals, CGHS, AYUSH and Medical education and research is also included. The state governments’ budgets largely finance medical care and medical education through hospitals and dispensaries as well as some primary health care. Table 1 summarises the priorities of the Central government in the health sector.

 Table 1: Health Sector Allocations for the Union Ministry of Health and Family Welfare (Rs. Crores) Budget 2010-2011

Health Program	2009-10 BE	2009-10 RE	2010-11 BE
A.Medical and Public Health	21113	20217	23530
B. AYUSH	922	863	964
C. Health Research	606	600	660
Total Health	22641	21680	25154 EAP 3986
Of which Priority Programs
1. Hospitals & Dispensaries	844	1020	982
2. Medical Education and Training	3256	2699	2678
3. HIV/AIDS	993	888	1266 EAP 1229
4.NRHM	12529	12096	13910 EAP 2389
Key Components  under NRHM
a) Disease Control	1063	1008	1050 EAP 435
b)RCH	99	151	193 EAP 180
c)Rural FW	2335	2540	2793
d) Urban FW	157	145	172
e) Contraception	370	268	358
f) Routine Immunisation	388	388	417 EAP 37
g) Pulse Polio	1102	1163	1017 EAP 561
h) Flexipool NRHM	3034	2743	3569
i) Flexipool RCH	3049	2958	3396 EAP 1074

EAP= externally assisted programs; BE=Budget Estimates; RE=Revised estimates

 What the above table also tells us is that in most instances the revised estimates are lower than budget estimates and generally previous years’ expenditure data also reveal that actual expenditures tend to be even lower. Thus the budget estimates for 2010-11 may appear to give the impression that over the previous fiscal it is higher by nearly 14% we know that this will be much lower when expenditures are accounted for. Further given an inflation of over 9% even this increase is not really impressive. 

 One interesting feature of the 2010-11 budget is that for the first time the externally aided component is being shown within the line budgets of the Ministries. This is certainly a positive development in the direction of transparency clearly telling us where donor interests lie in financing health budgets. This is important to know because, while donor financing is very small as a proportion of the health budget, it contributes significantly to skewing health policies and programs in line with global vested interests.

 At the state level Table 2 indicates the declining state investments and expenditures, especially post 1991 across all states and this is certainly not because cost of healthcare has gone down but clearly an indicator of continued under-financing of public health services, mostly medical care. This trend has facilitated the growth of the private health sector because demand for healthcare has increased manifold. The private health sector is completely unregulated and has a complete absence of ethics in practice. Infact the recent arrest of Dr. Ketan Desai, President of the Medical Council of India, epitomizes this lack of ethics and the widespread corruption in the health sector. 

 What the state level trends also imply that the public health provision is also declining and given the privatization policies, including user fee charges in public facilities for various health services, the states are making way for the strengthening of the private health sector across the board.

 Data from consumption expenditure surveys by NSSO and CSO estimates for National Accounts provide evidence for this trend indicating rapid growth of private health expenditures, mostly out-of-pocket, especially post 1995 which is exactly the period that witnessed the expansion of the private health sector, especially corporate hospitals and medical cities, medical tourism, private health insurance, TPAs etc..

 So we live in a time where the private health sector fully dominates, public health sector is declining and the private health insurance is emerging and trying to take control of the private health markets. Our close neighbour Thailand also witnessed the same trend in the nineties but political will and sense prevailed at the turn of the millennium and Thailand swiftly took control of the health system, organized it, changed the financing strategy to a single payer mechanism and today has almost achieved universal access to healthcare. India is doing much better on the economic front than Thailand and there is no reason why it cannot do what Thailand was able to do in 5 to 6 years time. We were given to believe that NRHM was going to make thes architectural corrections in the health system but 5 years down NRHM we don’t see any significant change. The recent audit report on NRHM by CAG highlights its poor performance and inability to achieve its goals. Our bureaucrats have failed once more but they have failed because our politicians have not provided the political will to change for the benefit of its citizens. Both the bureaucrats and politicians engage in patronage and hence come up periodically with schemes and that is what the NRHM seems to be, another scheme. And schemes will only lead to scheming and benefiting the bureaucrats and politicians because when it comes to their own healthcare needs and costs public money is used freely to get them the best available care form the elite hospitals of this country.  But for those whom they govern they throw up crumbs from time to time, create segmentation for the purposes of appeasement and their political gains and take us even further away from realizing universal access and health for all. 

