The highlights of the presentation made on behalf of the Maharashtra Council of the LRS
As per the 2011 census, the population of Maharashtra was 11.24 crore, with 45% (5.08 crore) in urban areas and 55% (6.15 crore) in rural areas. The sex ratio was 929 females per 1000 males. With 534 towns and 43662 villages, it is divided into 6 revenue divisions, 36 districts and 355 talukas. The estimated state population in 2020 is 12.57 crore.
While the state GDP more than doubled from 2012 to 2019, and the per capita state income increased by 93% in the same period, the living conditions of the people have in fact worsened. The State’s expenditure on health was only 1% of the Gross State Domestic Product in 1985-86, and it further dropped to 0.49% in 2017-18! If we factor in the population increase as well as price rise, we see that the health budget for 2017-18 was cut by more than 10%, from Rs. 12726 crore in 2016-17 to Rs. 12167 crore.
India as a whole fares miserably as compared to most other countries as far as public spending on health is concerned. In 2017, the governments (state and center) spent only $19 per capita on health, which is less than one third of the average for Africa as a whole ($60). The corresponding figures for Sri Lanka, Bhutan, Thailand, Malaysia, Brazil and Cuba are, respectively, USD 69, 72, 188, 194, 389 and a massive 889! This means that Cuba spends over 46 times more than India!
Within India, Maharashtra is one of the worst states in this matter. The per capita spending on public health in Delhi is Rs. 2167. In Chhattisgarh, Orissa and Bihar (All of which are considered to be much less developed than Maharashtra), the figures are respectively Rs. 1552, Rs. 1123 and Rs. 792, while in Maharashtra it is a pittance of Rs. 776! As a result, the people residing in Maharashtra bear 78% of the expenditure on health, while the government grudgingly spends 22%. Is there any correlation with how Maharashtra has been faring in the ongoing Covid pandemic?
In 2017 (the latest year in which data could be obtained), 60% posts of surgeons, gynecologists, pediatricians, and other specialists in rural hospitals across the state were vacant. There are practically no specialists in district hospitals such as those of Akola, Nanded and Parbhani.
As per the norms of the Government of India, a three tier health infrastructure is supposed to have been built. In the primary tier, there are Sub Centres (SC), Primary Health Centres (PHC) and Community Health Centers (CHC).
SCs are supposed to provide counselling for maternal and child health care, family welfare, nutrition, immunization, and control diarrhea and communicable diseases.
PHCs should have an outdoor patients department (OPD), six beds indoor ward, emergency services, and operative and laboratory facilities. They are supposed to supply medicines to treat patients referred by sub-centers and provide family planning services.
There should be one SC for 3000 tribal and 5000 non-tribal people and one PHC for 20,000 tribal and 30,000 non-tribal people. One CHC is supposed to serve as a referral center for every 4 or 5 PHCs (i.e. a population of 80,000 to 1,20,000).
Maharashtra – Grim Reality
As we can see from the table, the actual reality in Maharashtra is very far from the norms.
Even if we assume that the entire estimated population of the state of 12.57 crore is non tribal, we can see that the actual number of centers is not even half of the numbers mandated by the norms. The last Master Plan for Maharashtra was prepared in 2013-14 and that was based on the 2001 census when the population would have been much less! Even within that there was a shortfall of 107 PHCs from the previous Master Plan that was made in 1997. The last column reveals that the so-called GOI norms are only on paper. For instance, when there is a shortage of more than 15000 Subcentres, the plan is only to build 911, and as we have seen, even this is not implemented fully. (Reference: Aarogya Maharashtra)
There has been hardly any increase in either the rural or urban public health infrastructure over the last 25 years. The number of beds available per lakh people in urban areas has in fact fallen from the (very poor figure of) 114 in 1980 to 103 now. The norms for government expenditure on medicine have not been revised since 2007 and amount to a pathetic Rs. 6 per patient per day. Likewise the norms for supply of other essential material are also so low as to almost non-existent. This amounts to the patient spending practically all the money on medicines and other essentials such as tests, etc. from his or her own pocket.
As if this was not bad enough, the shocking manpower shortage makes it worse (See Table; this data has been obtained from the latest entry on the official website; 31st December 2018).
The National Health Mission (NHM) consists of the National Rural Health Mission (NRHM) launched in 2005 and the National Urban Health Mission (NUHM) which was implemented in Maharashtra in 2013. The NHM has this lofty declared aim: To provide universal access to health care by strengthening health systems, institutions and human resource capabilities. 15 years later there are only 40 Mobile Medical Units operating under the NRHM to provide health care services for population living in remote and inaccessible areas of the state! The NUHM is supposed to serve the 2.01 crore slum population in the state. In 6 years till Dec’19 only 10 mobile medical units had been put in operation! Under NHM, 60,852 Accredited Social Health Activist (ASHA) workers have been appointed unto December, 2019. Their pathetic condition has been highlighted in the recent times.
Data for Thane district reveals that it fares even worse than the state. This data is not easy to obtain. The Citizen Services tab on the official website for Thane District does not have Public Health. Similarly the Citizens’ Charter declared by the District Collector on 31st December 2013 does not mention anything about Public Health.
The shortfalls in the number of Sub centers and PHCs are over 90%, while that of Rural Hospitals is over 75%. According to the District Socioeconomic Report 2016, Thane district has only 1343 beds in Government hospitals! With an estimated population of 124 lakhs in 2020 this means only 11 beds per lakh population are available in government hospitals!
The abysmal lack of infrastructure and manpower shortage in the rural areas result in the overcrowding of patients in the civil hospital in Thane city, and the unbearable load on the medical and other staff. As a result most people do not get proper treatment there.
Data for Thane Municipal Corporation could be obtained with great difficulty. The budgetary provision for hospitals and dispensaries is a very low percentage of the income of TMC. According to different experts this should be from 10% to 20%. The money spent on medicines is less than 4% of the total expenses which is pathetically low! Almost nothing is spent on Dialysis, CT scan and X-Ray etc.
This is why people do not want to be treated in government health centers and hospitals unless they have no choice and are desperate! The average cost of healthcare has tripled between 2005 and 2015. On an average, for the whole country, patients bear 70% of the expenses for health treatment, which is extremely high compared to the rest of the world. The average expenditure on hospitalization is Rs. 31,850, which is the entire income of more than five months of a family working daily on MNREGA. There are some estimates that about 5 crore people are pushed below the poverty line (which itself is disgracefully low) every year due to some illness in the family.