Healthcare in India: Nine poorest states' budgets lie unspent, 581 million affected by inadequate infrastructure

By Ojaswi Rao

Nine of India’s poorest states — home to 581 million or 48 percent of India’s population — account for 70 percent of the country’s infant deaths, 75 percent of under-five deaths and 62 percent of maternal deaths, but do not spend even the money they have set aside for healthcare, according to an IndiaSpend analysis of 2017 Reserve Bank of India data on state budgets.

 Healthcare in India: Nine poorest states budgets lie unspent, 581 million affected by inadequate infrastructure

Representational image. Reuters

The data also reveal:

a. The maternal mortality ratio — deaths of mothers per 100,000 births — in these states is 32 percent higher (244) than the national average (167).

b. 38 percent and 40 percent children in these states are underweight (low weight-for-age) and stunted (low height-for-age), respectively, higher than the national average of 36 percent and 38 percent, respectively, according to 2015-16 national health data, the latest available.

c. Uttar Pradesh, Bihar, Madhya Pradesh and Rajasthan — with 372 million people, more than the combined populations of US, Australia, Sweden and Greece —together contribute to about 58 percent of all child deaths in India.

The nine poorest large states — in official jargon called “high-focus”, a term that implies they need special attention — spent an average of 4.7 percent of their social-sector expenditure on public healthcare and family welfare annually, marginally less than the national average of 4.8 percent. Social-sector expenditure includes water supply and sanitation, housing and urban development.


NOTE: * – Actual Figures; ** – Maternal mortality ratio in these states (Andhra Pradesh, Himachal Pradesh, Jammu and Kashmir, Manipur, Meghalaya, Mizoram, Nagaland, Sikkim, Telangana and Tripura) is 126 deaths per 100,000 births as per the Sample Registration System (SRS) Report published in 2011-13

India’s average spending on health, as a proportion of gross domestic product, is already the lowest among BRICS nations, as IndiaSpend reported on 8 May, 2017.

The “high-focus” states are Bihar, Chhattisgarh, Jharkhand, Madhya Pradesh, Odisha, Rajasthan, Uttarakhand, Uttar Pradesh and Assam.

“In 2005, it was observed by (the) government of India that some states were performing poorly in various indicators,” Avani Kapur, senior researcher, Accountability Initiative, an advocacy, told IndiaSpend. “So, these states were clubbed together as high-focus states and additional resources were given to improve those indicators.”

Poorest states spent less money than their budgets allowed

Of the nine poorest states, Rajasthan spent the highest (5.6 percent) and Bihar the lowest (3.8 percent) proportion of aggregate expenditure on public healthcare and family welfare, according to the RBI data on 2014-15 actual spending, lower than the budgeted 4.1 percent for Bihar and 6.6 percent for Rajasthan.

Seven of the nine “high-focus” states report such underspending.

“High focus states allocate large amounts to social sector to improve their indicators but in reality they spend only a small amount, compared to what is allotted,” Kapur said. “Hence, it is necessary to consider actual accounts in order to know the proper outcomes.”

So, while some “high-focus” states spent less money than set aside by their budgets, other states outspent — by proportion as ratio to aggregate expenditure — other larger states on healthcare and family welfare, but that had no relation to their healthcare indicators.

For instance, Rajasthan (68.6 million people) reported an MMR of 244 deaths per 100,000 births in 2011-13, the second lowest in India and worse off than Bangladesh and Nepal, both poorer countries, by per capita income. In contrast, Andhra Pradesh (84.6 million people), another big state, spent 4.1 percent of total expenditure on public healthcare and family welfare but reported an MMR of 92, according to government data.

Since 2008, Rajasthan increased its spending by 0.8 percent and its MMR decreased 23 percent while Andhra Pradesh’s spending increased by 0.5 percent and MMR decreased 31 percent.

Assam, which spends 4.2 percent of its total expenditure on health and has 31.2 million people, has an MMR of 300 deaths per 100,000 births — comparable to Zambia and Thailand — while Kerala, which spends 5.3 percent on 33.4 million, reported an MMR of 61, comparable to Sri Lanka and Poland.

Madhya Pradesh, which reported an infant mortality rate (IMR) — deaths per 1,000 live births — of 51 in 2015-16, spends 4.3 percent of total expenditure on healthcare — against 5 percent that was budgeted — and, as IndiaSpend reported on January 21, 2016, is worse off than some of the world’s poorest countries, such as the Gambia and Ethiopia.

Spending more on healthcare did not improve institutional births

In the nine “high-focus” states we studied, 72.6 percent of all births were in healthcare institutions, a steady improvement but below the national average of 78.9 percent, according to the 2015-16 National Family Health Survey (NFHS-4) data, the latest available.

Tamil Nadu with 72.1 million people spends 4.7 percent of its total budgeted expenditure on public healthcare and family welfare and reports 99 percent institutional births, while Jharkhand, with 33 million, spends 4 percent and reports 61.9 percent institutional births.

Uttar Pradesh (78), Madhya Pradesh (65), Chhattisgarh (64), Bihar (58) and Assam (56) report India’s highest under-five mortality rates–deaths per 1,000 live births — IndiaSpend reported on  20 March, 2017.

Odisha reported an 118 percent increase in institutional births over 10 years, but the IMR declined by no more than 63 percent over this period.

The poor health indicators can be attributed to the lack of healthcare infrastructure and human resources in these states.

Not enough doctors and healthcare institutions

Bihar is 81 percent short of community health centres (CHCs), which provide secondary healthcare in the form of referrals and specialists to rural areas, and Jharkhand is 66 percent short of primary healthcare centres (PHCs), the first point of access to a qualified public-sector doctor in rural areas, according to the RBI report.

There is a 13 percent shortfall of CHCs in the “high-focus” states, according to India’s Health Management Information System.

Bihar was 93 percent short of specialists in CHCs, while the comparable figures were 90 percent, 84 percent and 84 percent in Chhattisgarh, Uttar Pradesh and Jharkhand, respectively, in March 2016, according to Accountability Initiative budget brief on National Health Mission.

The infrastructure shortage is made worse by the fact that in all the nine states, healthcare programmes are accessed by richer households while many poor households are excluded due to high direct and indirect costs, according to this 2012 study in PLOS-ONE, an online open-access scientific journal.


Such infrastructure shortages exacerbate inadequate spending and deliver low heath achievements. Increased primary healthcare spending reduces child and infant mortality rates, according to this 1999 research paper by the International Monetary Fund.

Promoting community-based education on improved maternal and newborn care, and home-based treatment for newborn infections could enhance child survival in the “high- focus” states “significantly”, said the 2012 PLOS-ONE study. is a data-driven, public-interest journalism non-profit initiative, scrutinising for veracity and context statements made by individuals and organisations in public life. 

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Updated Date: Jul 03, 2017 09:29:15 IST