 Table 2: Health Expenditure of State governments as a percent of total Government Expenditure 1981-2008

State/Year	1981	1987	1991	1996	1998	2001	2003	2005	2008	2009
Andhra Pradesh	5.80	7.88	5.53	4.65	5.44	4.74	3.96	3.53	3.3	3.3
Arunachal Pradesh	5.91	9.77	4.89	4.66	5.04	NA	4.68	4.45	3.0	2.7
Assam	3.96	10.21	NA	5.84	5.87	4.66	3.69	3.06	6.0	5.6
Bihar	3.78	8.49	5.10	5.79	5.24	4.01	3.17	3.24	4.1	4.2
Chhattisgarh	-	-	-	-	-	4.13	3.99	3.74	4.7	4.7
Delhi	-	-	-	-	-	7.16	6.34	6.65	7.8	7.2
Goa,Daman & Diu	7.19	13.45	8.70	5.39	4.89	3.90	4.02	3.27	3.7	4.2
Gujarat	4.38	9.58	5.03	4.70	4.57	3.38	3.21	3.05	3.1	3.1
Haryana	4.33	8.25	4.11	2.95	3.27	3.26	2.88	2.59	2.8	2.7
Himachal  Pradesh	6.63	13.50	3.32	6.16	7.04	5.64	4.50	5.08	4.5	4.7
Jammu & Kashmir	3.79	12.50	5.56	5.50	4.97	4.89	5.30	4.78	5.1	5.3
Jharkhand	-	-	-	-	-	NA	4.18	3.65	5.6	5.3
Karnataka	3.79	8.23	5.40	5.28	5.85	5.11	4.17	3.49	3.9	4.1
Kerala	6.56	9.85	7.21	6.53	5.68	5.25	4.74	4.71	4.6	4.7
Madhya Pradesh	4.94	10.11	5.16	4.81	4.57	5.09	4.11	3.39	3.9	3.9
Maharashtra	4.85	9.38	5.13	4.56	4.29	3.87	3.71	3.51	3.3	3.1
Manipur	2.60	12.61	4.38	4.83	4.48	4.82	2.89	3.72	2.8	4.0
Meghalaya	6.25	13.25	6.26	6.19	6.86	5.65	5.88	5.23	4.6	4.4
Mizoram	7.89	11.85	3.50	4.18	NA	4.96	5.01	3.96	4.0	6.3
Nagaland	5.39	10.88	5.96	5.95	5.68	4.87	4.65	4.68	4.8	4.6
Orissa	5.17	8.50	5.13	5.16	4.82	4.15	3.75	3.90	3.6	3.8
Pondicherry	9.05	10.01	7.82	0.03	0.04	NA	NA	5.4	7.2	5.0
Punjab	3.67	10.52	6.73	4.62	4.93	4.54	3.54	3.10	3.1	3.2
Rajasthan	4.85	14.48	6.50	5.70	7.97	5.16	4.24	3.94	4.3	4.6
Sikkim	4.49	6.44	7.89	2.72	1.92	3.67	2.03	2.56	2.6	2.7
Tamil Nadu	6.18	10.04	6.91	6.29	6.28	4.86	4.10	4.20	4.2	4.2
Tripura	2.51	7.37	5.18	14.74	4.79	4.04	3.79	3.79	5.8	5.0
Union Government	0.22	0.29	0.56	0.46	0.52	0.77	0.76	0.83	1.53	1.44
Uttar Pradesh	4.69	9.08	6.31	6.03	1.74	3.98	3.75	4.49	5.2	5.6
Uttarakhand	-	-	-	-	-	3.08	3.77	4.34	2.9	4.9
West Bengal	6.30	9.73	8.37	6.43	NA	5.63	4.95	3.94	4.4	4.4

Sources: Upto 1987 is Combined Finance and Revenue Accounts, Comptroller and Auditor General of   India GOI, respective years; For year 2001 is State Finance A Study of Budget, RBI, 2003; for 2003-2009 Public Finance, CMIE, 2005 and State Finances, RBI, 2008 and 2009. Please note that 2005, 2008 and 2009 are budget estimates